Self-Efficacy,Pain-Related Fear,and Disability in a Heterogeneous Pain Sample

The fear avoidance model of chronic pain is well established for specific chronic pain groups and of considerable clinical utility, but it suffers from poor generalizability. Therefore, in this study we examined the role of self-efficacy (SE) in the relationship between pain-related fear (PRF) and three pain-related outcomes—pain severity, disability, and depression—in a more heterogeneous chronic pain sample. Sixty-eight participants between the ages of 18 and 75 years experiencing chronic pain were recruited from the general public. Participants completed a questionnaire that measured catastrophizing, SE, fear of movement, avoidance behavior, PRF, pain severity, disability, and depression. In support of our first hypotheses, higher SE was associated with: 1) less catastrophizing, fear of movement, avoidance of pain, and PRF; and 2) less pain severity, disability, and depression. And higher catastrophizing, fear of movement, avoidance of pain, and PRF were associated with higher pain severity, disability, and depression. Although complete mediation was not found, post hoc examination of partial correlations revealed that the relationship between PRF and disability was partially mediated by SE; however, SE had no mediatory effect on the relationship between PRF and either pain severity or depression. Within the constraints of a relatively small sample size, we concluded that within a heterogeneous pain population, PRF remains the most integral component of the fear avoidance model.     

Self-efficacy mediates the relation between pain-related fear and outcome in chronic low back pain patients.

This study aimed to determine whether self-efficacy beliefs mediated the relation between pain-related fear and pain, and between pain-related fear and disability in CLBP patients who exhibited high pain-related fear. In a cross-sectional design, 102 chronic low back pain (CLBP) patients completed measures for pain, disability, self-efficacy and pain-related fear (fear of movement and catastrophizing). Multistep regression analyses were performed to determine whether self-efficacy mediated the relation between pain-related fear and outcome (pain and/or disability). Self-efficacy was found to mediate the relation between pain-related fear and pain intensity, and between pain-related fear and disability. Therefore, this study suggests that when self-efficacy is high, elevated pain-related fear might not lead to greater pain and disability. However, in instances where self-efficacy is low, elevated pain-related fear is likely to lead to greater pain and disability. In view of these findings, we conclude that it is imperative to assess both pain-related fear and self-efficacy when treating CLBP patients with high pain-related fear.     

Self-efficacy, fear avoidance, and pain intensity as predictors of disability in subacute and chronic musculoskeletal pain patients in primary health care

This study examined the relations between disability, as measured by the Pain Disability Index (PDI) and self-efficacy, fear avoidance variables (kinesiophobia and catastrophizing), and pain intensity, using a prospective design. Two primary health care samples (n(1)=210; n(2)=161) of patients with subacute, chronic or recurring musculoskeletal pain completed sets of questionnaires at the beginning of a physiotherapy treatment period. Multiple hierarchial regression analyses showed that self-efficacy explained a considerably larger proportion of the variance in disability scores than the fear avoidance variables in the first sample. This finding was replicated in the second sample. Pain intensity explained a small, but significant proportion of the variance in disability scores in one sample only. Gender, age, and pain duration were not related to disability. These findings suggest that self-efficacy beliefs are more important determinants of disability than fear avoidance beliefs in primary health care patients with musculoskeletal pain. The findings also suggest that pain-related beliefs, such as self-efficacy and fear avoidance, in turn, are more important determinants of disability than pain intensity and pain duration in these patients.     

Musculoskeletal pain in primary health care: subgroups based on pain intensity, disability, self-efficacy, and fear-avoidance variables.

The purpose of this study was to identify and describe subgroup profiles based on self-reported pain intensity, disability, self-efficacy, fear of movement/(re)injury, and catastrophizing in patients with musculoskeletal pain. Two primary health care samples (n = 215 and n = 161) were used. Self-report questionnaires were completed at the start of physical therapy treatment. Cluster analysis was used to generate subgroups. Three subgroups were identified in sample 1 and replicated in sample 2. These were labeled "High self-efficacy-Low fear-avoidance," "Low self-efficacy-Low fear-avoidance," and "Low self-efficacy-High fear-avoidance." The subgroups differed significantly in work-status in both samples (P < .001), but not in age, gender, or duration of pain. The results show the presence of subgroups based on pain intensity, disability, self-efficacy, fear of movement/(re)injury, and catastrophizing. The profile patterns suggest that different management strategies may be relevant in each subgroup. PERSPECTIVE: This article presents subgroups of patients with musculoskeletal pain with different profiles in pain intensity, disability, and psychosocial variables possible to modify by physical therapy management. The results could potentially aid clinicians in tailoring assessment and treatment approaches to each subgroup.     

