Skip to content
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

Abstract

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.

Methods

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.

Results

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.

Conclusions

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.

Implications

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: http://dx.doi.org/10.1016/j.sjpain.2017.09.014



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 ClinicalTrials.gov.

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

Acknowledgements

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

References

[1] Vlaeyen JWS, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain 2000;85:317–32.10.1016/S0304-3959(99)00242-0Search in Google Scholar

[2] Bailey KM, Carleton RN, Vlaeyen WS, Asmundson GJG. Treatments addressing pain-related fear and anxiety in patients with chronic musculoskeleta pain: a preliminary review. Cogn Behav Ther 2010;39:46–63.10.1080/16506070902980711Search in Google Scholar PubMed

[3] Schutze R, Rees C, Preece M, Schutze M. Low mindfulness predicts pain catas-trophizing in a fear-avoidance model of chronic pain. Pain 2010;148:120–7.10.1016/j.pain.2009.10.030Search in Google Scholar PubMed

[4] Carmody J, Baer RA. Relationships between mindfulness practice and levels of mindfulness, medical and psychological symptoms and well-being in a mindfulness-based stress reduction program. J Behav Med 2008;31:23–33.10.1007/s10865-007-9130-7Search in Google Scholar PubMed

[5] Chan RR, Larson JL. Meditation interventions forchronic disease populations: asystematic review. J Holist Nurs 2015;33:351–65.10.1177/0898010115570363Search in Google Scholar PubMed

[6] Hoge EA, Bui E, Marques L, Metcalf CA, Morris LK, Robinaugh DJ, Worthington JJ, Pollack MH, Simon NM. Randomized controlledtrial of mindfulness meditation forgeneralized anxietydisorder: effects on anxiety and stress reactivity. J Clin Psychiatr 2013;74:786–92.10.4088/JCP.12m08083Search in Google Scholar PubMed PubMed Central

[7] Meize-Grochowski R, Shuster G, Boursaw B, DuVal M, Murray-Krezan C, Schrader R, Smith BW, Herman CJ, Prasad A. Mindfulness meditation in older adults with postherpetic neuralgia: a randomized controlled pilot study Geriatr Nurs 2015;36:154–60.10.1016/j.gerinurse.2015.02.012Search in Google Scholar PubMed PubMed Central

[8] Michaelsen A, Kunz N, Jeitler M, Brunnhuber S, Meier L, Ludtke R, Bussing A, Kessler C. Effectiveness of focused meditation for patients with chronic low back pain - a randomized controlled clinical trial. Complement Ther Med 2016;26:79–84.10.1016/j.ctim.2016.03.010Search in Google Scholar PubMed

[9] Zhang J, Liu X, Xie X, Zhao D, Shan M, Zhang X, Kong X, Cui H. Mind fulness-based stress reduction for chronic insomnia in adults older than 75 years: a randomized, controlled, single-blind clinical trial. Explore 2015;11:180–5.10.1016/j.explore.2015.02.005Search in Google Scholar PubMed

[10] Cimmino MA, Ferrone C, Cutolo M. Epidemiology of chronic musculoskeletal pain. Best Pract Res Clin Rheumatol 2011;25:173–83.10.1016/j.berh.2010.01.012Search in Google Scholar PubMed

[11] Faul F, Erdfelder E, Buchner A, Lang AG. Statistical power analyses using G*Power3. 1:tests for correlation and regression analyses.Behav Res Methods 2009;41:1149–60.10.3758/BRM.41.4.1149Search in Google Scholar PubMed

[12] Mendoza T, Mayne T, Rublee D, Cleeland C. Reliability and validity of a modified Brief Pain Inventory short form in patients with osteoarthritis. Eur J Pain 2006;10:353–61.10.1016/j.ejpain.2005.06.002Search in Google Scholar PubMed

[13] Tan G, Jensen MP, Thornby JI, Shanti BF. Validation of the BriefPain Inventory forchronic nonmalignant pain. J Pain 2004;5:133–7.10.1016/j.jpain.2003.12.005Search in Google Scholar PubMed

[14] Osman A, Barrios FX, Kopper BA, Hauptmann W, Jones J, O’Neill E. Factorstructure, reliability, and validity of the Pain Catastrophizing Scale. J Behav Med 1997;20:589–605.10.1023/A:1025570508954Search in Google Scholar

[15] Osman A, Barrios FX, Gutierrez PM, Kopper BA, Merrifield T, Grittmann L. The Pain Catastrophizing Scale: further psychometric evaluation with adult samples. J Behav Med 2000;23:351–65.10.1023/A:1005548801037Search in Google Scholar

[16] McCracken LM, Keogh E. Acceptance, mindfulness, and values-based action may counteract fear and avoidance of emotions in chronic pain: an analysis of anxiety sensitivity. J Pain 2009;10:408–15.10.1016/j.jpain.2008.09.015Search in Google Scholar PubMed

