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Journal articles on the topic 'Fear-avoidance model'

Author: Grafiati

Published: 4 June 2021

Last updated: 17 February 2022

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1

Pincus, Tamar, Rob J. E. M. Smeets, Maureen J. Simmonds, and Michael J. L. Sullivan. "The Fear Avoidance Model Disentangled: Improving the Clinical Utility of the Fear Avoidance Model." Clinical Journal of Pain 26, no. 9 (November 2010): 739–46. http://dx.doi.org/10.1097/ajp.0b013e3181f15d45.

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Zdun-Ryżewska, Agata, and Krzysztof Basiński. "Fear avoidance model – review of selected reports." BÓL 17, no. 4 (January 6, 2017): 41–48. http://dx.doi.org/10.5604/01.3001.0009.7382.

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SUMMARY: Based on the bio-psycho-social approach, fear-avoidance model can be used in situations when somebody avoids movement because of fear of pain. This model can be applied in groups of patients with low back pain and musculoskeletal pain and explains how acute pain becomes chronic. A simple behavioral model of classical and operant conditioning that explains activity avoidance was developed into a more sophisticated, cognitive-behavioral fear-avoidance model, postulating the existence of a vicious circle that causes increasing disability of patients in chronic pain. The variables involved in this mechanism are catastrophizing, fear of activity, avoiding movement, increased distress and fear-avoidance beliefs. This article also presents some further improvements to the model that include pain intensity and motivational theory. A brief overview of tools used in research on fear-avoidance is also presented. It is recommended to take Fear Avoidance Model in to consideration when working with patients with no improvement and the risk of recurrent episodes of pain. Further studies are needed to empirically verify the fear-avoidance model.

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Crombez, Geert, Christopher Eccleston, Stefaan Van Damme, Johan W. S. Vlaeyen, and Paul Karoly. "Fear-Avoidance Model of Chronic Pain." Clinical Journal oF Pain 28, no. 6 (2012): 475–83. http://dx.doi.org/10.1097/ajp.0b013e3182385392.

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Vlaeyen, Johan W. S., Geert Crombez, and Steven J. Linton. "The fear-avoidance model of pain." PAIN 157, no. 8 (August 2016): 1588–89. http://dx.doi.org/10.1097/j.pain.0000000000000574.

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Asmundson, Gordon JG, Melanie Noel, Mark Petter, and Holly A. Parkerson. "Pediatric Fear-Avoidance Model of Chronic Pain: Foundation, Application and Future Directions." Pain Research and Management 17, no. 6 (2012): 397–405. http://dx.doi.org/10.1155/2012/908061.

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The fear-avoidance model of chronic musculoskeletal pain has become an increasingly popular conceptualization of the processes and mechanisms through which acute pain can become chronic. Despite rapidly growing interest and research regarding the influence of fear-avoidance constructs on pain-related disability in children and adolescents, there have been no amendments to the model to account for unique aspects of pediatric chronic pain. A comprehensive understanding of the role of fear-avoidance in pediatric chronic pain necessitates understanding of both child/adolescent and parent factors implicated in its development and maintenance. The primary purpose of the present article is to propose an empirically-based pediatric fear-avoidance model of chronic pain that accounts for both child/adolescent and parent factors as well as their potential interactive effects. To accomplish this goal, the present article will define important fear-avoidance constructs, provide a summary of the general fear-avoidance model and review the growing empirical literature regarding the role of fear-avoidance constructs in pediatric chronic pain. Assessment and treatment options for children with chronic pain will also be described in the context of the proposed pediatric fear-avoidance model of chronic pain. Finally, avenues for future investigation will be proposed.

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Bagraith, Karl S., Jenny Strong, and Roland Sussex. "Disentangling Disability in the Fear Avoidance Model." Clinical Journal oF Pain 28, no. 3 (2012): 273–74. http://dx.doi.org/10.1097/ajp.0b013e3182273e47.

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7

Nieto, Rubén, Jordi Miró, and Anna Huguet. "The fear-avoidance model in whiplash injuries." European Journal of Pain 13, no. 5 (May 2009): 518–23. http://dx.doi.org/10.1016/j.ejpain.2008.06.005.

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Wilson, Anna C., Amy S. Lewandowski, and Tonya M. Palermo. "Fear-Avoidance Beliefs and Parental Responses to Pain in Adolescents with Chronic Pain." Pain Research and Management 16, no. 3 (2011): 178–82. http://dx.doi.org/10.1155/2011/296298.

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BACKGROUND: The fear-avoidance model of chronic pain posits that fear of pain is associated with fear and avoidance of activity, which can lead to deconditioning and persistence of pain and disability. Despite being well supported in adults, little is known about the role of fear-avoidance beliefs regarding physical activity in children. Research has shown that parental protectiveness contributes to activity limitations in children; however, no studies have examined relationships between protectiveness, and fear and avoidance.OBJECTIVES: To conduct a cross-sectional study to provide additional information regarding the reliability and validity of the Fear-Avoidance Beliefs Questionnaire physical activity subscale among adolescents with chronic pain; examine fear-avoidance beliefs and depressive symptoms as concurrent predictors of physical activity limitations; and test competing models using fear-avoidance beliefs as mediators and moderators of the association between parental protectiveness and activity limitations.METHODS: Adolescents (n=42) 11 to 17 years of age with chronic pain completed questionnaires assessing pain intensity, fear-avoidance beliefs, depressive symptoms and physical activity limitations. Their parents completed questionnaires regarding protectiveness and adolescent activity limitations.RESULTS: The Fear-Avoidance Beliefs Questionnaire physical activity subscale was useful for assessing fear-avoidance beliefs in the present population. In support of hypotheses, greater fear-avoidance beliefs were associated with greater activity limitations, above pain intensity and depressive symptoms. Support was found for fear-avoidance beliefs as mediators of the association between parental protectiveness and activity limitations. Tests of moderation were not significant.CONCLUSIONS: Fear-avoidance beliefs may be an important target for interventions focused on decreasing activity limitations in youth with chronic pain. Future research should investigate these associations longitudinally.