A prospective sequential analysis of the fear-avoidance model of pain

The primary purpose of this study was to analyze the sequential relationships proposed by the fear-avoidance model of pain [Vlaeyen JWS et al. The role of fear of movement/(re)injury in pain disability. J Occup Rehab 1995;5:235–52]. Specifically, this study evaluated whether early change in catastrophizing predicted late change in fear of movement, and whether these factors influenced post-treatment return-to-work. Secondary analyses tested relationships between (1) early change in catastrophizing, late change in depression, and disability; and (2) early change in catastrophizing, late change in pain severity, and disability. Analyses were conducted on a sample of 121 individuals (82 men and 32 women) with a work-related musculoskeletal injury, and high baseline catastrophizing and fear of movement scores. Participants were enrolled in a 10-week community-based disability management intervention, and they completed measures of catastrophizing, fear of movement, depression and pain severity at pre-, mid- and post-treatment. Return-to-work was assessed 4 weeks following termination of the intervention. Contrary to predictions, results from correlational analyses revealed non-significant relationships among indices of early change in catastrophizing and late changes in fear of movement, depression and pain severity. Multiple logistic regression analyses revealed that early change in catastrophizing, late changes in fear of movement and late change in pain severity were significant predictors of return-to-work, while late changes in depression were not. These findings highlight the importance of reductions in psychosocial risk factors in augmenting return-to-work outcomes. Implications for the fear-avoidance model and future research are discussed.     

The influence of fear of movement and pain catastrophizing on daily pain and disability in individuals with acute whiplash injury: a daily diary study

Previous research supports the fear-avoidance model in explaining the transition from acute to chronic non-specific musculoskeletal pain. However, there is still little knowledge on when this vicious circle of pain, disability, pain catastrophizing and fear of movement starts. We performed a daily diary study in 42 patients with acute whiplash injury. Pain, disability, pain catastrophizing and fear of movement were measured on a daily basis with paper diaries for 21 consecutive days. Most participants showed a decline in pain and disability from day 1 to day 21 and this was paralleled by a decline in the fear of movement and pain catastrophizing. Multilevel analyses showed that both between and within persons, high levels of pain catastrophizing and fear of movement are associated with more pain and disability. Moreover, the fear of movement was also predictive of pain and disability on the following day. We also examined the reverse association, that is, whether the changes in pain predict changes in the next day's fear of movement and pain catastrophizing. Although for the fear of movement the model reached significance, the amount of explained variance was negligible. In conclusion, this study provides evidence that already in the early stages of whiplash-related complaints, significant associations between fear of movement and pain intensity and disability occur, and that this association may be predictive of the persistence of pain.     

The Interplay of Pain-Related Self-Efficacy and Fear on Functional Outcomes Among Youth With Headache

Pain-related self-efficacy and pain-related fear have been proposed as opposing predictors of pain-related functional outcomes in youth with chronic pain. Self-efficacy is a potential resiliency factor that can mitigate the influence that pain-related fear has on outcomes in youth with chronic pain. Drawing from theoretical assertions tested among adults with chronic pain, this study aimed to determine whether pain-related self-efficacy mediates the adverse influence of pain-related fear on functional outcomes in a sample of youth with chronic headache. In a cross-sectional design of 199 youth with headache, self-efficacy was strongly associated with fear, disability, school impairment, and depressive symptoms. Pain intensity and self-efficacy were only modestly related, indicating that level of pain has less influence on one's confidence functioning with pain. Self-efficacy partially mediated relationships between pain-related fear and both functional disability and school functioning but did not mediate the relationship between pain-related fear and depressive symptoms. These results suggest that confidence in the ability to function despite pain and fear avoidance each uniquely contributes to pain-related outcomes in youth with chronic headache. These results further suggest that treatment for chronic headache in youth must focus not only on decreasing pain-related fear but also on enhancing a patient's pain-related self-efficacy.PerspectivePain-related self-efficacy is an important resiliency factor impacting the influence of pain-related fear on functional disability and school functioning in youth with headache. Enhancing self-efficacy may be a key mechanism for improving behavioral outcomes. Clinicians can reduce pain-related fear and enhance pain-related self-efficacy through interventions that encourage accomplishment and self-confidence.     

