The fear avoidance model is useful in preventing acute LBP developing into chronic LBP and in understanding that exaggerated pain perception in chronic LBP maintains pain and pain behaviours that are maladaptive; patients are described as having types of roles

  • Avoiders
  • Confrontors 


Figure 1: Fear avoidance/confrontation impact

The following exert from the ‘Back Book’ (Roland M et al 2007) describes the characteristics of both types, these are obviously the extremes but illustrate the principle:

  • The avoider gets frightened by the pain and worries about the future.
    • The avoider is afraid that hurting always means further damage – it doesn’t.
    • The avoider rests a lot, and just waits for the pain to get better
  • The coper knows that the pain will get better and does not fear the future
  1. The coper carries on as normal as possible.
  2. The coper deals with the pain by being positive, staying active and getting on with life.

Who suffers most?

  • Avoiders suffer the most; they have pain for longer, they have more time off work and they can become disabled.
  • Copers get better faster, enjoy life more and have less trouble in the long run.

Chapman, C. R. 1978. Pain: the perception of noxious events. In: Sternbach, R.A. ed. The Psychology of Pain. New York: Raven Press, pp. 169-202.
Eccleston, C. and Crombez, G. 1999. Pain demands attention: a cognitive-affective model of the interruptive function of pain. Psychol Bull 125(3), pp. 356-366.
Henschke, N. et al. 2010. Behavioural treatment for chronic low-back pain. Cochrane Database Syst Rev (7), p. CD002014.
Keefe, F. J. et al. 1991. Analyzing pain in rheumatoid arthritis patients. Pain coping strategies in patients who have had knee replacement surgery. Pain 46(2), pp. 153-160.
Leeuw, M. et al. 2007. The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. J Behav Med 30(1), pp. 77-94.
McCracken, L. M. and Keogh, E. 2009. Acceptance, mindfulness, and values-based action may counteract fear and avoidance of emotions in chronic pain: an analysis of anxiety sensitivity. J Pain 10(4), pp. 408-415.
McCracken, L. M. and Vowles, K. E. 2007. Psychological flexibility and traditional pain management strategies in relation to patient functioning with chronic pain: an examination of a revised instrument. J Pain 8(9), pp. 700-707.
Macfarlane, G. J. et al. 1999. Predictors of early improvement in low back pain amongst consulters to general practice: the influence of pre-morbid and episode-related factors. Pain 80(1-2), pp. 113-119.
Pincus, T. and Morley, S. 2001. Cognitive-processing bias in chronic pain: a review and integration. Psychol Bull 127(5), pp. 599-617.
Schoth, D. E. et al. 2012. Attentional bias towards pain-related information in chronic pain; a meta-analysis of visual-probe investigations. Clin Psychol Rev 32(1), pp. 13-25.
van der Windt, D. et al. 2008. Psychosocial interventions for low back pain in primary care: lessons learned from recent trials. Spine (Phila Pa 1976) 33(1), pp. 81-89.
Villemure, C. and Bushnell, M. C. 2002. Cognitive modulation of pain: how do attention and emotion influence pain processing? Pain 95(3), pp. 195-199.
Waddell G. The Back Pain Revolution. 2nd ed. Edinburgh: Churchill Livingstone; 2004.
Roland M, Waddell G, Klaber Moffett J, Burton K, Main C. The Back Book. Norwich, UK The Stationary Office : 2007