In an attempt to explain how and why some individuals with musculoskeletal pain develop a chronic pain syndrome, Lethem et al. (Lethem J, Slade PD, Troup JDG, Bentley G. Outline of fear-avoidance model of exaggerated pain perceptions. Behav Res Ther 1983; 21: 401-408).ntroduced a so-called 'fear-avoidance' model. The central concept of their model is fear of pain. 'Confrontation' and 'avoidance' are postulated as the two extreme responses to this fear, of which the former leads to the reduction of fear over time. The latter, however, leads to the maintenance or exacerbation of fear, possibly generating a phobic state. In the last decade, an increasing number of investigations have corroborated and refined the fear-avoidance model. The aim of this paper is to review the existing evidence for the mediating role of pain-related fear, and its immediate and long-term consequences in the initiation and maintenance of chronic pain disability. We first highlight possible precursors of pain-related fear including the role negative appraisal of internal and external stimuli, negative affectivity and anxiety sensitivity may play. Subsequently, a number of fear-related processes will be discussed including escape and avoidance behaviors resulting in poor behavioral performance, hypervigilance to internal and external illness information, muscular reactivity, and physical disuse in terms of deconditioning and guarded movement. We also review the available assessment methods for the quantification of pain-related fear and avoidance. Finally, we discuss the implications of the recent findings for the prevention and treatment of chronic musculoskeletal pain. Although there are still a number of unresolved issues which merit future research attention, pain-related fear and avoidance appear to be an essential feature of the development of a chronic problem for a substantial number of patients with musculoskeletal pain.

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Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art

&NA; In an attempt to explain how and why some individuals with musculoskeletal pain develop a chronic pain syndrome, Lethem et al.(Lethem J, Slade PD, Troup JDG, Bentley G. Outline of fear‐avoidance model of exaggerated pain perceptions. Behav Res Ther 1983; 21: 401‐408).ntroduced a so‐called ‘fear‐avoidance’ model. The central concept of their model is fear of pain. ‘Confrontation’ and ‘avoidance’ are postulated as the two extreme responses to this fear, of which the former leads to the reduction of fear over time. The latter, however, leads to the maintenance or exacerbation of fear, possibly generating a phobic state. In the last decade, an increasing number of investigations have corroborated and refined the fear‐avoidance model. The aim of this paper is to review the existing evidence for the mediating role of pain‐related fear, and its immediate and long‐term consequences in the initiation and maintenance of chronic pain disability. We first highlight possible precursors of pain‐related fear including the role negative appraisal of internal and external stimuli, negative affectivity and anxiety sensitivity may play. Subsequently, a number of fear‐related processes will be discussed including escape and avoidance behaviors resulting in poor behavioral performance, hypervigilance to internal and external illness information, muscular reactivity, and physical disuse in terms of deconditioning and guarded movement. We also review the available assessment methods for the quantification of pain‐related fear and avoidance. Finally, we discuss the implications of the recent findings for the prevention and treatment of chronic musculoskeletal pain. Although there are still a number of unresolved issues which merit future research attention, pain‐related fear and avoidance appear to be an essential feature of the development of a chronic problem for a substantial number of patients with musculoskeletal pain.

Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art.

Retrospective study: The diagnostic accuracy of conventional forceps biopsy of gastric epithelial compared to endoscopic submucosal dissection (STROBE compliant).

STUDY DESIGN: The literature on psychological factors in neck and back pain was systematically searched and reviewed.

OBJECTIVES: To summarize current knowledge concerning the role of psychological variables in the etiology and development of neck and back pain.

SUMMARY OF BACKGROUND DATA: Recent conceptions of spinal pain, especially chronic back pain, have highlighted the role of psychological factors. Numerous studies subsequently have examined the effects of various psychological factors in neck and back pain. There is a need to review this material to ascertain what conclusions may be drawn.

METHODS: Medical and psychological databases and cross-referencing were used to locate 913 potentially relevant articles. A table of 37 studies was constructed, consisting only of studies with prospective designs to ensure quality. Each study was reviewed for the population studied, the psychological predictor variables, and the outcome.

RESULTS: The available literature indicated a clear link between psychological variables and neck and back pain. The prospective studies indicated that psychological variables were related to the onset of pain, and to acute, subacute, and chronic pain. Stress, distress, or anxiety as well as mood and emotions, cognitive functioning, and pain behavior all were found to be significant factors. Personality factors produced mixed results. Although the level of evidence was low, abuse also was found to be a potentially significant factor.

CONCLUSIONS: Psychological factors play a significant role not only in chronic pain, but also in the etiology of acute pain, particularly in the transition to chronic problems. Specific types of psychological variables emerge and may be important in distinct developmental time frames, also implying that assessment and intervention need to reflect these variables. Still, psychological factors account for only a portion of the variance, thereby highlighting the multidimensional view. Because the methodologic quality of the studies varied considerably, future research should focus on improving quality and addressing new questions such as the mechanism, the developmental time factor, and the relevance that these risk factors have for intervention.

Patricia Dolan

Papers

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On the use of axis systems in quentification of lumbar loading during asymmetric lifting

Chapter 19 – What is the relation between proprioception and low back pain?

Intervertebral disc decompression following endplate damage: Middle-aged discs are affected most

Measuring inertial forces acting on the lumbar spine during lifting