Brazilian Journal of Pain
https://brjp.org.br/article/doi/10.5935/2595-0118.20220015
Brazilian Journal of Pain
Review Article

Therapeutic approach to pain-related fear and avoidance in adults with chronic musculoskeletal pain: an integrative review and a roadmap for clinicians

Abordagem terapêutica do medo relacionado à dor e da evitação em adultos com dor musculoesquelética crônica: revisão integrativa e roteiro para o clínico

Gisele Harumi Hotta; Anamaria Siriani de Oliveira; Rafael Krasic Alaiti; Felipe José Jandre dos Reis

Downloads: 7
Views: 155

Abstract

BACKGROUND AND OBJECTIVES: Cognitive-behavioral approaches have been applied in patients with chronic pain as a treatment strategy to reduce symptoms and disability, since fear related to pain, kinesiophobia and catastrophizing may be important psychosocial barriers for recovery. The relevance of fear and avoidance behaviors in the development and maintenance of processes of disabling chronic pain is already well established in the scientific literature.

CONTENTS: The cognitive-behavioral approach defines the relationship of pain with defense behaviors and the contribution to functional disability, assisting clinicians to recognize signs of these defensive behaviors during practice, as well as providing strategies for clinical practice, highlighting approaches that can be used, such as pain neuroscience education and exposure therapy. Therefore, it is possible to provide a guide to facilitate the implementation of these concepts in clinical practice for the management of chronic musculoskeletal pain, helping clinicians to ground the theories of fear learning and avoidance in the context of pain and to address the psychosocial factors of patients who present an association between pain and movement.

CONCLUSION: Pain-related fear and catastrophic thoughts influence pain intensity and functional disability. Recognizing pain within a multidimensional context assists in establishing targeted approaches. Cognitive-behavioral approaches based on exposure therapy focus on the view beyond body structures.

Keywords

Adaptation psychological, Chronic pain, Exercise therapy, Fear, Musculoskeletal pain, Pain

Resumo

JUSTIFICATIVA E OBJETIVOS: As abordagens cognitivo-comportamentais têm sido aplicadas em pacientes com dor crônica como estratégia de tratamento para redução de sintomas e incapacidade, uma vez que o medo relacionado a dor, a cinesiofobia e a catastrofização podem representar barreiras psicossociais importantes para a recuperação. A relevância do medo e de comportamentos de evitação no desenvolvimento e manutenção de processos de dor crônica incapacitante já é bem estabelecida na literatura científica.

CONTEÚDO: A abordagem cognitivo-comportamental fundamenta a relação da dor com comportamentos de defesa e a contribuição para a incapacidade funcional, auxiliando os clínicos a reconhecer sinais destes comportamentos defensivos na prática, além de fornecer estratégias para prática clínica, destacando as abordagens que podem ser utilizadas, como a educação em neurociência da dor e as terapias de exposição. Dessa maneira, é possível fornecer um guia para facilitar a implementação desses conceitos na prática clínica para a abordagem de pessoas com dor musculoesquelética crônica, ajudando os clínicos a fundamentar as teorias de aprendizado do medo e evitação no contexto da dor e a lidar com fatores psicossociais dos pacientes que apresentam associação entre dor e movimento.

CONCLUSÃO: O medo relacionado à dor e os pensamentos catastróficos influenciam na intensidade da dor e na incapacidade funcional. O reconhecimento da dor dentro do contexto multidimensional auxilia no estabelecimento de abordagens direcionadas. As abordagens cognitivo-comportamentais baseadas em terapia de exposição têm como enfoque o olhar para além das estruturas do corpo.

Palavras-chave

Adaptação psicológica, Dor, Dor crônica, Dor musculoesquelética, Medo, Terapia por exercício

References

Reid KJ, Harker J, Bala MM, Truyers C, Kellen E, Bekkering GE. Epidemiology of chronic non-cancer pain in Europe: Narrative review of prevalence, pain treatments and pain impact. Curr Med Res Opin. 2011;27(2):449-62.

