What is the role of fear and escape/avoidance in chronic pain? Models, structural analysis and future directions

The fear-avoidance model of chronic pain has stimulated extensive research and the development of a variety of interventions focused on reducing pain-related fear, avoidance behavior and functional disability in individuals with chronic pain. Although there is considerable evidence supporting the model, oversight of potentially important factors and inconsistent findings regarding postulated pathways have led to proposed model revisions. The purpose of this brief narrative review is to provide an overview of the original model, highlight key model revisions and review existing research that directly analyzed the pathways proposed in the original and revised models. The growing body of evidence emerging from analysis of proposed fear-avoidance pathways using structural equation modeling is generally supportive of the original model, as well as various proposed revisions. Additional evaluation using structural equation modeling may lead to a formulation of the fear-avoidance model that balances parsimony with heuristic value. Clinical implications and areas for future research are discussed.