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Boselie, Jantine J. L. M., and Johan W. S. Vlaeyen. "Broadening the fear-avoidance model of chronic pain?" Scandinavian Journal of Pain 17, no. 1 (October 1, 2017): 176–77. http://dx.doi.org/10.1016/j.sjpain.2017.09.014.

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10

Moseley, Lorimer G. "A new direction for the fear avoidance model?" Pain 152, no. 11 (November 2011): 2447–48. http://dx.doi.org/10.1016/j.pain.2011.06.024.

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11

Kromer, Thilo O., Judith M. Sieben, Rob A. de Bie, and Caroline H. G. Bastiaenen. "Influence of Fear-Avoidance Beliefs on Disability in Patients With Subacromial Shoulder Pain in Primary Care: A Secondary Analysis." Physical Therapy 94, no. 12 (December 1, 2014): 1775–84. http://dx.doi.org/10.2522/ptj.20130587.

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Background Little information exists about the role of fear-avoidance beliefs and catastrophizing in subacromial pain syndrome. Objective The purpose of this study was to investigate the associations among pain, catastrophizing, fear, and disability and the contribution of fear-avoidance beliefs to disability at baseline and at 3-month follow-up. Design A cross-sectional and longitudinal analysis was conducted. Methods Baseline demographic and clinical data, including fear-avoidance beliefs and catastrophizing, of 90 patients were assessed for this analysis. Disability was measured with the Shoulder Pain and Disability Index at baseline and at 3-month follow-up. First, bivariate and partial correlations were calculated among pain, fear-avoidance beliefs, catastrophizing, and disability, based on the fear-avoidance model. Second, the contribution of fear-avoidance beliefs to disability at baseline and at 3-month follow-up was examined with hierarchical regression analyses. Results Correlations between clinical variables and disability were largely in line with the fear-avoidance model. Regression analyses identified a significant contribution of fear-avoidance beliefs to baseline disability but not to disability at 3 months. Limitations Patients with subacromial pain syndrome were studied; therefore, the results should be transferred with caution to other diagnoses. A modified version of the Fear-Avoidance Beliefs Questionnaire was used, which was not validated for this patient group. Conclusions Fear-avoidance beliefs contribute significantly to baseline disability but not to disability change scores after 3-month follow-up. Duration of complaints and baseline disability were the main factors influencing disability change scores. Although the results help to improve understanding of the role of fear-avoidance beliefs, further studies are needed to fully understand the influence of psychological and clinical factors on the development of disability in patients with subacromial shoulder pain.

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Zale, Emily L., and Joseph W. Ditre. "Pain-related fear, disability, and the fear-avoidance model of chronic pain." Current Opinion in Psychology 5 (October 2015): 24–30. http://dx.doi.org/10.1016/j.copsyc.2015.03.014.

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13

Kroska, Emily B. "A meta-analysis of fear-avoidance and pain intensity: The paradox of chronic pain." Scandinavian Journal of Pain 13, no. 1 (October 1, 2016): 43–58. http://dx.doi.org/10.1016/j.sjpain.2016.06.011.

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AbstractBackgroundThe fear-avoidance model of chronic pain has established avoidance as a predictor of negative outcomes in chronic pain patients. Avoidance, or deliberate attempts to suppress or prevent unwanted experiences (e.g., pain), has been studied extensively, with multiple reviews implicating this behavior as a predictor of disability, physical disuse, and depression. Despite hundreds of studies examining the associations between different components of this model (i.e., catastrophizing, fear, avoidance, depression), the association between fear-avoidance and pain intensity has remained unclear. The present study seeks to clarify this association across samples.MethodThe present analyses synthesize the literature (articles from PsycInfo, PubMed, and ProQuest) to determine if fear-avoidance and pain intensity are consistently correlated across studies, samples, and measures. Eligible studies measured pain intensity and fear-avoidance cross-sectionally in chronic pain patients. The search resulted in 118 studies eligible for inclusion. A random-effects model was used to estimate the weighted mean effect size. Comprehensive Meta-Analysis software was used for all analyses. Moderation analyses elucidate the variables that affect the strength of this association. Meta-regression and meta-ANOVA analyses were conducted to examine moderating variables. Moderator variables include demographic characteristics, pain characteristics, study characteristics, and national cultural characteristics (using Hofstede’s cultural dimensions). Publication bias was examined using the funnel plot and the p-curve.ResultsResults indicate a small-to-moderate positive association between fear-avoidance and pain intensity. The results were stable across characteristics of the sample, including mean age, gender distribution, marital status, and duration of pain. Moderation analyses indicate that the measures utilized and cultural differences affect the strength of this association. Weaker effect sizes were observed for studies that utilized measures of experiential avoidance when compared to studies that utilized pain-specific fear-avoidance measures. Studies that utilized multiple measures of fear-avoidance had stronger effect sizes than studies that utilized a single measure of fear-avoidance. Three of Hofstede’s cultural dimensions moderated the association, including Power Distance Index, Individualism versus Collectivism, and Indulgence versus Restraint.ConclusionsThe present meta-analysis synthesizes the results from studies examining the association between fear-avoidance and pain intensity among individuals with chronic pain. The positive association indicates that those with increased fear-avoidance have higher pain intensity, and those with higher pain intensity have increased fear-avoidance. Findings indicate that cultural differences and measurement instruments are important to consider in understanding the variables that affect this association. The significant cultural variations may indicate that it is important to consider the function of avoidance behavior in different cultures in an effort to better understand each patient’s cultural beliefs, as well as how these beliefs are related to pain and associated coping strategies.ImplicationsThe results from the current meta-analysis can be used to inform interventions for patients with chronic pain. In particular, those with more intense pain or increased fear-avoidance should be targeted for prevention and intervention work. Within the intervention itself, avoidance should be undermined and established as an ineffective strategy to manage pain in an effort to prevent disability, depression, and physical deconditioning.

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Krulichová, Eva, and Zuzana Podaná. "Adolescent fear of crime: Testing Ferraro’s risk interpretation model." European Journal of Criminology 16, no. 6 (July 30, 2018): 746–66. http://dx.doi.org/10.1177/1477370818788014.

