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Licensed Unlicensed Requires Authentication Published by De Gruyter October 1, 2017

The relationship between chronic musculoskeletal pain, anxiety and mindfulness: Adjustments to the Fear-Avoidance Model of Chronic Pain

Katherine B. Curtin and Deborah Norris


Background and purpose

The Fear-Avoidance Model of Chronic Pain proposed by Vlaeyen and Linton states individuals enter a cycle of chronic pain due to predisposing psychological factors, such as negative affectivity, negative appraisal or anxiety sensitivity. They do not, however, address the closely related concept of anxious rumination. Although Vlaeyen and Linton suggest cognitive-behavioral treatment methods for chronic pain patients who exhibit pain-related fear, they do not consider mindfulness treatments. This cross-sectional study investigated the relationship between chronic musculoskeletal pain (CMP), ruminative anxiety and mindfulness to determine if (1) ruminative anxiety is a risk factor for developing chronic pain and (2) mindfulness is a potential treatment for breaking the cycle of chronic pain.


Middle-aged adults ages 35-50 years (N = 201) with self-reported CMP were recruited online. Participants completed standardized questionnaires assessing elements of chronic pain, anxiety, and mindfulness.


Ruminative anxiety was positively correlated with pain catastrophizing, pain-related fear and avoidance, pain interference, and pain severity but negatively correlated with mindfulness. High ruminative anxiety level predicted significantly higher elements of chronic pain and significantly lower level of mindfulness. Mindfulness significantly predicted variance (R2) in chronic pain and anxiety outcomes. Pain severity, ruminative anxiety, pain catastrophizing, pain-related fear and avoidance, and mindfulness significantly predicted 70.0% of the variance in pain interference, with pain severity, ruminative anxiety and mindfulness being unique predictors.


The present study provides insight into the strength and direction of the relationships between ruminative anxiety, mindfulness and chronic pain in a CMP population, demonstrating the unique associations between specific mindfulness factors and chronic pain elements.


It is possible that ruminative anxiety and mindfulness should be added into the Fear-Avoidance Model of Chronic Pain, with ruminative anxiety as a psychological vulnerability and mindfulness as an effective treatment strategy that breaks the cycle of chronic pain. This updated Fear-Avoidance Model should be explored further to determine the specific mechanism of mindfulness on chronic pain and anxiety and which of the five facets of mindfulness are most important to clinical improvements. This could help clinicians develop individualized mindfulness treatment plans for chronic pain patients.

DOI of refers to article:

Children’s National Health System, Children’s Research Institute, Center for Translational Science, 111 Michigan Avenue NW, 6th Floor Main, Washington, DC 20010-2970, USA. E-mail:

  1. Ethical issues: This study was approved by the IRB at American University in Washington, DC. Informed consent was provided to participants online via Qualtrics. As this was not an interventional study, it was not mandated that it be registered at

  2. Conflicts of interest: There are no conflicts of interest to report.


This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.


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Appendix A.

Covariates related to primary and secondary outcomes

OutcomeRelated covariateF statisticSignificance level
BPI-sf pain severity(1) Gender(1) 4.226(1) 0.016
(2) Parental status(2) 3.966(2) 0.048
(3) Pain medicine use(3) 7.035(3) 0.009
(4) Asian race(4) 3.892(4) 0.050
BPI-sf pain interferenceN/AN/AN/A
PCS total(1) Education(1) 2.293(1) 0.047
PASS 20 total(1) Education(1) 2.309(1) 0.046
(2) Meditation experience(2) 5.817(2) 0.004
PSS 10 total(1) Meditation experience(1) 4.152(1) 0.019
FFMQ-sftotal(1) Pain vulnerability(1) 5.497(1) 0.005
(2) Hispanic race(2) 5.294(2) 0.023
PSQI total(1) Gender(1) 5.383(1) 0.005
(2) Education(2) 2.441(2) 0.036
(3) Pain medicine use(3) 8.271(3) 0.004
(4) Pain vulnerability(4) 4.218(4) 0.017
(5) Asian race(5) 19.685(5) 0.0001
(6) White race(6) 17.508(6) 0.0001

Received: 2017-05-26
Revised: 2017-07-15
Accepted: 2017-08-19
Published Online: 2017-10-01
Published in Print: 2017-10-01

© 2017 Scandinavian Association for the Study of Pain