Pain-related avoidance versus endurance in primary care patients with subacute back pain: psychological characteristics and outcome at a 6-month follow-up

Pain. 2012 Jan;153(1):211-217. doi: 10.1016/j.pain.2011.10.019. Epub 2011 Nov 16.


Recent research has found individual differences in back pain patients due to behavioral avoidance vs persistence. However, there is a lack of prospective studies of nonspecific low back pain patients. The avoidance-endurance model (AEM) suggests at least 3 pathways leading to chronic pain: fear-avoidance response, distress-endurance response, and eustress-endurance response. We sought to compare these 3 maladaptive subgroups with an adaptive group using a classification tool that included the following scales: the thought suppression and behavioral endurance subscale of the Avoidance-Endurance Questionnaire and the Beck Depression Inventory. The psychological characteristics, and pain and disability of the AEM subgroups were investigated. We report results from 177 patients with subacute nonspecific low back pain at the start of outpatient treatment and at follow-up after 6 months. At baseline, a multivariate analysis of variance found that the fear-avoidance patients scored higher in pain catastrophizing than the other groups. The distress-endurance patients displayed elevated anxiety/depression and helplessness/hopelessness accompanied with the highest scores in the classification variables thought suppression and persistence behavior. The eustress-endurance patients had the highest humor/distraction scores, pain persistence, and positive mood despite pain. All 3 maladaptive groups revealed a higher pain intensity than the adaptive patients at follow-up after 6 months; however, disability at follow-up was elevated only in the fear-avoidance and distress-endurance patients. The study provides preliminary evidence for the construct and prospective validity of AEM-based subgroups of subacute, nonspecific back pain patients. The results suggest the need for individually targeted cognitive behavioral treatments in the maladaptive groups.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adaptation, Psychological*
  • Adult
  • Aged
  • Avoidance Learning
  • Back Pain / psychology*
  • Depression / psychology
  • Disability Evaluation
  • Fear / psychology*
  • Female
  • Follow-Up Studies
  • Humans
  • Male
  • Middle Aged
  • Pain Measurement
  • Primary Health Care
  • Prospective Studies
  • Surveys and Questionnaires