Rethinking the fear avoidance model of pain: an empirical and theory-based evaluation

Persistent pain and disability are commonly associated with musculoskeletal injury and can result in considerable personal suffering and societal burden. The Fear Avoidance Model (FAM) provides a theoretical account of how pain-related disability develops, and has inspired a large body of research that aims to mitigate the negative consequences of musculoskeletal injury. While the FAM is currently a leading theory of disability, several aspects of the model have yet to be considered in the literature. This critical review aims to address these aspects by synthesizing recent empirical findings and conducting a novel evaluation of model-relevant theoretical assumptions. Three lines of research are considered. First, recent longitudinal evaluations of the model are reviewed. These findings suggest limited support for the model’s prospective sequential relationships and for the role of fear as a common conduit for different pain-related outcomes. Second, research testing the FAM’s proposed mechanism for disability development is evaluated. Contrary to predictions, there is little evidence suggesting that fear-avoidance causes deconditioning. Finally, recent research exploring alternate, non-FAM, relationships is reviewed. This research suggests risk factors addressed within the FAM interrelate in a cumulative, rather than sequential, fashion. Together, these empirical findings suggest that the specific inter-relationships proposed within the FAM may not accurately portray the experiences of people living with musculoskeletal pain. The theory-based evaluation explores three FAM assumptions that may help account for the model’s limited support. Specifically, this evaluation explores how the model’s central emphasis on pain-related phobia may limit its validity and generalizability; how the model’s implied co-presentation of chronic pain and disability make it difficult to explain the observed variance in these two states; and how the model’s failure to integrate pain-related physiological mechanisms is at odds with a large body of biopsychosocial research. The benefits of exploring new models of pain-related disability are discussed.