Acute low back pain: pain-related fear and pain catastrophizing influence physical performance and perceived disability

Pain-related fear and pain catastrophizing are associated with disability and actual performance in chronic pain patients. In acute low back pain (LBP), little is known about the prediction of actual performance or perceived disability by pain-related fear and pain catastrophizing. This experimental, cross-sectional study aimed at examining whether pain-related fear and pain catastrophizing were associated with actual performance and perceived disability. Ninety six individuals with an episode of acute LBP performed a dynamic lifting task to measure actual performance. Total lifting time was used as outcome measure. The results show that pain-related fear, as measured with the Tampa Scale for Kinesiophobia, was the strongest predictor of this physical task. Using the Roland Disability Questionnaire as a measure of perceived disability, both pain-related fear and pain catastrophizing, as measured with the Pain Catastrophizing Scale, were significantly predictive of perceived disability and more strongly than pain intensity was. The results of the current study suggest that pain-related fear is an important factor influencing daily activities in individuals suffering an episode of acute LBP. The study results have important clinical implications, especially in the development of preventive strategies for chronic LBP.     

The role of perceived injustice in the prediction of pain and function after total knee arthroplasty

Emerging evidence suggests that the appraisal of pain and disability in terms of justice-related themes contributes to adverse pain outcomes. To date, however, research on the relation between perceived injustice and pain outcomes has focused primarily on individuals with musculoskeletal injuries. The primary aim of this study was to investigate the role of perceived injustice in the prediction of pain and disability after total knee arthroplasty (TKA). The study sample consisted of 116 individuals (71 women, 45 men) with osteoarthritis of the knee scheduled for TKA. Participants completed measures of pain severity, physical disability, perceptions of injustice, pain catastrophizing, and fear of movement before surgery, and measures of pain and disability 1 year after surgery. Prospective multivariate analyses revealed that perceived injustice contributed modest but significant unique variance to the prediction of postsurgical pain severity, beyond the variance accounted for by demographic variables, comorbid health conditions, presurgical pain severity, pain catastrophizing, and fear of movement. Pain catastrophizing contributed significant unique variance to the prediction of postsurgical disability. The current findings add to a growing body of evidence supporting the prognostic value of perceived injustice in the prediction of adverse pain outcomes. The results suggest that psychosocial interventions designed to target perceptions of injustice and pain catastrophizing before surgery might contribute to more positive recovery trajectories after TKA.     

Psychologic Influence on Experimental Pain Sensitivity and Clinical Pain Intensity for Patients with Shoulder Pain

Pain-related fear and pain catastrophizing are 2 central psychologic factors in fear-avoidance models. Our previous studies in healthy subjects indicated that pain-related fear, but not pain catastrophizing, was associated with cold pressor pain outcomes. The current study extends previous work by investigating pain-related fear and pain catastrophizing in a group of subjects with shoulder pain, and included concurrent measures of experimental and clinical pain. Fifty nine consecutive subjects seeking operative treatment of shoulder pain were enrolled in this study (24 women, mean age = 50.4, SD = 14.9). Subjects completed validated measures of pain-related fear, pain catastrophizing, and clinical pain intensity and then underwent a cold pressor task to determine experimental pain sensitivity. Multivariate regression models used sex, age, pain-related fear, and pain catastrophizing to predict experimental pain sensitivity and clinical pain intensity. Results indicated that only pain-related fear uniquely contributed to variance in experimental pain sensitivity (β = ?.42, P < .01). In contrast, sex (β = ?.29, P = .02) and pain catastrophizing (β = .43, P < .01) uniquely contributed to variance in clinical pain intensity. These data provide additional support for application of fear-avoidance models to subjects with shoulder pain. Our results also suggest that pain-related fear and pain catastrophizing may influence different components of the pain experience, providing preliminary support for recent theoretical conceptualizations of the role of pain catastrophizing.PerspectiveThis study provided additional information on how specific psychological variables potentially influence experimental and clinical pain. In this sample of subjects with shoulder pain, we replicated findings from our previous studies involving healthy subjects, as fear of pain was uniquely associated with experimental pain sensitivity. In contrast, pain catastrophizing emerged as the sole psychological variable related to clinical pain intensity.     