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The aim of this study is to broaden the scope of knowledge on fear of crime by examining if Ferraro’s risk interpretation model of fear of crime also holds true for the adolescent population. Using data on approximately 1500 Czech students in middle and grammar school, we test three different models. First, the classic model of fear of crime, applied originally to adults, is estimated. Second, the role of perceived school disorganization is examined, taking into account that adolescents spend a substantial part of the day at school. Finally, we propose an extension of Ferraro’s model by considering parental supervision as a factor influencing adolescent fear of crime through risk perception and avoidance behaviour. The results indicate that Ferraro’s original model of fear of crime can be appropriately applied to both adults and adolescents. Nevertheless, adolescent risk perception, which remains the most influential determinant of individual fear, seems to be influenced by stimuli stemming from the school rather than the neighbourhood environment. Furthermore, the relationship between parental supervision and fear of crime is mediated by avoidance behaviour, while no direct effect of parental supervision on risk perception and fear of crime was found in the data.

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Pedler, Ashley, Steven J. Kamper, Annick Maujean, and Michele Sterling. "Investigating the Fear Avoidance Model in People With Whiplash." Clinical Journal of Pain 34, no. 2 (February 2018): 130–37. http://dx.doi.org/10.1097/ajp.0000000000000524.

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Beneciuk, Jason M., Michael E. Robinson, and Steven Z. George. "Low Back Pain Subgroups Using Fear-Avoidance Model Measures." Clinical Journal oF Pain 28, no. 8 (October 2012): 658–66. http://dx.doi.org/10.1097/ajp.0b013e31824306ed.

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San-Antolín, Marta, David Rodríguez-Sanz, Davinia Vicente-Campos, Patricia Palomo-López, Carlos Romero-Morales, María Benito-de-Pedro, Daniel López-López, and César Calvo-Lobo. "Fear Avoidance Beliefs and Kinesiophobia Are Presented in Athletes who Suffer from Gastrocnemius Chronic Myofascial Pain." Pain Medicine 21, no. 8 (January 31, 2020): 1626–35. http://dx.doi.org/10.1093/pm/pnz362.

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Abstract Objective To compare and predict kinesiophobia and fear avoidance beliefs between athletes with gastrocnemius myofascial pain syndrome (MPS) and healthy athletes. Design Case–control. Setting Outpatient clinic. Subjects Fifty athletes were divided into athletes with chronic gastrocnemius MPS (N = 25) and healthy athletes (N = 25). Methods Kinesiophobia symptoms total and domain scores (harm and activity avoidance) and levels were determined by the Tampa Scale of Kinesiophobia (TSK-11). Fear avoidance beliefs total and domain scores (physical and working activities) were measured by the Fear Avoidance Beliefs Questionnaire (FABQ). Results Significant differences (P < 0.05) with a large effect size (d = 0.81–4.22) were found between both groups, with greater kinesiophobia symptom scores for the TSK-11 activity avoidance domain and total scores, and greater fear avoidance beliefs scores for the FABQ physical and working activities domains and total scores of athletes with gastrocnemius MPS with respect to healthy athletes. TSK-11 total score showed a prediction model (R2 = 0.256) based on the FABQ total score. The FABQ total score showed a prediction model (R2 = 0.741) based on gastrocnemius MPS presence (R2 = 0.665), levels of kinesiophobia (R2 = 0.052), and height (R2 = 0.025). Conclusions Greater kinesiophobia levels, greater total and activity avoidance domain scores (but not for the harm domain), and greater fear avoidance beliefs total and domain scores (work and physical activity) were shown for athletes with gastrocnemius MPS vs healthy athletes. Higher kinesiophobia symptoms were predicted by greater fear avoidance beliefs in athletes. Greater fear avoidance beliefs were predicted by the presence of gastrocnemius MPS, higher levels of kinesiophobia, and lower height in athletes.

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Thomtén, Johanna, and Andreas Karlsson. "Psychological factors in genital pain: The role of fear-avoidance, pain catastrophizing and anxiety sensitivity among women living in Sweden." Scandinavian Journal of Pain 5, no. 3 (July 1, 2014): 193–99. http://dx.doi.org/10.1016/j.sjpain.2014.01.003.

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AbstractObjectivesOne in five women under the age of 30 report recurrent genital pain and pain during sexual intercourse. Female genital pain negatively affects sexual and general health, as well as dyadic function and quality of life. Although the current field of research and clinical expertise in general agree upon a biopsychosocial conceptualization, there is still a lack of theoretical models describing the psychosocial mechanisms involved in the development of genital pain. Originally developed to outline the transition from acute to chronic back pain, the fear avoidance (FA) model has lately been proposed as a possible tool in illustrating the mechanisms involved in genital pain. However, only few studies have empirically tested the components of the FA model empirically. The aim of the present study is to examine fear avoidance beliefs, pain catastrophizing, and symptoms of depression and anxiety among women reporting genital pain, and to relate these concepts to sexual satisfaction/function and the characteristics of pain.MethodsThe study was a population-based study using a postal questionnaire administered to 4052 women (age 18–35). Of these 944 (response rate: 23%) took part in the study.ResultsGenital pain of six months duration was reported by 16.1% of the women. Women with pain reported elevated levels of symptoms of anxiety, fear avoidance beliefs, pain catastrophizing and anxiety sensitivity. Symptoms of anxiety also predicted pain in the explanatory model together with vaginal tension and fungal infection. Vaginal tension has previously been described as a fear-response to painful intercourse and the results thereby seem to give further support to viewing genital pain from a fear avoidance perspective. Furthermore, fear avoidance beliefs seem to be of similar importance as lack of desire for the experience of sexual satisfaction and could also predict pain during specific activities among women with pain. The results also indicate that sexual satisfaction is related to a specific pain-related fear, rather than a heightened level of general anxiety.ConclusionsThe study had a low response rate, but still indicates that genital pain is common and is associated with several aspects of fear and avoidance. In sum, the results support the FA model by giving strong support for fear reactions (vaginal tension) and fear avoidance beliefs, and moderate support for negative affect. In the model negative affect drives pain catastrophizing.ImplicationsIt seems that the experience of genital pain among women in the general population is common and could be associated with increased levels of anxiety and fear-avoidance beliefs. However, the associations should not be understood in isolation from physiological mechanisms but seem to indicate interactions between, e.g. fungal infections, negative appraisals of pain and symptoms, lack of sexual function and satisfaction and increased pain experience. It is possible that psychological mechanisms work in the transition from acute physiological pain to chronic psychologically maintained pain in terms of secondary reactions to, e.g. repeated fungal infections by adding emotional distress, fear of pain and avoidance behaviours.

