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.