The joint contribution of physical pathology, pain-related fear and catastrophizing to chronic back pain disability

The present study examined the contribution of physical pathology, pain-related fear and catastrophizing cognitions to pain intensity and disability in 100 patients with non-specific low back pain. Self-report instruments were completed as part of the intake procedure of patients, while physical pathology was quantified from medical charts using the MEDICS procedure. Results of the multiple regression analyses, adjusted for relevant demographic variables, pain intensity and pain duration, indicated that physical pathology was associated with pain intensity, but not with self-reported physical disability. Disability showed the strongest association with pain intensity. However, pain-related fear and catastrophizing contributed 4-10% additional explained variance to the regression models for pain intensity and disability. Thus, this study confirms the relationship between biological and psychological variables in determining the severity of low back pain complaints, and underscores the necessity for a multidisciplinary approach to diagnostics and intervention.     

The Pediatric Pain Screening Tool (PPST) can Rapidly Identify Elevated Pain and Psychosocial Symptomatology in Treatment-Seeking Youth with Acute Musculoskeletal Pain

This cross-sectional study examines the utility of the Pediatric Pain Screening Tool (PPST) for rapidly assessing pain and psychosocial symptomatology in treatment-seeking youth with acute musculoskeletal pain. Participants were 166 youth (10-18 years, 53.6% female) participating in one of two larger cohort studies of youth with acute musculoskeletal pain. Youth completed the PPST and measures of pain, pain-related fear, pain catastrophizing, pain-related disability, and sleep quality. Participants were categorized into PPST risk groups using published cut-offs. ANOVA and chi-square examined associations between PPST risk groups and self-report measures; receiver operating characteristic (ROC) analyses examined associations among PPST scores and clinical reference cut-offs. The PPST classified 28.3% of youth as high, 23.5% as moderate, and 48.2% as low-risk. Females were more likely to be high-risk. ANOVAs revealed differences in clinical factors by PPST risk group particularly differences among youth labeled high versus low-risk. ROC analyses showed the PPST is effective in discriminating “cases” versus “non-cases” on pain-related disability, pain-fear and catastrophizing. Results reveal the PPST is effective for rapidly screening youth with acute pain for pain and psychosocial symptomatology. An important next step will be to examine the validity of the PPST in predicting recovery outcomes of acute pain samples.PerspectiveThis article presents the Pediatric Pain Screening Tool (PPST) as a measure for rapidly screening youth with acute pain for pain and psychosocial symptomatology. The tool categorizes youth into low, moderate or high-risk groups and discriminates among those with versus without clinically significant levels of disability, pain-related fear and catastrophizing.     

Psychological factors in chronic pelvic pain in women: relevance and application of the fear-avoidance model of pain

Chronic pelvic pain in women is a debilitating, costly condition often treated by physical therapists. The etiology of this condition is multifactorial and poorly understood, given the complex interplay of muscles, bones, and soft tissue that comprise the pelvis. There are few guidelines directing treatment interventions for this condition. In the last decade, several investigators have highlighted the role of psychological variables in conditions such as vulvodynia and painful bladder syndrome. Pain-related fear is the focus of the fear-avoidance model (FAM) of pain, which theorizes that some people are more likely to develop and maintain pain after an injury because of their emotional and behavioral responses to pain. The FAM groups people into 2 classes on the basis of how they respond to pain: people who have low fear, confront pain, and recover from injury and people who catastrophize pain-a response that leads to avoidance/escape behaviors, disuse, and disability. Given the presence of pain-related cognitions in women with chronic pelvic pain, including hypervigilance, catastrophizing, and anxiety, research directed toward the application of the FAM to guide therapeutic interventions is warranted. Isolated segments of the FAM have been studied to theorize why traditional approaches (ie, medications and surgery) may not lead to successful outcomes. However, the explicit application of the FAM to guide physical therapy interventions for women with chronic pelvic pain is not routine. Integrating the FAM might direct physical therapists' clinical decision making on the basis of the pain-related cognitions and behaviors of patients. The aims of this article are to provide information about the FAM of musculoskeletal pain and to provide evidence for the relevance of the FAM to chronic pelvic pain in women.     

