In part 1 and 2 of this series (read them here & here) I discuss the problematic application of the fear avoidance model and the relationships the model proposes that lead to disability. In this last installment, I will expand on where we should focus our efforts. Perpetuating the assumptions in the model runs the risk of misdirecting clinical treatment. Studies examining interventions, based on the presumed relationships within the model, have tended to be underpowered and suffer from design flaws. It is suggested that future research look at characteristics of subgroups, when assessing interventions to better identify what intervention may benefit whom and when.
Dr. Pincus and her co-authors in 2010 reviewed limitations within the evidence and offered guidance on what an expansion of the model might look like. The methodology of how fear-based beliefs and pain has been studied raises concerns of ecological validity when you consider studies performed in healthy populations and the differing features of spontaneous pain versus clinically-afflicted pain and the Hawthorne effect of behaving differently when being watched. Work seeking to validate the model via cross-sectional studies has not shown the same results as those that employ prospective designs. In other words, looking at relationships in a single point in time, is not the same as looking at causal inferences over time.
They go on to note that appreciating fear as being unconnected from avoidance and identifying treatment response to subsets of fear (fear of pain, movement, injury, exercise, and activity) may be helpful. Also, they point out that it is important to distinguish between beliefs about avoidance versus actual fear-based avoidance. Current outcome measures don’t differentiate between these fully. We do not have the evidence to substantiate the claim that simply holding the belief “I must lift with a straight back" will lead to persistent pain.
She suggests two expanded models termed “the social pathway model” and the “depression pathway model”. However, neither extend to include self-efficacy as a path to recovery despite wide evidence of such. She identifies exploring narratives to better understand how a person came to possess their views of fear and avoidance as a necessary step to recovery.
Crombez et al discuss “disengagement” from what they term “unrealistic goals” What is an unrealistic goal? Is it unrealistic forever, or for now? How do clinicians manage this? “I don’t think this is a realistic goal” may be code for “I don’t believe in you.” Which is different from “This is a great goal, let’s look at breaking it down and see what steps to focus on right now as we pursue it.” Our perception of what successful goal attainment looks like may not match what their expectation of successful goal attainment is. Perhaps they are ecstatic with partial engagement when I was imagining full participation. They raise the question that it is perhaps not beliefs of hurt=harm that are integral to the model, but instead a belief that pain must be mitigated for return to valued tasks to occur. I can’t emphasize this enough. This opens the very important door of living well in-spite of pain and using self-management strategies to facilitate engagement with valued tasks, while on the path to seeking total abolishment of pain. This should be added to the schema.
Often “pain education” is promoted as a path to reduce fear and catastrophic thinking. First, the evidence of that is questionable (see my discussion on this here). PIncus et al 2010 also noted in their review that graded exposure to the feared movement only changed that specific activity. It did not lead to broader participation in other activities. They describe it as the “‘exception to the rule’…that one activity is not dangerous but other activities are.” As noted in the previous blog in this series (read it here), self-efficacy is a mediator and predictor of better function in the presence of fear of movement. It empowers the individual to generalize strategies to other encounters. If other factors mediate and moderate the relationship, we should be focusing on those.
The fear avoidance model in it’s evolved form isn’t enough. It continues to focus on the creation of fear based beliefs and avoidance behaviors. It perpetuates the relationships of the factors in ways the evidence has not supported when viewed prospectively. This emphasis directs attention to the development of pain states as reflexive. Without subgroup consideration, this is misleading. It implies that this pathway to pain persistence is the same throughout the continuum, and identifies the correlations as reflexive, and allows no path for interruption. I believe leaving self-efficacy out of the model is a critical error. I suggest clinically we focus a bit less on the pathway of creation, beyond encouraging and reassuring early movement. After that, our focus should be on self-efficacy. The question that should be primarily guiding us isn’t “are they kinesphobic?” The question we should seek to understand is “do they feel that they have the tools and strategies to successfully manage their pain to engage with the word, the way they want to.”
Costa, L. da C. M., Maherl, C. G., McAuleyl, J. H., Hancockl, M. J., & Smeetsl, R. J. E. M. (2011). Self-efficacy is more important than fear of movement in mediating the relationship between pain and disability in chronic low back pain. European Journal of Pain, 15(2), 213–219.
Crombez G, Eccleston C, Van Damme S, Vlaeyen JWS, Karoly P. Fear- avoidance model of chronic pain: the next generation. Clin J Pain 2012; 28:475–83.
Lee, H., Hübscher, M., Moseley, G. L., Kamper, S. J., Traeger, A. C., Mansell, G., & Mcauley, J. H. (2015). How does pain lead to disability? A systematic review and meta-analysis of mediation studies in people with back and neck pain. Pain, 1.
MJ,SullivanMJL,HaythornthwaiteJA,EdwardsRR. Rethinking the fear avoidance model: toward a multidimensional framework of pain-related disability. PAIN 2013;154:2262–5.
Pincus, T., Smeets, R., Simmonds, M. and Sullivan, M., 2010. The Fear Avoidance Model Disentangled: Improving the Clinical Utility of the Fear Avoidance Model. The Clinical Journal of Pain, 26(9), pp.739-746.
Pincus, T., Vogel, S., Burton, A., Santos, R. and Field, A., 2006. Fear avoidance and prognosis in back pain: A systematic review and synthesis of current evidence. Arthritis & Rheumatism, 54(12), pp.3999-4010.
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