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Mental Being Research for Doctors
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Musculoskeletal Pain
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1. Leeuw, M. et al. The Fear-Avoidance Model of Musculoskeletal Pain: Current State of Scientific Evidence. J Behav Med. 2006 Dec 20; [Epub ahead of print]
Research studies focusing on the fear-avoidance model have expanded considerably.
The fear-avoidance model is a cognitive-behavioral account that explains why a minority of acute low back pain sufferers develop a chronic pain problem.
This paper reviews the current state of scientific evidence for the individual components of the model: pain severity, pain catastrophizing, attention to pain, escape/avoidance behavior, disability, disuse, and vulnerabilities.
This review of the literature also discusses support for the contribution of pain-related fear in the inception of low back pain, the development of chronic low back pain from an acute episode, and the maintenance of enduring pain.
Available evidence on recent clinical applications is also provided, and unresolved issues that need further exploration are discussed.
2. Vlaeyen JW, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain. 2000 Apr; 85(3):317-32.
In an attempt to explain how and why some individuals with musculoskeletal pain develop a chronic pain syndrome, Lethem et al. Outline of fear-avoidance model of exaggerated pain perceptions. Behav Res Ther 1983; 21: 401-408) introduced 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 (since the year 2000), 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.
A number of fear-related processes are discussed in this paper including:
- Escape and avoidance behaviors resulting in poor behavioral performance
- Hypervigilance to internal and external illness information
- Muscular reactivity
- Physical disuse in terms of deconditioning and guarded movement.
This paper also attempts to quantify pain-related fear and avoidance, along with discussing findings for prevention and treatment of chronic musculoskeletal pain.
Although there are a number issues associated with chronic pain, pain-related fear and avoidance appears to be an essential feature of the development of a chronic problem for a substantial number of patients with musculoskeletal pain.
3. Boersma K, Linton SJ. Psychological processes underlying the development of a chronic pain problem: a prospective study of the relationship between profiles of psychological variables in the fear-avoidance model and disability. Clin J Pain. 2006 Feb;22 (2):160-6.
Understanding the psychological processes that underlie the development of a chronic pain problem is important to improve prevention and treatment.
This study intended to test whether distinct profiles of variables within the fear-avoidance model could be identified and could be related to disability in a meaningful way.
Cluster analysis was used on 81 people with musculoskeletal pain problems to identify subgroups with similar patterns on fear and avoidance beliefs, catastrophizing, and depression.
The clusters were examined cross-sectionally and prospectively on function, pain, health care usage, and sick leave.
RESULTS:
Five distinct profiles were found:
- Pain-related fear
- Pain-related fear + depressed mood
- Medium pain-related fear
- Depressed mood
- Low risk.
The majority of those classified in the clusters "Pain-related fear," "Pain-related fear + depressed mood," and "Depressed mood" reported long-term sick leave during follow-up.
The subjects in the clusters with high scores on the depression measure reported the highest percentage of health care usage during follow-up (70% in the "Pain-related fear + depressed mood" group and 42% in the "Depressed mood" group reported more than 10 health care visits).
CONCLUSIONS:
Distinct profiles of psychological functioning could be extracted and meaningfully related to future disability. These profiles give support to the fear-avoidance model and underscore the need to address the psychological aspects of the pain experience early on.
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