In this issue of PAIN, Drs. Vlaeyen and Linton [2] present a cogent review of research regarding the fear-avoidance model of chronic musculoskeletal pain, a model that Dr. Vlaeyen has pioneered. The model was developed in order to explain how persistent fear-based avoidance behavior could produce much of the suffering and disability associated with pain states. They highlight the key role of fear in developing pain avoidance behaviors. Pain can be considered an unconditioned stimulus (US) that activates immediate reactive measures in the acute setting. In the longer term, conditioned stimuli (interoceptive, exteroceptive, or propri-oceptive) become associated with the US and then conditioned responses, such as fear/avoidance result from exposure to the conditioned stimuli. Direct experience or indirect experience, such as verbal information or observations, may influence fear, avoidance, and pain perceptions. The authors review a number of studies demonstrating the powerful effects of such indirect experience in research settings. They describe how in vivo exposure procedures have emerged as an important means of reducing fear-induced avoidance behaviors associated with pain.
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