DR. GATCHEL HAS NO CONFLICTS OF INTEREST TO DISCLOSE. Gatchel

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1 Robert J. Gatchel, Ph.D., ABPP Nancy P. and John G. Penson Endowed Professor of Clinical Health Psychology Distinguished Professor of Psychology, College of Science Director, Center of Excellence for the Study of Health and Chronic Illnesses, The University of Texas at Arlington Director of Biopsychosocial Research, The Osteopathic Research Center, The University of North Texas Health Science Center, FT. Worth, TX 1

2 DR. GATCHEL HAS NO CONFLICTS OF INTEREST TO DISCLOSE. Gatchel

3 Well-established that patients with chronic pain will often avoid activities that may exacerbate their pain. The basic fear-avoidance model posits that, if individuals are especially sensitive to the negative experience of pain, then this will result in: o o o pain-related fear of movement avoidance of daily activities that may result in pain Hyper-vigilance or over-monitoring of bodily sensations and potential increase in pain The above can, in turn, result in physical deconditioning, depression, as well as disability/avoidance of work, recreation, and/or family activities. Fear-avoidance is closely related to increased pain, physical disability, and long-term sick leave in chronic pain patients (e.g., Gatchel et. al, 2007)

4 Lethem and colleagues (1983) first introduced the fear-avoidance model of exaggerated pain perception in order to explain how and why some people develop a chronic pain syndrome. This model was further developed and refined by other investigators (e.g., Asmundson et. al, 1999; Vlaeyen & Linton, 2000). Two oposing behavioral responses to pain are postulated: Approach behavior occurs in the absence of any serious somatic pathology. Considered an adaptive response that eventually may lead to a reduction of fear and pain, and a promotion of the recovery of physical functioning. Avoidance behavior may be initially adaptive, but may lead to the maintenance or exacerbation of fear in the long-run, resulting in disability.

5 FIGURE. Cognitive-behavioral Model of Pain-related Fear (from Vlaeyen & Linton, 2000)

6 Examples of Items from Pain- Related Fear Questionnaires Tampa Scale for Kinesiophobia (TSK) Harm I wouldn't have this much pain if there weren't something potentially dangerous going on in my body. My body is telling me I have something dangerously wrong. Fear of re-injury I'm afraid that I might injure myself accidentally. I'm afraid that I might injure myself if I exercise. Exercise It's really not safe for a person with a condition like mine to be physically active. My pain would probably be relieved if I were to exercise [reverse scored]. Avoidance of activity If I were to try to overcome it, my pain would increase. Pain lets me know when to stop exercising so that I don't injure myself.

7 Examples of Items from Pain- Related Fear Questionnaires Pain and Impairment Relationship Scale (PAIRS) An increase in pain is an indication that I should stop what I am doing until the pain decreases. I have to be careful not to do anything that might make my pain worse. I have come to accept that I am a disabled person, due to my chronic pain. All of my problems would be solved if my pain would go away. Fear Avoidance Beliefs Questionnaire (FABQ) Fear avoidance beliefs about work My pain was caused by my work or by an accident at work. My work might harm my back. Fear avoidance beliefs about physical activity My pain was caused by physical activity. I cannot do physical activities which (might) make my pain worse.

8 Examples of Items from Pain- Related Fear Questionnaires Pain Anxiety Symptoms Scale (PASS) Cognitive anxiety I can't think straight when in pain. During painful episodes it is difficult for me to think of anything besides the pain. Escape/avoidance I go immediately to bed when I feel severe pain. I will stop any activity as soon as I sense pain coming on. Fear I think that if my pain gets too severe, it will never decrease. When I feel pain I am afraid that something terrible will happen. Physiological anxiety I begin trembling when engaged in an activity that increases pain. Pain seems to cause my heart of pound or race.

9 Examples of Items from Pain- Related Fear Questionnaires The Fear of Pain Questionnaire, Children s Version (FOPQ-C) Fear of pain I can t do all the things normal people do because it s so easy to hurt my body. Feelings of pain are scary for me. Avoidance of activities I cancel plans when I am in pain. I stop any activity if I start to hurt or my pain becomes worse.

