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The Fear Avoidance Model Disentangled: Improving the Clinical Utility of the Fear Avoidance Model

Pincus, Tamar PhD*; Smeets, Rob J.E.M. MD, PhD; Simmonds, Maureen J. PhD, PT; Sullivan, Michael J.L.§

doi: 10.1097/AJP.0b013e3181f15d45
Special Topic Series

Background The model of fear avoidance proposes that fear of movement in back pain patients is an obstacle to recovery and leads over time to increased disability. Therefore, fear of movement should be targeted explicitly by interventions.

Aims To review the evidence (1) for the causal components proposed by the model, and (2) about interventions that attempt to reduce fear of movement. In addition, we aim to propose alternatives and extensions to the current model in order to increase the clinical utility of the model.

Methods A collaborative narrative review.

Results The fear avoidance model needs to be conceptually expanded and further tested to provide adequate and appropriate clinical utility. Currently, although there is experimental support for the model, observational studies in patients show contradictory results. Interventions based on the model have not delivered convincing results, only partly due to methodological shortcomings. Some assumptions inherent in the current model need adjusting, and other factors should be incorporated to indicate subgroupings within patients high in avoidance behavior. In addition, both theoretical and methodological limitations were identified in measurements of fear and avoidance.

Conclusions Future research should elucidate whether the proposed subgrouping of patients with avoidance behavior is helpful. Further research should focus on developing more accurate and psychometrically sound assessment tools as well as targeted interventions to improve activities and participation of patients with chronic disabling musculoskeletal pain disorders.

*Department of Psychology, Royal Holloway, University of London, Surrey, United Kingdom

Rehabilitation Foundation Limburg and Department of Rehabilitation Medicine, CAPHRI, Maastricht University, The Netherlands

School of Physical and Occupational Therapy

§Department of Psychology, McGill University, Canada

Reprints: Tamar Pincus, PhD, Department of Psychology, Royal Holloway, University of London, Egham, Surrey, TW20 0EX (e-mail:

Received for publication March 17, 2010; accepted March 19, 2010

© 2010 Lippincott Williams & Wilkins, Inc.