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Hunt, Emily R., Shelby E. Baez, Anne D. Olson, Timothy A. Butterfield, and Esther Dupont-Versteegden. "Using Massage to Combat Fear-Avoidance and the Pain Tension Cycle." International Journal of Athletic Therapy and Training 24, no. 5 (September 1, 2019): 198–201. http://dx.doi.org/10.1123/ijatt.2018-0097.

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Massage is a common therapeutic modality utilized by clinicians in a variety of settings to help treat injuries, reduce pain, and return function to patients. Massage benefits the patients both psychologically and physiologically, as patients report less pain and anxiety along with better mood and even decreased blood pressure following massage. Additionally, on the cellular level, massage has the ability to modulate the damaging inflammatory process and, in some cases, influence protein synthesis. Although massage has not been linked to a rehabilitation theory to date, this paper will propose how massage may influence fear-avoidance beliefs, or the patient’s inability to cope with pain that then leads to a pain tension cycle. Pain will often result in use avoidance, which creates muscle tension that further exacerbates the pain. Massage can affect the Fear-Avoidance Model because the beneficial effects of massage can break the cycle by either relieving the patient’s pain or eliminating the muscle tension. A modified Fear-Avoidance Model is presented that conceptualizes how pain and fear-avoidance lead to tension and muscle dysfunction. Massage has been incorporated into the model to demonstrate its potential for breaking the pain tension cycle. This model has the potential to be applied in clinical settings and provides an alternate treatment to patients with chronic pain who present with increased levels of fear-avoidance beliefs.

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Slepian, P. Maxwell, Brett Ankawi, and Christopher R. France. "Longitudinal Analysis Supports a Fear-Avoidance Model That Incorporates Pain Resilience Alongside Pain Catastrophizing." Annals of Behavioral Medicine 54, no. 5 (November 11, 2019): 335–45. http://dx.doi.org/10.1093/abm/kaz051.

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Abstract Background The fear-avoidance model of chronic pain holds that individuals who catastrophize in response to injury are at risk for pain-related fear and avoidance behavior, and ultimately prolonged pain and disability. Purpose Based on the hypothesis that the predictive power of the fear-avoidance model would be enhanced by consideration of positive psychological constructs, the present study examined inclusion of pain resilience and self-efficacy in the model. Methods Men and women (N = 343) who experienced a recent episode of back pain were recruited in a longitudinal online survey study. Over a 3-month interval, participants repeated the Pain Resilience Scale, Pain Catastrophizing Scale, Tampa Scale of Kinesiophobia, Pain Self-Efficacy Questionnaire, the McGill Pain Questionnaire, and NIH-recommended measures of pain, depressive symptoms, and physical dysfunction. Structural equation modeling assessed the combined contribution of pain resilience and pain catastrophizing to 3-month outcomes through the simultaneous combination of kinesiophobia and self-efficacy. Results An expanded fear-avoidance model that incorporated pain resilience and self-efficacy provided a good fit to the data, Χ2 (df = 14, N = 343) = 42.09, p = .0001, RMSEA = 0.076 (90% CI: 0.05, 0.10), CFI = 0.97, SRMR = 0.03, with higher levels of pain resilience associated with improved 3-month outcomes on measures of pain intensity, physical dysfunction, and depression symptoms. Conclusions This study supports the notion that the predictive power of the fear-avoidance model of pain is enhanced when individual differences in both pain-related vulnerability (e.g., catastrophizing) and pain-related protective resources (e.g., resilience) are considered.

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Dover, Geoffrey, and Vanessa Amar. "Development and Validation of the Athlete Fear Avoidance Questionnaire." Journal of Athletic Training 50, no. 6 (June 1, 2015): 634–42. http://dx.doi.org/10.4085/1062-6050-49.3.75.

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Context The fear-avoidance model was developed in an attempt to explain the process by which “pain experience” and “pain behavior” become dissociated from the actual pain sensation in individuals who manifest the phenomenon of exaggerated pain perception. High levels of fear avoidance can lead to chronic pain and disability and have successfully predicted rehabilitation time in the work-related–injury population. Existing fear-avoidance questionnaires have all been developed for the general population, but these questionnaires may not be specific enough to fully assess fear avoidance in an athletic population that copes with pain differently than the general population. Objective To develop and validate the Athlete Fear Avoidance Questionnaire (AFAQ). Design Qualitative research to develop the AFAQ and a cross-sectional study to validate the scale. Patients or Other Participants For questionnaire development, a total of 8 experts in the fields of athletic therapy, sport psychology, and fear avoidance were called upon to generate and rate items for the AFAQ. For determining concurrent validity, 99 varsity athletes from various sports participated. Data Collection and Analysis A total of 99 varsity athletes completed the AFAQ, the Fear-Avoidance Beliefs Questionnaire, and the Pain Catastrophizing Scale. We used Pearson correlations to establish concurrent validity. Results Concurrent validity was established with significant correlations between the AFAQ and the Fear Avoidance Beliefs Questionnaire-Physical Activity (r = 0.352, P > .001) as well as with the Pain Catastrophizing Scale (r = 0.587, P > .001). High internal consistency of our questionnaire was established with a Cronbach α coefficient of 0.805. The final version of the questionnaire includes 10 items with good internal validity (P < .05). Conclusions We developed a questionnaire with good internal and external validity. The AFAQ is a scale that measures sport-injury–related fear avoidance in athletes and could be used to identify potential psychological barriers to rehabilitation.

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Vangronsveld, Karoline, Madelon Peters, Mariëlle Goossens, Steven Linton, and Johan Vlaeyen. "Applying the fear-avoidance model to the chronic whiplash syndrome." Pain 131, no. 3 (October 2007): 258–61. http://dx.doi.org/10.1016/j.pain.2007.04.015.