Fear of Pain in the Context of Intensive Pain Rehabilitation Among Children and Adolescents With Neuropathic Pain: Associations With Treatment Response

Recent research has implicated pain-related fear in relation to functional outcomes in children with chronic pain. The current study examined fear of pain, disability, and depression within the context of an intensive pain rehabilitation program. One hundred forty-five children and adolescents who participated in an intensive interdisciplinary pediatric pain rehabilitation day program were assessed in this study. Patients completed measures of pain intensity, pain-related fears, functional disability, and depressive symptoms at admission, discharge, and on average, 2 months postdischarge. After controlling for pain intensity, pain-related fear was significantly related to disability and depressive symptoms at all time points. As predicted, a decline in pain-related fear was significantly associated with a decrease in disability and depressive symptoms. Interestingly, high levels of pain-related fears at admission predicted less reduction in functional disability and depression at discharge, suggesting that high levels of pain-related fear may be a risk factor in relation to treatment outcomes. Overall, results indicate that the relationship between fear of pain and changes in disability and depressive symptoms are closely linked, with fear of pain playing an important role in treatment.     

Fear of pain influences outcomes after exercise-induced delayed onset muscle soreness at the shoulder

OBJECTIVES: This study investigated whether anxiety, fear of pain, or pain catastrophizing were predictive of pain-related outcomes after induced delayed onset muscle soreness (DOMS) at the shoulder. METHODS: Healthy participants (19 males and 23 females) were eligible for participation if they had (a) no history of neck or shoulder pain, (b) no sensory or motor impairments of the upper-extremity, (c) not regularly participating in upper-extremity weight training, (d) not currently or regularly taking pain medication, and (e) no history of upper-extremity surgery. Participants completed self-report measures for fear of pain, pain catastrophizing, and anxiety. Then, participants underwent a standard fatigue protocol to induce DOMS in the shoulder external rotator muscles. Participants were reassessed 24 hours after DOMS induction on clinical and evoked pressure pain reports, muscle force production, self-report of upper-extremity disability, and kinesiophobia. Stepwise regression models considered sex, anxiety, pain intensity, fear of pain, and pain catastrophizing as outcome predictors. RESULTS: Fear of pain alone explained 16% (P=0.008) of the variance in clinical pain and 10% (P=0.047) evoked pressure pain intensity. Clinical pain intensity alone explained 11% (P<0.031) of the variance in muscle force production. Clinical pain intensity and fear of pain explained 50% (P<0.001) of the variance in upper-extremity disability, whereas fear of pain and sex accounted for 26% (P=0.005) of the variance in kinesiophobia. CONCLUSIONS: With the exception of muscle force production, fear of pain had a consistent influence on shoulder DOMS outcomes, even after controlling for pain intensity. This study suggests fear of pain may be a relevant psychologic factor to consider in clinical studies investigating the development and treatment of chronic shoulder pain.     

The role of presurgical expectancies in predicting pain and function one year following total knee arthroplasty

The present study examined the prospective value of response expectancies (ie, pain, sleep) and behavioral outcome expectancies (ie, return to function) in the prediction of pain severity and functional limitations 12 months after total knee arthroplasty (TKA). The study sample consisted of 120 individuals (73 women, 47 men) with osteoarthritis of the knee who were scheduled for TKA. Measures of expectancies, pain severity, pain catastrophizing, pain-related fears of movement, and depression were completed prior to surgery. Participants also completed measures of pain severity and functional limitations 12 months following surgery. Analyses revealed that behavioral outcome expectancies were stronger predictors of follow-up pain and functional limitations than response expectancies. Consistent with previous research, analyses also revealed that pain catastrophizing, pain-related fear of movement, and depression predicted follow-up pain and function. In a multivariate analysis, only pain catastrophizing contributed significant unique variance to the prediction of follow-up pain and function. Behavioral outcome expectancies partially mediated the relation between catastrophizing and follow-up pain and function. The relation between catastrophizing and follow-up pain severity and functional limitations remained significant even when controlling for behavioral outcome expectancies. The results suggest that interventions designed to specifically target behavioral outcome expectancies and catastrophizing might improve post-surgical outcomes.     

