Cook AJ, Brawer PA, Vowles KE. The fear-avoidance model of chronic pain: validation and age analysis using structural equation modeling

Department of Anesthesiology, Division of Pain Management, University of Virginia Health System, Charlottesville, VA 22908, USA.
Pain (Impact Factor: 5.21). 05/2006; 121(3):195-206. DOI: 10.1016/j.pain.2005.11.018
Source: PubMed


The cognitive-behavioral, fear-avoidance (FA) model of chronic pain (Vlaeyen JWS, Kole-Snijders AMJ, Boeren RGB, van Eek H. Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance. Pain 1995a;62:363-72) has found broad empirical support, but its multivariate, predictive relationships have not been uniformly validated. Applicability of the model across age groups of chronic pain patients has also not been tested. Goals of this study were to validate the predictive relationships of the multivariate FA model using structural equation modeling and to evaluate the factor structure of the Tampa Scale of Kinesiophobia (TSK), levels of pain-related fear, and fit of the FA model across three age groups: young (< or =40), middle-aged (41-54), and older (> or =55) adults. A heterogeneous sample of 469 chronic pain patients provided ratings of catastrophizing, pain-related fear, depression, perceived disability, and pain severity. Using a confirmatory approach, a 2-factor, 13-item structure of the TSK provided the best fit and was invariant across age groups. Older participants were found to have lower TSK fear scores than middle-aged participants for both factors (FA, Harm). A modified version of the Vlaeyen JWS, Kole-Snijders AMJ, Boeren RGB, van Eek H (Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance. Pain 1995a;62:363-72.) FA model provided a close fit to the data (chi(2)(29)=42.0, p>0.05, GFI=0.98, AGFI=0.97, CFI=0.99, RMSEA=0.031 (90% CI 0.000-0.050), p close fit=0.95). Multigroup analyses revealed significant differences in structural weights for older vs. middle-aged participants. For older chronic pain patients, a stronger mediating role for pain-related fear was supported. Results are consistent with a FA model of chronic pain, while indicating some important age group differences in this model and in levels of pain-related fear. Longitudinal testing of the multivariate model is recommended.

Download full-text


Available from: Andrew J Cook, Jun 20, 2014
  • Source
    • "brain networks may be involved in conferring vulnerability to painful conditions that likely contribute to some of these discrepancies ( Denk et al . , 2014 ; Simons et al . , 2014a ) . The most consistent finding is the strong predictive power of FABs and pain - related fear for perceived disability in chronic pain ( Vlaeyen et al . , 1995a , b ; Cook et al . , 2006 ) . Although not everyone agrees that pain - related fear should be considered as a phobia , pain researchers and clinicians alike do agree on the importance of pain - related fear and FABs in explaining disabilities and the transition from acute to chronic musculoskeletal pain ( Vlaeyen et al . , 1995a , b ; Vlaeyen and Linton , 2000 ;"
    [Show abstract] [Hide abstract]
    ABSTRACT: In most individuals suffering from chronic low back pain, psychosocial factors, specifically fear avoidance beliefs (FABs), play central roles in the absence of identifiable organic pathology. On a neurobiological level, encouraging research has shown brain system correlates of somatic and psychological factors during the transition from (sub) acute to chronic low back pain. The characterization of brain imaging signatures in pain-free individuals before any injury will be of high importance regarding the identification of relevant networks for low back pain (LBP) vulnerability. Fear-avoidance beliefs serve as strong predictors of disability and chronification in LBP and current research indicates that back pain related FABs already exist in the general and pain-free population. Therefore, we aimed at investigating possible differential neural functioning between high- and low fear-avoidant individuals in the general population using functional magnetic resonance imaging. Results revealed that pain-free individuals without a history of chronic pain episodes could be differentiated in amygdala activity and connectivity to the pregenual anterior cingulate cortex by their level of back pain related FABs. These results shed new light on brain networks underlying psychological factors that may become relevant for enhanced disability in a future LBP episode.
    Full-text · Article · Jul 2015 · Frontiers in Human Neuroscience
  • Source
    • "The older patients in our study experience more depressive symptoms and lower quality of life. Other studies indicated that there is an association between pain and depression in older adults, but not in younger adults (Turk et al., 1995; Cook et al., 2006). This association could explain the difference between depressive symptoms between the age groups. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Although back pain is common among older people, limited information is available about the characteristics of these patients in primary care. Earlier research suggests that the severity of back symptoms increases with older age. Patients aged >55 years visiting a general practitioner with a new episode of back pain were included in the BACE study. Information on patients' characteristics, characteristics of the complaint and physical examination were derived from the baseline measurement. Cross-sectional differences between patients aged >55-74 and ≥75 years were analysed using an unpaired t-test, Mann-Whitney U-test or a chi-square test. A total of 675 back pain patients were included in the BACE study, with a median age of 65 (interquartile range 60-71) years. Patients aged >55-74 years had a mean disability score (measured with the Roland Disability Questionnaire) of 9.4 [standard deviation (SD) 5.8] compared with 12.1 (SD 5.5) in patients aged ≥75 years (p ≤ 0.01). The older group reported more additional musculoskeletal disorders and more often had low bone quality (based on ultrasound measurement of the heel) than patients aged >55-74 years. Average back pain severity over the previous week showed no difference (p = 0.11) between the age groups, but severity of back pain at the moment of filling in the questionnaire was higher (p = 0.03) in the older age group. In this study, older back pain patients reported more disabilities and co-morbidity. However, the clinical relevance of these differences for the course of the back pain episode in older patients remains a subject for further research.
    Full-text · Article · Feb 2014 · European journal of pain (London, England)
  • Source
    • "It should be mentioned that Vlaeyen and Linton's [55] catastrophizing-based fear-avoidance model is partly based on Philips' work [41]. Still, Cook et al. [14] emphasized the need to include self-efficacy beliefs in the fear-avoidance model since they account for greater variance in disability than catastrophizing [3] [16]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Studies in the literature do not show clear evidence supporting the relationship between pain and depressive symptoms in individuals experiencing acute/subacute pain compared to those experiencing chronic pain. However, more information is needed about which variables act as mediators in the pain-depression relationship in people having acute/subacute pain, before pain becomes chronic. Our objectives were to test the suitability of the fear-avoidance model in a sample of 110 health care workers experiencing acute/subacute pain using path analyses, to improve the model as needed, and to examine a model involving both pain catastrophizing and pain self-efficacy with work status as a final outcome. Overall, the results indicated that adjustments to the fear-avoidance model were required for people experiencing acute/subacute pain, in which fear-avoidance beliefs and depressive symptoms were concurrent rather than sequential. The catastrophizing concept was most closely associated with depressive symptoms, while pain self-efficacy was directly associated with fear-avoidance beliefs and indirectly to work outcomes. Assessing and modifying pain self-efficacy in acute/subacute pain patients is important for interventions aiming to decrease fear-avoidance and improve work outcomes.
    Full-text · Article · Aug 2011 · Pain
Show more