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Vlaeyen, Johan W. S., and Steven J. Linton. "Fear-avoidance model of chronic musculoskeletal pain: 12 years on." Pain 153, no. 6 (June 2012): 1144–47. http://dx.doi.org/10.1016/j.pain.2011.12.009.

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Frank, Guido K. W. "From Desire to Dread—A Neurocircuitry Based Model for Food Avoidance in Anorexia Nervosa." Journal of Clinical Medicine 10, no. 11 (May 21, 2021): 2228. http://dx.doi.org/10.3390/jcm10112228.

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Anorexia nervosa is a severe psychiatric illness associated with food avoidance. Animal models from Berridge et al. over the past decade showed that environmental ambience, pleasant or fear inducing, can trigger either appetitive (desire) or avoidance (dread) behaviors in animals via frontal cortex, nucleus accumbens dopamine D1 and D2 receptors, and hypothalamus. Those mechanisms could be relevant for understanding anorexia nervosa. However, models that translate animal research to explain the psychopathology of anorexia nervosa are sparse. This article reviews animal and human research to find evidence for whether this model can explain food avoidance behaviors in anorexia nervosa. Research on anorexia nervosa suggests fear conditioning to food, activation of the corticostriatal brain circuitry, sensitization of ventral striatal dopamine response, and alterations in hypothalamic function. The results support the applicability of the animal neurocircuitry derived model and provide directions to further study the pathophysiology that underlies anorexia nervosa.

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HAYWARD, C., J. D. KILLEN, and C. B. TAYLOR. "The relationship between agoraphobia symptoms and panic disorder in a non-clinical sample of adolescents." Psychological Medicine 33, no. 4 (May 2003): 733–38. http://dx.doi.org/10.1017/s0033291702006955.

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Background. The purpose of this study was to evaluate the clinical correlates of agoraphobic fear and avoidance and panic disorder in a non-clinical sample of adolescents.Method. In a sample of 2365 high school students, combined data from a questionnaire and a structured clinical interview were used to classify subjects with agoraphobic fear and avoidance. Panic symptoms, major depression, childhood separation anxiety disorder, anxiety sensitivity and negative affectivity were also assessed.Results. Fifteen subjects met study criteria for agoraphobic fear and avoidance in the past year. Only three (20%) of those with agoraphobia symptoms reported histories of panic attacks and there was no overlap between those with agoraphobic fear and avoidance and the 12 subjects who met DSM-III-R criteria for panic disorder. However, subjects with agoraphobia symptoms and those with panic disorder reported similar levels of anxiety sensitivity and negative affectivity. Childhood separation anxiety disorder was more common among those with agoraphobic fear and avoidance compared to those without.Conclusion. Agoraphobic avoidance is rare in non-clinical samples of adolescents and usually not associated with panic attacks. However, adolescents with agoraphobia symptoms and those with panic disorder have similar clinical correlates consistent with a panic/agoraphobia spectrum model.

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Curtin, Katherine B., and Deborah Norris. "The relationship between chronic musculoskeletal pain, anxiety and mindfulness: Adjustments to the Fear-Avoidance Model of Chronic Pain." Scandinavian Journal of Pain 17, no. 1 (October 1, 2017): 156–66. http://dx.doi.org/10.1016/j.sjpain.2017.08.006.

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AbstractBackground and purposeThe 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.MethodsMiddle-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.ResultsRuminative 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.ConclusionsThe 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.ImplicationsIt 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.

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Norberg, M. "POS1273 A CHANGE IN A REHABILITATION MODEL INCREASES WORK CAPACITY AT 36 MONTHS IN LOW BACK PAIN." Annals of the Rheumatic Diseases 80, Suppl 1 (May 19, 2021): 921.1–921. http://dx.doi.org/10.1136/annrheumdis-2021-eular.1816.

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Background:In chronic low back pain, the most expensive patients are them with long-standing sick-leave of more than 6 months. Several studies have showed the importance of rehabilitation models working with kinesiophobia (fear of movement). One possibility of treating chronic low back pain is a multidisciplinary rehabilitation program.Objectives:The aim of this study was to analyze the impact of a change in a rehabilitation program for chronic lumbar pain by introducing a progressive exposure procedure to decrease apprehension associated with low back pain. We studied its impact on work capacity after 3 years, compared to our classic program.Methods:We have compared the results of 1004 of our patients that have accomplished a multi-disciplinary program and that have been followed over 12 months. They were divided in two groups: one before the implantation of PHODA (PHOto of Daily Activity: photos showing activites) associated with occupational training and work exposure. Then a second one including 200 patients that followed the new program. The program contained physical training, occupational tasks developed on the basis of the apprehension following a cogntivo-comportemental approach.We have analyzed the evolution of apprehension according to different questionnaires (FABQ, Tampa scale (TSK) and PACT (evaluating the subjective work capacity)), the Phoda results and the official work capacity at beginning of the program and after 36 months.Results:We saw a clear increase in the global work capacity at 12 months after completing the program: passing from 40 to 79% (p < 0.01) in the old program comparing to the new one with an increase of 86% (p< 0.01). These results were confirmed at 36 months, with stabilized results. In parallel there was an increase in the subjective sensation of physical capacity (Pact), but less in the new program. This increase was correlated with a decrease in fear-avoidance according to the Fabq, and in the TSKConclusion:In chronic low back, a multidisciplinary rehabilitation program, gives a global work capacity of 79%. This capacity could be increased on focalising on patient’s apprehensions with gradual exposure according the fear-avoidance model developed by Waddell and explored by Vlayen. The correlation were confirmed on the psychological part, with less apprehension and less anxiety.Finally, the SF 36 showed an increase in body confidence as an important factor in these functional restoration programs.References:[1]Waddell G et al. Low back pain, fear-avoidance beliefs and disability: With the development of a Fear-Avoidance Beliefs (FAB) questionnaire. Pain 1993;52:157-68[2]Vlaeyen JWS et al. Graded exposure in vivo in the treatment of pain-related fear: a replicated single-case experimental design in four patients with chronic low back pain. Behaviour Res Therapy 2001;39(2):151–66[3]Waddell G et al. Low back pain, fear-avoidance beliefs and disability: With the development of a Fear-Avoidance Beliefs (FAB) questionnaire. Pain 1993;52:157-68[4]Vlaeyen JWS et al. Graded exposure in vivo in the treatment of pain-related fear: a replicated single-case experimental design in four patients with chronic low back pain. Behaviour Res Therapy 2001;39(2):151–66Disclosure of Interests:None declared

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Wideman, Timothy H., Heather Adams, and Michael J. L. Sullivan. "A prospective sequential analysis of the fear-avoidance model of pain." Pain 145, no. 1 (September 2009): 45–51. http://dx.doi.org/10.1016/j.pain.2009.04.022.