Jackson T, Thomas S, Stabile V, Shotwell M, Han X, McQueen K. A systematic review and meta-analysis of the global burden of chronic pain without clear etiology in low-and middle-income countries: trends in heterogeneous data and a proposal for new assessment methods. Anesth Analg. 2016;123(3):739-48.

Briggs AM, Cross MJ, Hoy DG, Sànchez-Riera L, Blyth FM, Woolf AD. Musculoskeletal health conditions represent a global threat to healthy aging: a report for the 2015 World Health Organization World Report on Ageing and Health. Gerontologist. 2016;56(Suppl2):S243-55.

Vos T, Allen C, Arora M, Barber RM, Bhutta ZA, Brown A. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388(10053):1545-602.

Phillips CJ. The cost and burden of chronic pain. Rev Pain. 2009;3(1):2-5.

Treede RD, Rief W, Barke A, Aziz Q, Bennett MI, Benoliel R. A classification of chronic pain for ICD-11. Pain. 2015;156(6):1003-7.

Treede RD, Rief W, Barke A, Aziz Q, Bennett MI, Benoliel R. Chronic pain as a symptom or a disease. Pain. 2019;160(1):19-27.

Ampiah PK, Hendrick P, Moffatt F, Ahenkorah J. Operationalisation of a biopsycho-social approach for the non-pharmacological management of patients with chronic musculoskeletal pain in low- and middle-income countries: a systematic review. Musculoskeletal Care. 2020;18(3):227-44.

Asmundson GJG, Vlaeyen JWS, Crombez G. Understanding and treating fear of pain. 2004.

Vlaeyen JWS, Crombez G, Linton SJ. The fear-avoidance model of pain. Pain. 2016;157(8):1599.

Vlaeyen JWS, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. 2000;85(3):317-32.

Meulders A. From fear of movement-related pain and avoidance to chronic pain disability: a state-of-the-art review. Curr Opin Behav Sci. 2019;26:130-6.

Crombez G, Vlaeyen JW, Heuts PH, Lysens R. Pain-related fear is more disabling than pain itself: evidence on the role of pain-related fear in chronic back pain disability. 1999;8(1-2):329-39.

Leeuw M, Goossens ME, Linton SJ, Crombez G, Boersma K, Vlaeyen JW. The fear-avoidance model of musculoskeletal pain: Current state of scientific evidence. J Behav Med. 2007;30(1):77-94.

Asmundson GJ, Norton PJ, Norton GR. Beyond pain: the role of fear and avoidance in chronicity. Clin Psychol Rev. 1999;19(1):97-119.

López-de-Uralde-Villanueva I, Munõz-García D, Gil-Martínez A, Pardo-Montero J, Munõz-Plata R, Angulo-Díaz-Parrenõ S. A systematic review and meta-analysis on the effectiveness of graded activity and graded exposure for chronic nonspecific low back pain. Pain Med. 2016;17(1):172-88.

Macedo LG, Smeets RJ, Maher CG, Latimer J, McAuley JH. Graded activity and graded exposure for persistent nonspecific low back pain: a systematic review. Phys Ther. 2010;90(6):860-79.

Williams AC, Eccleston C, Morley S. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev. 2012.

Goossens ME, de Kinderen RJ, Leeuw M, de Jong JR, Ruijgrok J, Evers SM. Is exposure in vivo cost-effective for chronic low back pain? A trial-based economic evaluation. BMC Health Serv Res. 2015;15:549.

Meulders A. Fear in the context of pain: lessons learned from 100 years of fear conditioning research. Behav Res Ther. 2020;131:103635.

Vlaeyen JWS. Learning to predict and control harmful events: chronic pain and conditioning. Pain. 2015;156(Suppl 1):S86-93.

Jozefowiez J. Associative Learning.. Encyclopedia of the Sciences of Learning. 2012:330-4.

LeDoux JE. Coming to terms with fear. Vol. 111, Proceedings of the National Academy of Sciences of the United States of America. 2014:2871-8.

Pavlov PI. Conditioned reflexes: an investigation of the physiological activity of the cerebral cortex. Ann Neurosci. 2010;17(3):136-41.