10 THE NEWER FEAR-AVOIDANCE COMPONENTS SCALE (FACS) Developed because of the need for a better all-encompassing set of constructs that would more effectively deal with critical issues not comprehensively addressed in previous measures. More importance now of disability and functional recovery (because of the greater societal impact and costs of worker disability insurance) Secondary gain issues (worker-related injuries, or accidents in which another party is at fault ). New research on the important role of victimization by an employer or injuring party Specific pain catastrophizing component*

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12 An exaggerated negative orientation toward actual or anticipated pain experiences a set of maladaptive beliefs Pain Catastrophizing plays an important role in chronic pain, and is associated with higher self-reported pain and disability. It is believed to be a precursor of fear-avoidance behaviors. Pain Catastrophizing Scale (Sullivan et. al, Psychological Assessment, 7: , 1995). See SPECIAL ISSUE ON PAIN CATASTROPHIZING by Gatchel [An Introduction and Overview. SPECIAL ISSUE on Pain Catastrophizing, Journal of Applied Biobehavioral Research, 22 (1): 1, 2017]. It includes articles by experts in this area (e.g., Haythornthwaite, Jamison, Linton, Neblett, Shaw, Sullivan).

13 Development of the Fear-Avoidance Components Scale (FACS) items, including specific FA components from previous FA-related patient-report outcome (PRO) measures, sample items from these PRO measures, and the related FACS items representing each of these components (Neblett et. al, 2015) Fear avoidance components Activity avoidance due to pain (without specifying fear) Items from previous patient-report outcome measures Activity Avoidance PASS - I try to avoid activities that cause pain PASS - I will stop any activity as soon as I sense pain coming on Resulting FACS items 1) I try to avoid activities and movements that make my pain worse Activity avoidance due to pain-related fear Activity avoidance due to fear of injury (or re-injury) FABQ I should not do physical activities which (might) make my pain worse No specific items found TSK - I can t do all the things normal people do because it s just too easy for me to get injured 11) I don t attempt certain activities and movements because I am fearful that my pain will increase 5) I don t attempt certain activities because I am fearful that I will injure (or re-injure) myself TSK - I m afraid that I might injure myself accidentally (or if I exercise) TSK I m afraid that I might injure myself if I exercise FABQ Physical activity might harm my

14 Development of the Fear-Avoidance Components Scale (FACS) items, including specific FA components from previous FA-related patient-report outcome (PRO) measures, sample items from these PRO measures, and the related FACS items representing each of these components (Neblett et. al, 2015) Vulnerability to injury or reinjury Beliefs and Feelings about One's Painful Medical Condition TSK - My accident has put my body at risk for the rest of my life TSK - It s really not safe for a person with a condition like mine to be physically active 8) My painful medical condition puts me at risk for future injuries (or re-injuries) for the rest of my life A perception of one's painful medical condition as permanent, rather than transient TSK My accident has put my body at risk for the rest of my life IEQ - I feel that this has affected me in a permanent way 9) Because of my painful medical condition, my life will never be the same IEQ - My life will never be the same PCS - It s terrible and I think it s never going to get any better Someone else is to blame PCS - I worry all the time about whether the pain will end IEQ - I am suffering because of someone else s negligence 12) It is someone else s fault that I have this painful medical condition IEQ: Injustice Experience Questionnaire

15 Development of the Fear-Avoidance Components Scale (FACS) items, including specific FA components from previous FA-related patient-report outcome (PRO) measures, sample items from these PRO measures, and the related FACS items representing each of these components (Neblett et. al, 2015) Sense of unfairness IEQ - It all seems so unfair 7) It is unfair that I have to live with my painful medical condition Other people don't understand TSK - People aren t taking my medical condition seriously enough 14) No one understands how severe my painful medical condition is Helplessness / lack of control over pain Interpretation of pain as harmful and dangerous IEQ - Most people don t understand how severe my condition is PCS - There s nothing I can do to reduce the intensity of the pain TSK - My body is telling me I have something dangerously wrong TSK - I wouldn t have this much pain if there weren t something potentially dangerous going on in my body 10) I have no control over my pain 13) The pain from my medical condition is a warning signal that something is dangerously wrong with me. TSK - Pain always means I have injured my body PASS When I feel pain I think I might be seriously ill