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Simons, Laura E., and Karen J. Kaczynski. "The Fear Avoidance Model of Chronic Pain: Examination for Pediatric Application." Journal of Pain 13, no. 9 (September 2012): 827–35. http://dx.doi.org/10.1016/j.jpain.2012.05.002.

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Tüscher, Johanne, Cyrille Burrus, Philippe Vuistiner, Bertrand Léger, Gilles Rivier, and François Luthi. "Predictive Value of the Fear-Avoidance Model on Functional Capacity Evaluation." Journal of Occupational Rehabilitation 28, no. 3 (November 1, 2017): 513–22. http://dx.doi.org/10.1007/s10926-017-9737-7.

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Lundberg, M., A. Grimby-Ekman, J. Verbunt, and M. J. Simmonds. "Pain-Related Fear: A Critical Review of the Related Measures." Pain Research and Treatment 2011 (November 15, 2011): 1–26. http://dx.doi.org/10.1155/2011/494196.

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Objectives: In regards to pain-related fear, this study aimed to: (1) identify existing measures and review their measurement properties, and (2) identify the optimum measure for specific constructs of fear-avoidance, pain-related fear, fear of movement, and kinesiophobia. Design: Systematic literature search for instruments designed to measure fear of pain in patients with persistent musculoskeletal pain. Psychometric properties were evaluated by adjusted Wind criteria. Results: Five questionnaires (Fear-Avoidance Beliefs Questionnaire (FABQ), Fear-Avoidance of Pain Scale (FAPS), Fear of Pain Questionnaire (FPQ), Pain and Anxiety Symptoms Scale (PASS), and the Tampa Scale for Kinesiophobia (TSK)) were included in the review. The main findings were that for most questionnaires, there was no underlying conceptual model to support the questionnaire's construct. Psychometric properties were evaluated by diverse methods, which complicated comparisons of different versions of the same questionnaires. Construct validity and responsiveness was generally not supported and/or untested. Conclusion: The weak construct validity implies that no measure can currently identify who is fearful. The lack of evidence for responsiveness restricts the current use of the instruments to identify clinically relevant change from treatment. Finally, more theoretically driven research is needed to support the construct and thus the measurement of pain-related fear.

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Sindhu, Bhagwant S., Leigh A. Lehman, Sergey Tarima, Mark D. Bishop, Dennis L. Hart, Matthew R. Klein, Mikesh Shivakoti, and Ying-Chih Wang. "Influence of Fear-Avoidance Beliefs on Functional Status Outcomes for People With Musculoskeletal Conditions of the Shoulder." Physical Therapy 92, no. 8 (May 24, 2012): 992–1005. http://dx.doi.org/10.2522/ptj.20110309.

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Background The influence of elevated fear-avoidance beliefs on change in functional status is unclear. Objective The purpose of this study was to determine the influence of fear-avoidance on recovery of functional status during rehabilitation for people with shoulder impairments. Design A retrospective longitudinal cohort study was conducted. Methods Data were collected from 3,362 people with musculoskeletal conditions of the shoulder receiving rehabilitation. At intake and discharge, upper-extremity function was measured using the shoulder Computerized Adaptive Test. Pain intensity was measured using an 11-point numerical rating scale. Completion rate at discharge was 57% for function and 47% for pain intensity. A single-item screen was used to classify patients into groups with low versus elevated fear-avoidance beliefs at intake. A general linear model (GLM) was used to describe how change in function is affected by fear avoidance in 8 disease categories. This study also accounted for within-clinic correlation and controlled for other important predictors of functional change in functional status, including various demographic and health-related variables. The parameters of the GLM and their standard errors were estimated with the weighted generalized estimating equations method. Results Functional change was predicted by the interaction between fear and disease categories. On further examination of 8 disease categories using GLM adjusted for other confounders, improvement in function was greater for the low fear group than for the elevated fear group among people with muscle, tendon, and soft tissue disorders (Δ=1.37, P<.01) and those with osteopathies, chondropathies, and acquired musculoskeletal deformities (Δ=5.52, P<.02). These differences were below the minimal detectable change. Limitations Information was not available on whether therapists used information on level of fear to implement treatment plans. Conclusions The influence of fear-avoidance beliefs on change in functional status varies among specific shoulder impairments.

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Held, Sabine Melanie, Roman Rolke, Rolf-Detlef Treede, Kirsten Schmieder, Zohra Karimi, Sigrid Christa Sudhaus, and Monika Ilona Hasenbring. "Pain-Related Endurance, Fear-Avoidance and Somatosensory Sensitivity as Correlates of Clinical Status after Lumbar Disc Surgery." Open Pain Journal 6, no. 1 (May 30, 2013): 165–75. http://dx.doi.org/10.2174/1876386301306010165.

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Most pain and disability variance in patients with low back pain still remains unexplained. The aim of this study was to enhance the degree of explained variance by including measures of pain and tactile sensitivity as well as pain-related endurance and fear-avoidance responses. Thirty-six post lumbar disc surgery patients completed psychometric questionnaires (Avoidance-Endurance Questionnaire, Fear-Avoidance Beliefs Questionnaire, Beck Depression Inventory) and underwent quantitative sensory testing (QST) with measures of pain (pressure (PPT) and mechanical pain threshold) and tactile sensitivity (MDT). Bivariate correlations and hierarchical multiple regression analysis were computed. In addition to the contribution of fear-avoidance responses, pressure pain sensitivity and endurance behavior significantly contributed to explanations of pain variance, whereas disability was primarily predicted by fear-avoidance. While all psychological variables and MDT were positively related to pain or disability, PPT was negatively related to pain. The regression model accounted for 69 % of the variance in back pain intensity and 68 % of the variance in disability. Tactile hypaesthesia was related to increased clinical pain. Pain-related endurance responses and pressure pain hyperalgesia were significant additional predictors for pain, but not for disability. These findings are compatible with generalized disinhibition via descending pathways and a general inhibition of tactile acuity by ongoing pain.