[17] McCracken LM, Dhingra L. A short version of the Pain Anxiety Symptoms Scale (PASS-20): preliminary development and validity. Pain Res Manag 2002;7:45–50.10.1155/2002/517163Search in Google Scholar PubMed

[18] Deckers L. Seven stress, coping and health.In: Motivation: biological, psychological, and environmental. fourth ed. New York, NY: Routledge; 2016. p. 170.Search in Google Scholar

[19] Roberti JW, Harrington LN, Storch EA. Further psychometric support for the 10-item version of the Perceived Stress Scale. JColl Couns 2006;9:135–47.10.1002/j.2161-1882.2006.tb00100.xSearch in Google Scholar

[20] Camara RJ, Schoepfer AM, Pittet V, Begre S, von Kanel R. Mood and non-mood components of perceived stress and exacerbation of Crohn’s disease. Inflamm Bowel Dis 2011;17:2358–65.10.1002/ibd.21623Search in Google Scholar PubMed

[21] Morgado P, Freitas D, Bessa JM, Sousa N, Cerqueira JJ. Perceived stress in Obsessive-Compulsive Disorder is related with obsessive but not compulsive symptoms. Front Psychiatry 2013;4:1–6.10.3389/fpsyt.2013.00021Search in Google Scholar PubMed PubMed Central

[22] Ussher M, Spatz A, Copland C, Nicolaou A, Cargill A, Amini-Tabrizi N, McCracken LM. Immediate effects of a brief mindfulness-based body scan on patients with chronic pain. J Behav Med 2014;37:127–34.10.1007/s10865-012-9466-5Search in Google Scholar

[23] Bohlmeijer E, Klooster PMT, Fledderus M, Veehof M, Baer R. Psychometric properties of the five facet mindfulness questionnaire in depressed adults and development of a short form. Assess 2011;18:308–20.10.1177/1073191111408231Search in Google Scholar

[24] Carpenter JS, Andrykowski MA. Psychometrice valuation of the Pittsburgh Sleep Quality Index. J Psychosomat Res 1998;45:5–13.10.1016/S0022-3999(97)00298-5Search in Google Scholar

[25] Backhaus J, Junghanns K, Broocks A, Riemann D, Hohagen F. Test-retest reliability and validity of the Pittsburgh Sleep Quality Index in primary insomnia. J Psychosomat Res 2002;53:737–40.10.1016/S0022-3999(02)00330-6Search in Google Scholar

[26] Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav 1983;24:385–96.10.2307/2136404Search in Google Scholar

[27] Cabin RJ, Mitchell RJ. To Bonferroni ornotto Bonferroni: whenand how arethe questions. Bull Ecol Soc Am 2000;81:246–8.Search in Google Scholar

[28] Cohen J. Statistical power analysis for the behavioral sciences. Hillsdale, NJ: Lawrence Erlbaum Associates; 1988.Search in Google Scholar

[29] Hayes AF, Darlington RB. Regression Analysis and Linear Models: concepts, applications and implementations. New York, NY: The Guilford Press; 2016.Search in Google Scholar

[30] Bair MJ, Wu J, Damush TM, Sutherland JM, Kroenke IC. Association of depression and anxiety alone and in combination with chronic musculoskeletal pain in primary care patients. Psychosomat Med 2008;70:890–7.10.1097/PSY.0b013e318185c510Search in Google Scholar PubMed PubMed Central

[31] Mutso AA, Radzicki D, Baliki MN, Huang L, Banisadr G, Centeno MV, Radulovi J, Martina M, Miller RJ, Apkarian AV. Abnormalities in hippocampal functioning with persistent pain. Neurobiol Dis 2012;31:5747–56.10.1523/JNEUROSCI.0587-12.2012Search in Google Scholar PubMed PubMed Central

[32] Vachon-Presseau E, Roy M, Martel MO, Caron E, Marin MF, Chen J, Albouy G, Plante I, Sullivan MJ, Lupien SJ, Rainville P. The stress model of chronic pain: evidence from basal cortisol and hippocampal structure and function in humans. Brain: J Neurol 2013;136:815–27.10.1093/brain/aws371Search in Google Scholar PubMed

[33] McCracken LM, Carson JW, Keefe FJ. Acceptance and change in the context of chronic pain. Pain 2004;109:4–7.10.1016/j.pain.2004.02.006Search in Google Scholar PubMed

[34] Moskowitz JT, Duncan LG, Moran PJ, Acree M, Epel ES, Kemeny ME, Hecht FM, Folkman S. Dispositional mindfulness in people with HIV: associations with psychological and physical health. Pers Individ Dif 2015;86:88–93.10.1016/j.paid.2015.05.039Search in Google Scholar PubMed PubMed Central

[35] Holzel BK, Lazar SW, Gard T, Schuman-Olivier Z, Vago DR, Ott U. How does mindfulness meditation work? Proposing mechanisms of action from a conceptual and neural perspective. Perspect Psychol Sci 2011;6:537–59.10.1177/1745691611419671Search in Google Scholar PubMed

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