The treatment of fear of movement/(re)injury in chronic low back pain: further evidence on the effectiveness of exposure in vivo

BACKGROUND AND OBJECTIVE: Several cognitive-behavioral factors contribute to the persistence of pain disability in patients with chronic back pain. Fear-avoidance beliefs and fear of movement/(re)injury in particular have been shown to be strong predictors of physical performance and pain disability. Patients reporting substantial pain-related fear might benefit from exposure in vivo to a set of individually tailored, fear-eliciting, and hierarchically ordered physical movements rather than more general graded activity. PATIENTS AND INTERVENTIONS: Six consecutive patients with chronic low back pain who reported substantial fear of movement/(re)injury were included in the study. After a no-treatment baseline measurement period, the patients were randomly assigned to one of two interventions. In the first intervention, patients received exposure in vivo first, followed by graded activity. In the second intervention, the sequence of treatment modules was reversed. Before each treatment module, treatment credibility was assessed. Daily measures of pain-related fear, pain catastrophizing, and pain intensity were completed using visual analog scales. In addition, standardized measures of pain disability, pain-related fear, and pain vigilance were taken before and after each treatment module and at the 1-year follow-up. To obtain more objective data on actual activity levels, an ambulatory activity monitor was carried by the patients during 1 week before and after each treatment module. RESULTS: Time series analysis of the daily measures showed that improvements in pain-related fear and pain catastrophizing occurred only during the exposure in vivo and not during the graded activity, irrespective of the treatment order. Analysis of the pretreatment to post-treatment differences also revealed that decreases in pain-related fear also concurred with decreases in pain disability and pain vigilance and an increase in physical activity levels. All improvements remained at the 1-year follow-up.     

Pain catastrophizing predicts pain intensity, disability, and psychological distress independent of the level of physical impairment.

OBJECTIVE: The aim of the current study was to examine the relation between catastrophizing and pain intensity, pain-related disability, and psychological distress in a group of patients with chronic pain, controlling for the level of physical impairment. Furthermore, it was examined whether these relations are the same for three subgroups of chronic pain patients: those with chronic low back pain, those with chronic musculoskeletal pain other than low back pain, and those with miscellaneous chronic pain complaints, low back pain and musculoskeletal pain excluded. DESIGN: Correlational, cross-sectional. PATIENTS AND SETTING: Participants in this study were 211 consecutive referrals presenting to a university hospital pain management and research center, all of whom had a chronic pain problem. RESULTS: Overall, chronic pain patients who catastrophize reported more pain intensity, felt more disabled by their pain problem, and experienced more psychological distress. Regression analyses revealed that catastrophizing was a potent predictor of pain intensity, disability, and psychological distress, even when controlled for physical impairment. No fundamental differences between the three subgroups were found in this respect. Finally, it was demonstrated that there was no relation between physical impairment and catastrophizing. CONCLUSIONS: It was concluded that for different subgroups of chronic pain patients, catastrophizing plays a crucial role in the chronic pain experience, significantly contributing to the variance of pain intensity, pain-related disability, and psychological distress. These relations are not confounded by the level of physical impairment. Some clinical implications of the results are discussed. Finally, the authors concluded that these results support the validity of a cognitive-behavioral conceptualization of chronic pain-related disability.     

Reduction of pain-related fear and increased function and participation in work-related upper extremity pain (WRUEP): Effects of exposure in vivo

There is increasing evidence that pain-related fear influences the development and maintenance of pain disability, presumably mediated through the fear-related avoidance of valued activities. Individually tailored graded exposure in vivo (GEXP) has been demonstrated to reduce pain-related fear and increase functional abilities in patients with chronic low back pain, neck pain, and complex regional pain syndrome. The current study aimed to test whether these effects generalize towards patients with work-related upper extremity pain. A sequential replicated and randomized single-case experimental phase design with multiple measurements was used. Within each participant, GEXP was compared to a no-treatment baseline period and a no-treatment 6-month follow-up period. Eight patients who reported a high level of pain-related fear were included in the study. Daily changes in pain catastrophizing, pain-related fear, and pain intensity were assessed using a diary, and subjected to randomization tests. Before the start of the baseline period, just after GEXP, and at 6-month follow-up, clinically relevant changes of pain catastrophizing, pain-related fear, perceived harmfulness of physical activity, pain disability, and participation/autonomy were verified. When GEXP was introduced, levels of pain catastrophizing and pain-related fear decreased significantly. Clinically relevant improvements were observed for pain disability, perceived participation, and autonomy. These favourable changes were maintained until 6-month follow-up. The findings of the current study underscore the external validity of a cognitive-behavioural GEXP treatment for patients with chronic pain reporting increased pain-related fear.