LeDoux J, Daw ND. Surviving threats: neural circuit and computational implications of a new taxonomy of defensive behaviour. Nat Rev Neurosci. 2018;19(5):269-82.

LeDoux JE, Moscarello J, Sears R, Campese V. The birth, death and resurrection of avoidance: a reconceptualization of a troubled paradigm. Mol Psychiatry. 2017;22(1):24-36.

Vlaeyen JWS, Crombez G. Annual review of clinical psychology behavioral conceptualization and treatment of chronic pain. 2019;16(1).

Pincus T, Burton AK, Vogel S, Field AP. A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine. 2002;27(5).

Harvie DS, Weermeijer JD, Olthof NA, Meulders A. Learning to predict pain: differences in people with persistent neck pain and pain-free controls. PeerJ. 2020;8.

Meulders A, Boddez Y, Blanco F, Van Den Houte M, Vlaeyen JWS. Reduced selective learning in patients with fibromyalgia vs healthy controls. Pain. 2018;159(7):1268-76.

Harvie DS, Moseley GL, Hillier SL, Meulders A. Classical conditioning differences associated with chronic pain: a systematic review. J Pain. 2017;18(8):889-98.

Harvie DS, Meulders A, Madden VJ, Hillier SL, Peto DK, Brinkworth R. When touch predicts pain: Predictive tactile cues modulate perceived intensity of painful stimulation independent of expectancy. Scand J Pain. 2016:11-8.

Meulders A, Jans A, Vlaeyen JWS. Differences in pain-related fear acquisition and generalization: An experimental study comparing patients with fibromyalgia and healthy controls. Pain. 2015;156(1):108-22.

Meulders A, Vlaeyen JWS. Mere intention to perform painful movements elicits fear of movement-related pain: an experimental study on fear acquisition beyond actual movements. J Pain. 2013;14(4):412-23.

Dymond S, Dunsmoor JE, Vervliet B, Roche B, Hermans D. Fear Generalization in humans: systematic review and implications for anxiety disorder research. Behav Ther. 2015;46(5):561-82.

Dunsmoor JE, Murphy GL. Categories, concepts, and conditioning: How humans generalize fear. Trends Cogn Sci. 2015;19(2):73-7.

Rogers CR, Skinner BF. Some issues concerning the control of human behavior: a symposium. Science. 1956;124(3231):1057-66.

Skinner B. Science and human behavior. Pain. 1953:1134-5.

Fordyce WEC, Mosby CV. Behavioral methods for chronic pain and illness. Pain. 1977;3(3):291-2.

Vlaeyen JWS, Crombez G. Behavioral conceptualization and treatment of chronic pain. Ann Rev Clin Psychol. 2019;7(16):187-212.

Keefe FJ, Rumble ME, Scipio CD, Giordano LA, Perri LM. Psychological aspects of persistent pain: Current state of the science. J Pain. 2004;5(4):195-211.

Lee H, Hübscher M, Moseley GL, Kamper SJ, Traeger AC, Mansell G. How does pain lead to disability? A systematic review and meta-analysis of mediation studies in people with back and neck pain. Pain. 2015;156(6):988-97.

Jensen JN, Karpatschof B, Labriola M, Albertsen K. Do fear-avoidance beliefs play a role on the association between low back pain and sickness absence? A prospective cohort study among female health care workers. J Occup Environ Med. 2010;52(1):85-90.

Egnew TR. A narrative approach to healing chronic illness. Ann Fam Med. 2018;16(2):160-5.

Miller WR, Rollnick S. Motivational interviewing: helping people change. 2013:482-xii.

de Jong JR, Vlaeyen JWS, Onghena P, Cuypers C, den Hollander M, Ruijgrok J. Reduction of pain-related fear in complex regional pain syndrome type I: the application of graded exposure in vivo. Pain. 2005;116(3):264-75.

Leeuw M, Goossens ME, van Breukelen GJ, Boersma K, Vlaeyen JW. Measuring perceived harmfulness of physical activities in patients with chronic low back pain: the photograph series of daily activities-short electronic version. J Pain. 2007;8(11):840-9.