16 Development of the Fear-Avoidance Components Scale (FACS) items, including specific FA components from previous FA-related patient-report outcome (PRO) measures, sample items from these PRO measures, and the related FACS items representing each of these components (Neblett et. al, 2015) Pain-related anxiety / catastrophizing PASS - I worry when I am in pain PASS - Pain sensations are terrifying PCS - I can t seem to keep it out of my mind 2) I worry about my painful medical condition 3) I believe that my pain will keep getting worse until I won t be able to function at all Somatic symptoms of painrelated anxiety / catastrophizing PCS - It s awful and I feel that it overwhelms me PCS - I become afraid that the pain will get worse PASS I begin to trembling when engaged in activity that increases pain PASS Pain seems to cause my heart to pound or race 4) I am overwhelmed by fear when I think about my painful medical condition 6) When my pain is bad, I have other symptoms such as nausea, difficulty breathing, heart pounding, trembling, and/or dizziness PASS When I sense pain I feel dizzy or faint PASS Pain makes me nauseous

17 Development of the Fear-Avoidance Components Scale (FACS) items, including specific FA components from previous FA-related patient-report outcome (PRO) measures, sample items from these PRO measures, and the related FACS items representing each of these components (Neblett et. al, 2015) Type of Activities, and Level of Activities, that one is Avoiding FABQ - Physical activity makes my pain worse Due to my painful medical condition I have avoided the following.. Heavy activities Moderate activities 15.strenuous activities (like doing heavy yard work or moving heavy furniture) 16. moderate activities (like cooking dinner or cleaning the house) Light activities Normal duties/chores at home and/or work Recreational activities / exercise FABQ I cannot do my normal work with my present pain TSK - Pain lets me know when to stop exercising so that I don t injure myself 17. Light activities (like going to the movies or going out to lunch) 18).my full duties and chores at home and/or at work 19).recreation and/or exercise (things that I do for fun and good health) Activities involving one's painful body parts 20).activities where I have to use my painful body part(s)

18 FREA AVOIDANCE COMPONENTS SCALE

19 FREA AVOIDANCE COMPONENTS SCALE

20 FACS CUT-OFF SEVERITY SCORES TOTAL POSSIBLE SCORE: 100 Subclinical (0-20) Mild (21-40) Moderate (41-60) Severe (61-80) Extreme (81-100)

21 TREATMENT Graded Exposure In Vivo for Pain-Related Fear Vlaeyen, J.W.S., de Jong, J., Sieben, J. & Crombez, G. In D.C. Turk & R.J. Gatchel (Eds.). Psychological Approaches to Pain Management: A Practitioner s Handbook. Second Edition. New York: Guilford, Third Edition, in press Springer, K.S. et al. The development of a technology-based hierarchy to assess chronic low back pain and pain-related anxiety from a fear-avoidance model. The Journal of Pain, 17: , Fear of pain and what we do about it may be more disabling than pain itself (Waddell et. al, 1993, from Vlaeyen et. al, 2002)

22 REFERENCES Asmundson, G.J., Norton, P.J. & Norton, G.R. Beyond pain: The role of fear and avoidance in chronicity. Clinical Psychology Review, 19: , Gatchel, R.J. Pain Catastrophizing: An Introduction and Overview. SPECIAL ISSUE on Pain Catastrophizing (Editor: R.J. Gatchel). Journal of Applied Biobehavioral Research, in press. Gatchel, R.J. & Neblett, R. Pain Catastrophizing: What Clinicians Need to Know. Practical Pain Management, 15(6), 70-75, Gatchel, R. J., Peng, Y., Peters, M. L., Fuchs, P. N., & Turk, D. C. The Biopsychosocial Approach to Chronic Pain: Scientific Advances and Future Directions. Psychological Bulletin, 133: , Lethem, J., Slade, P.D., Troup, J.D. & Bentley, G. Outline of a fear-avoidance model of exaggerated pain perception: I. Behaviour Research and Therapy, 21: , Gatchel

23 Neblett, R., Mayer, T. G., Hartzell, M. M., Williams, M. J., & Gatchel, R. J. The Fear-avoidance Components Scale (FACS): Development and Psychometric Evaluation of a New Measure of Pain-related Fear Avoidance. Pain Practice, 16(4): , doi: /papr Sullivan, M. J., Bishop, S., & Pivik, J. The Pain Catastrophizing Scale: development and validation. Psychological Assessment, 7: , Vlaeyen, J.W.S., de Jong, J., Sieben, J. & Crombez, G. Graded Exposure In Vivo for Pain-Related Fear. In D.C. Turk & R.J. Gatchel (Eds.). Psychological Approaches to Pain Management: A Practitioner s Handbook, Second Edition. New York: Guilford, Vlaeyen, J.W. & Linton, S.J. Fear-avoidance and its consequences in chronic musculoskeletal pain: A state of the art. Pain, 85: , Gatchel