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Jay, Kenneth, Sannie Vester Thorsen, Emil Sundstrup, Ramon Aiguadé, Jose Casaña, Joaquin Calatayud, and Lars Louis Andersen. "Fear Avoidance Beliefs and Risk of Long-Term Sickness Absence: Prospective Cohort Study among Workers with Musculoskeletal Pain." Pain Research and Treatment 2018 (September 2, 2018): 1–6. http://dx.doi.org/10.1155/2018/8347120.

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Background and Objective. Musculoskeletal pain is common in the population. Negative beliefs about musculoskeletal pain and physical activity may lead to avoidance behavior resulting in absence from work. The present study investigates the influence of fear avoidance beliefs on long-term sickness absence. Methods. Workers of the general working population with musculoskeletal pain (low back, neck/shoulder, and/or arm/hand pain; n = 8319) from the Danish Work Environment Cohort Study were included. Long-term sickness absence data were obtained from the Danish Register for Evaluation and Marginalization (DREAM). Time-to-event analyses (cox regression) controlled for various confounders estimated the association between fear avoidance beliefs (very low, low, moderate [reference category], high, and very high) at baseline and long-term sickness absence (LTSA; ≥6 consecutive weeks) during a 2-year follow-up. Results. During the 2-year follow-up, 10.2% of the workers experienced long-term sickness absence. In the fully adjusted model, very high-level fear avoidance increased the risk of LTSA with hazard ratio (HR) of 1.48 (95% CI 1.15-1.90). Similar results were seen analyses stratified for occupational physical activity, i.e., sedentary workers (HR 1.72 (95% CI 1.04-2.83)) and physically active workers (HR 1.48 (95% CI 1.10-2.01)). Conclusion. A very high level of fear avoidance is a risk factor for long-term sickness absence among workers with musculoskeletal pain regardless of the level of occupational physical activity. Future interventions should target fear avoidance beliefs through information and campaigns about the benefits of staying active when having musculoskeletal pain.

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Ostelo, Raymond W. J. G., and Johan W. S. Vlaeyen. "Attitudes and beliefs of health care providers: Extending the fear-avoidance model." Pain 135, no. 1 (March 2008): 3–4. http://dx.doi.org/10.1016/j.pain.2007.12.003.

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Wijenberg, Melloney L. M., Sven Z. Stapert, Jeanine A. Verbunt, Jennie L. Ponsford, and Caroline M. Van Heugten. "Does the fear avoidance model explain persistent symptoms after traumatic brain injury?" Brain Injury 31, no. 12 (October 5, 2017): 1597–604. http://dx.doi.org/10.1080/02699052.2017.1366551.

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Gay, C. W., M. E. Horn, M. D. Bishop, M. E. Robinson, and J. E. Bialosky. "Investigating dynamic pain sensitivity in the context of the fear-avoidance model." European Journal of Pain 19, no. 1 (May 30, 2014): 48–58. http://dx.doi.org/10.1002/ejp.519.

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Rose, Michael J., Leslie Klenerman, Lesley Atchison, and Peter D. Slade. "An application of the fear avoidance model to three chronic pain problems." Behaviour Research and Therapy 30, no. 4 (July 1992): 359–65. http://dx.doi.org/10.1016/0005-7967(92)90047-k.

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Leeuw, Maaike, Mariëlle E. J. B. Goossens, Steven J. Linton, Geert Crombez, Katja Boersma, and Johan W. S. Vlaeyen. "The Fear-Avoidance Model of Musculoskeletal Pain: Current State of Scientific Evidence." Journal of Behavioral Medicine 30, no. 1 (December 20, 2006): 77–94. http://dx.doi.org/10.1007/s10865-006-9085-0.

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Hart, Dennis L., Mark W. Werneke, Steven Z. George, James W. Matheson, Ying-Chih Wang, Karon F. Cook, Jerome E. Mioduski, and Seung W. Choi. "Screening for Elevated Levels of Fear-Avoidance Beliefs Regarding Work or Physical Activities in People Receiving Outpatient Therapy." Physical Therapy 89, no. 8 (August 1, 2009): 770–85. http://dx.doi.org/10.2522/ptj.20080227.

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BackgroundScreening people for elevated levels of fear-avoidance beliefs is uncommon, but elevated levels of fear could worsen outcomes. Developing short screening tools might reduce the data collection burden and facilitate screening, which could prompt further testing or management strategy modifications to improve outcomes.ObjectiveThe purpose of this study was to develop efficient yet accurate screening methods for identifying elevated levels of fear-avoidance beliefs regarding work or physical activities in people receiving outpatient rehabilitation.DesignA secondary analysis of data collected prospectively from people with a variety of common neuromusculoskeletal diagnoses was conducted.MethodsIntake Fear-Avoidance Beliefs Questionnaire (FABQ) data were collected from 17,804 people who had common neuromusculoskeletal conditions and were receiving outpatient rehabilitation in 121 clinics in 26 states (in the United States). Item response theory (IRT) methods were used to analyze the FABQ data, with particular emphasis on differential item functioning among clinically logical groups of subjects, and to identify screening items. The accuracy of screening items for identifying subjects with elevated levels of fear was assessed with receiver operating characteristic analyses.ResultsThree items for fear of physical activities and 10 items for fear of work activities represented unidimensional scales with adequate IRT model fit. Differential item functioning was negligible for variables known to affect functional status outcomes: sex, age, symptom acuity, surgical history, pain intensity, condition severity, and impairment. Items that provided maximum information at the median for the FABQ scales were selected as screening items to dichotomize subjects by high versus low levels of fear. The accuracy of the screening items was supported for both scales.LimitationsThis study represents a retrospective analysis, which should be replicated using prospective designs. Future prospective studies should assess the reliability and validity of using one FABQ item to screen people for high levels of fear-avoidance beliefs.ConclusionsThe lack of differential item functioning in the FABQ scales in the sample tested in this study suggested that FABQ screening could be useful in routine clinical practice and allowed the development of single-item screening for fear-avoidance beliefs that accurately identified subjects with elevated levels of fear. Because screening was accurate and efficient, single IRT-based FABQ screening items are recommended to facilitate improved evaluation and care of heterogeneous populations of people receiving outpatient rehabilitation.

