Fear and the Role of Physical Therapy

From the Desk of Rachel Feinberg, P.T., D.P.T.


Fear and The Role of Physical Therapy

Fear of re-injury, fear of movement (kinesiophobia) and avoidance due to increased pain levels is a common barrier in returning to normal life, work or recreational activities after an injury. Research suggests that an individual's pain related fear and avoidance are important factors in determining activity level 6-12 months after an injury.

Fear, avoidance and the effect that this has on recovery continues to be widely researched. There are measures that can provide the clinician with the knowledge that fear or avoidance may be a barrier to recovery. Two of the most common measures include the Tampa Scale of Kinesiophobia (TSK) and the Fear Avoidance Beliefs Questionnaires (FABQ). Despite the ability to measure fear and avoidance, there is limited evidence-based or clinical based information that suggests how to treat this barrier from a physical therapy perspective.

With chronic pain, the patient and often the provider, do not understand the heightened pain response. The continued pain, when it is chronic, increases underlying fear and worry of continued damage or further injury that has not been identified. Driven by fear of further pain or the threat of further damage, many people with chronic pain increasingly restrict activities and begin to exhibit a maladaptive avoidance response. For patients that do have serious pathology, it can be confusing as to how to differentiate pain that could be damaging and pain that is likely not damaging. Unfortunately, this fear can be further propagated by healthcare providers as they instruct the patient to avoid painful movements or attempt to explain a patient’s diagnosis. Messages like “slipped disc”, “the spine is out of alignment” and “the back of an 80 year old” can lead the patient to higher levels of fear and disability.

When treating a person with chronic pain, the different aspects of fear and avoidance must first be determined. In many of the questionnaires and in the research, fear of re-injury, fear of increased pain level and avoidance due to other factors are grouped together, when in fact they are quite different. The clinician should spend the time to understand the concerns of the patient so that education can be directed towards addressing the aspect of fear that is limiting rehabilitation and recovery.

Treatment for over-coming fear of re-injury includes the patient understanding their diagnosis, the anatomy involved with this diagnosis, the physiology of why movement is not damaging and understanding the difference between pain and damage. This may include topics such as the role of hypersensitivity and changes in the spinal cord and brain with chronic pain.

A fear of increased pain levels with movement can be another barrier to recovery. In this case, the patient may understand that the pain is not damaging to them, but he or she does not want to suffer through high levels of pain and is fearful of being unable to control the increased pain level. Treatment focuses on education on the detrimental effects of avoidance or guarding and the importance of movement. Further treatment includes education and instruction on flare management skills such as relaxation breathing, pacing, meditation skills and appropriate activity progression. Identifying short and long term goals can be helpful in helping the patient stay focused on why they are pushing through pain. 

Another aspect of treating fear and avoidance is recognizing that mal-adaptive thinking styles can lead to higher levels of disability. Many people with chronic pain deal with anxiety, a lack of feeling in control, catastrophizing, disappointment from only being able to perform at a low physical level, and many other emotions and thinking styles. The Fear-Avoidance Model of Musculoskeletal Pain (FAM) encourages a psychological approach to deal with these thinking styles, however the physical therapist must be able to recognize if this could be contributing to a lack of progress. Most importantly, the physical therapist must be able to recognize when assisting the patient in over-coming their fear due to mal-adaptive thinking styles is out of their clinical capacity. A referral to a pain psychologist may be necessary.

Overall, with any type of fear, treatment includes education, repeated exposure to activities that have been avoided, instruction on active pain management techniques and taking an active role in recovery. The patient begins at a level of activity that is just above their comfort level and is encouraged to slowly, but consistently push that level further. The physical therapist plays a large role in this treatment plan and should work closely with the patient to provide the necessary education and guidance.