Psychological factors play an essential role in the maintenance of various chronic pain states, with fear avoidance beliefs contributing to significant functional limitation and disability in chronic spinal pain. Fear avoidance behaviors are typically managed with cognitive-behavioral interventions such as graded exposure to feared movements and graded activity programs. However, attempts to make patients with high pain-related fear perform painful actions using graded exposure therapy can be very challenging. These fear avoidance beliefs in individuals with pain are usually acquired through previous pain experiences, observation, and threating verbal input from others that movement is harmful to the spinal structures. Observational learning of fear has been recently demonstrated in several experimental studies, where participants acquired fear of pain after observing the distressed painful expressions of the volunteers performing a painful cold pressor task. The primary purpose of this paper is to propose action observation, a cognitive rehabilitation technique, as one of the treatment options for reducing fear avoidance behavior in chronic spinal pain. Action observation involves the visualization of others performing a movement or an action to influence motor behavior positively and is mainly used in stroke rehabilitation. The paper hypothesizes that the pain-related fear of movement may be reduced through observation of others performing threatening movements successfully without displaying pain or discomfort. Action observation of others successfully executing a strenuous task may break the preexisting cognitive association between movement and pain among patients with high pain-related fear. Other possible mechanisms through which observation may influence pain-related fear could be the activation of mirror neuron systems and subsequent modulation of nociceptive information through the interconnections between the amygdala (one of the brain centers for fear), descending pain modulatory system and higher cortical centers. Few initial studies that investigated the effects of action observation on other outcomes of pain, such as pain severity are described to review the hypothesis. Considering the influence of observational learning on pain-related fear, action observation may be explored as potential adjunctive treatment to reduce fear avoidance behavior in chronic spinal pain.
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