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Dewey, Daniel, David Schuldberg, and Renee Madathil. "Do Peritraumatic Emotions Differentially Predict PTSD Symptom Clusters? Initial Evidence for Emotion Specificity." Psychological Reports 115, no. 1 (August 2014): 1–12. http://dx.doi.org/10.2466/16.02.pr0.115c11z7.

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This study investigated whether specific peritraumatic emotions differentially predict PTSD symptom clusters in individuals who have experienced stressful life events. Hypotheses were developed based on the SPAARS model of PTSD. It was predicted that the peritraumatic emotions of anger, disgust, guilt, and fear would significantly predict re-experiencing and avoidance symptoms, while only fear would predict hyperarousal. Undergraduate students ( N = 144) participated in this study by completing a packet of self-report questionnaires. Multiple regression analyses were conducted with PCL-S symptom cluster scores as dependent variables and peritraumatic fear, guilt, anger, shame, and disgust as predictor variables. As hypothesized, peritraumatic anger, guilt, and fear all significantly predicted re-experiencing. However, only fear predicted avoidance, and anger significantly predicted hyperarousal. Results are discussed in relation to the theoretical role of emotions in the etiology of PTSD following the experience of a stressful life event.

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Martin, Ronald R., Thomas Hadjistavropoulos, and Donald R. McCreary. "Fear of Pain and Fear of Falling among Younger and Older Adults with Musculoskeletal Pain Conditions." Pain Research and Management 10, no. 4 (2005): 211–18. http://dx.doi.org/10.1155/2005/919865.

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BACKGROUND: The fear-avoidance model of pain accounts for the debilitating consequences of strong fear as a component of reactions to painful conditions (eg, movements become anxiety-provoking because they cause pain). The model, which is supported in the literature, posits that fear of pain interferes with recovery because it leads to avoidance of beneficial activity. Despite the high prevalence of pain among the elderly, investigations of fear of pain in this population are scarce. A related construct, fear of falling, has been studied among elderly (but not younger) adults as an age-specific concern.OBJECTIVES: To examine the relationship between fear of pain and fear of falling. Specifically, it is hypothesized that fear of pain and fear of falling are distinct constructs. Moreover, the authors investigated whether fear of falling becomes more relevant with increasing age in a sample of seniors and younger adults with musculoskeletal conditions.METHODS: A convenience sample of younger and older adult physiotherapy outpatients (n=226) receiving treatment for musculoskeletal conditions were recruited for the study. Fear of pain and fear of falling were assessed using self-report measures.RESULTS: There were no age differences with respect to fear of pain and fear of falling. Regression analyses showed that fear of pain measures contribute substantial unique variance to the prediction of each other; however, they only make minor unique contributions to the prediction of fear of falling. Similar results were obtained through confirmatory analyses using structural modelling techniques.CONCLUSIONS: The analyses supported the distinctiveness of fear of pain and fear of falling. Moreover, among physiotherapy outpatients with musculoskeletal pain conditions, fear of falling and fear of pain are distinct constructs that appear to represent the concerns of both seniors and younger pain patients.

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Gheldof, Els L. M., Geert Crombez, Eva van den Bussche, Jan Vinck, An Van Nieuwenhuyse, Guido Moens, Philippe Mairiaux, and Johan W. S. Vlaeyen. "Pain-related fear predicts disability, but not pain severity: A path analytic approach of the fear-avoidance model." European Journal of Pain 14, no. 8 (September 2010): 870.e1–870.e9. http://dx.doi.org/10.1016/j.ejpain.2010.01.003.

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Peeters, Geeske, Marc Bennett, Orna A. Donoghue, Sean Kennelly, and Rose Anne Kenny. "Understanding the aetiology of fear of falling from the perspective of a fear-avoidance model – A narrative review." Clinical Psychology Review 79 (July 2020): 101862. http://dx.doi.org/10.1016/j.cpr.2020.101862.

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Thomtén, Johanna, and Steven J. Linton. "A Psychological View of Sexual Pain among Women: Applying the Fear-Avoidance Model." Women's Health 9, no. 3 (May 2013): 251–63. http://dx.doi.org/10.2217/whe.13.19.

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Schütze, Robert, Clare Rees, Minette Preece, and Mark Schütze. "Low mindfulness predicts pain catastrophizing in a fear-avoidance model of chronic pain." Pain 148, no. 1 (January 2010): 120–27. http://dx.doi.org/10.1016/j.pain.2009.10.030.

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Wideman, Timothy H., Gordon G. J. Asmundson, Rob J. E. M. Smeets, Alex J. Zautra, Maureen J. Simmonds, Michael J. L. Sullivan, Jennifer A. Haythornthwaite, and Robert R. Edwards. "Rethinking the fear avoidance model: Toward a multidimensional framework of pain-related disability." Pain 154, no. 11 (November 2013): 2262–65. http://dx.doi.org/10.1016/j.pain.2013.06.005.

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Morgounovski, Johanna, Philippe Vuistiner, Bertrand Léger, and François Luthi. "The fear–avoidance model to predict return to work after an orthopedic trauma." Annals of Physical and Rehabilitation Medicine 59 (September 2016): e110-e111. http://dx.doi.org/10.1016/j.rehab.2016.07.246.

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Wideman, T. "Rethinking the fear avoidance model of pain: an empirical and theory-based evaluation." Journal of Pain 14, no. 4 (April 2013): S24. http://dx.doi.org/10.1016/j.jpain.2013.01.762.

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Wijenberg, Melloney L. M., Amelia J. Hicks, Marina G. Downing, Caroline M. van Heugten, Sven Z. Stapert, and Jennie L. Ponsford. "Relevance of the Fear-Avoidance Model for Chronic Disability after Traumatic Brain Injury." Journal of Neurotrauma 37, no. 24 (December 15, 2020): 2639–46. http://dx.doi.org/10.1089/neu.2020.7135.

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