Ansanello W, Reis FJJ, Tozzo MC, Zatiti SCA, Meulders A, Vlaeyen JWS. Development of the avoidance daily activities photo scale for patients with shoulder pain. Phys Ther. 2021;2.

Abreu AM, Faria CD, Cardoso SM, Teixeira-Salmela LF. Fear avoidance beliefs Questionnaire (The Brazilian version of the Fear Avoidance Beliefs Questionnaire). Cad Saude Publica. 2008;24(3):615-23.

de Souza FS, Marinho Cda S., Siqueira FB, Maher CG, Costa LO. Psychometric testing confirms that the Brazilian-Portuguese adaptations, the original versions of the Fear-Avoidance Beliefs Questionnaire, and the Tampa Scale of Kinesiophobia have similar measurement properties. Spine. 2008;33(9):1028-33.

Sardá Jr J, Nicholas MK, Pimenta CAM, Asghari A. Pain-related self-efficacy beliefs in a Brazilian chronic pain patient sample: a psychometric analysis. Stress Health. 2007;23(3):185-90.

Berniger Romariz JA, Nonnemacher C, Abreu M, Dickel Segabinazi J, Bandeira JS, Beltran G. The fear of pain questionnaire: psychometric properties of a version for adolescents and its relationship with brain-derived neurotrophic factor (BDNF). J Pain Res. 2019;12:2487-502.

Caneiro JP, Bunzli S, O’Sullivan P. Beliefs about the body and pain: the critical role in musculoskeletal pain management. Braz J Phys Ther. 2021;25(1):17-29.

Glombiewski JA, Riecke J, Holzapfel S, Rief W, König S, Lachnit H. Do patients with chronic pain show autonomic arousal when confronted with feared movements? An experimental investigation of the fear-avoidance model. Pain. 2015;156(3):547-54.

Caneiro JP, O’Sullivan P, Smith A, Moseley GL, Lipp OV. Implicit evaluations and physiological threat responses in people with persistent low back pain and fear of bending. Scand J Pain. 2017;17:355-66.

Lima M, Ferreira AS, Reis FJJ, Paes V, Meziat-Filho N. Chronic low back pain and back muscle activity during functional tasks. Gait Posture. 2018;61:250-6.

Malfliet A, Kregel J, Coppieters I, De Pauw R, Meeus M, Roussel N. Effect of pain neuroscience education combined with cognition-targeted motor control training on chronic spinal pain a randomized clinical trial. JAMA Neurol. 2018;75(7):808-17.

Ryan CG, Gray HG, Newton M, Granat MH. Pain biology education and exercise classes compared to pain biology education alone for individuals with chronic low back pain: a pilot randomised controlled trial. Man Ther. 2010;15(4):382-7.

Clarke CL, Ryan CG, Martin DJ. Pain neurophysiology education for the management of individuals with chronic low back pain: a systematic review and meta-analysis. Man Ther. 2011;16(6):544-9.

Louw A, Diener I, Butler DS, Puentedura EJ. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Arch Phys Med Rehabil. 2011;92(12):2041-56.

Louw A, Zimney K, Puentedura EJ, Diener I. The efficacy of pain neuroscience education on musculoskeletal pain: a systematic review of the literature. Physiother Theory Pract. 2016;32(5):332-55.

Moseley GL, Butler DS. Fifteen years of explaining pain: the past, present, and future. J Pain. 2015;16(9):807-13.

Watson JA, Ryan CG, Cooper L, Ellington D, Whittle R, Lavender M. Pain neuroscience education for adults with chronic musculoskeletal pain: a mixed-methods systematic review and meta-analysis. J Pain. 2019;20(10):1140.

What is Exposure Therapy? [Internet]. 2017;12.

Budtz CR, Mose S, Christiansen DH. Socio-demographic, clinical and psychological predictors of healthcare utilization among patients with musculoskeletal disorders: a prospective cohort study. BMC Health Serv Res. 2020;20(1):239.


Submitted date:
12/23/2021

Accepted date:
01/27/2022

6285a3d1a953956e7a34cee3 brjp Articles

BrJP

Share this page
Page Sections