Fear is a topic that I am exploring more in both the clinical setting and the literature.

I read an extremely interesting article by Gatchel et al (2007) entitled the “The biopsychosocial approach to chronic pain: scientific advances and future directions”. They summarised some interesting research into fear:

  • Approximately two thirds of chronic nonspecific low back pain sufferers avoid back straining activities because of fear of (re)injury.
  • Pain-­related fear was the best predictor of behavioral performance in trunk-­extension, flexion, and weightlifting tasks, even after the effects of pain intensity are partialled out.
  • Fear of movement and(re)­‐injury was the best predictor of self­‐reported disability among chronic back-pain patients and that physiological sensory perception of pain and biomedical findings did not add any predictive value.
  • Pain-­related fear and concerns about harm avoidance all appear to exacerbate symptoms.

In addition to this Moons et al (2010) reported that:

  • “Baseline anger and fear were related to greater cortisol and proinflammatory cytokines. However, anger reactions to the stressor were associated with greater stress- related increases in cortisol over time but not proinflammatory cytokines. In contrast, fear reactions to the stressor were associated with increases in stress-related proinflammatory cytokines over time and a decrease in cortisol. Results are consistent with the functional perspective that distinct emotional experiences appear to trigger temporally-patterned adaptive biological processes to mobilize energy in response to anger and to promote withdrawal in response to fear”.

My conclusion from Moons et al (2010) is that Fear may also play a role in persistent pain disorders by not only creating lack of movement/avoidance behaviours, but also maintain inflammatory mediators sand hence contribute to promotion of pain mechanisms such as peripheral and central sensitisation by the presence of these mediators causing lower thresholds of activation of nociceptors.

How do we measure/assess Fear?

  • Ask the patient:
    • I directly ask them questions about what concerns/beliefs they have in regards to their aggravating activities, and/or if they are afraid of re-injuring their injured area etc.
  • Use assessment tools:
    • One of the most common tools I use is the Tampa Scale for Kinesiophobia (TSK).
    • Kinesiophobia is defined as “an irrational, and debilitating fear of physical movement and activity resulting from a feeling of vulnerability to painful injury or (re)injury” (Kori et al 1990).
    • Hence the TSK measures this Fear of Movement/Re-injury.
    • A link to the TSK can be found here:
    • A link to scoring the TSK can be found here:

How do we treat it?

I plan to post a case study regarding a patient with a dominant fear aspect of their disorder. As far as how I think we can treat fear:

  • Educate the patient regarding aspects of their disorder and how their beliefs and subsequent postures/avoidance etc is likely to be contributing to their disorder.
  • Encouragement of relaxation of postures and avoid bracing muscles etc.
  • Gradual exposure to movements that are associated with  fear/pain. I think that these movements should be initially in a non-painful range.
  • Gradually increase in general work/home activity levels in line with physical and pain tolerances.

As part of the education process I think it is useful to utilise charts/diagrams. The following is from Linton and Shaw (2011):

Fear Cycle

Plan to post a case study soon…..


Gatchel RJ, Peng YB, Peters ML, Fuchs PN. Turk DC. The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychological Bulletinn. 2007;133(4):581-­‐624.

Kori SH, Miller RP,Todd DD. Kinesiophobia: A new view of chronic pain behaviour. Pain Management. 1990;3:35-43.

Linton SJ, Shaw WS. Impact of psychological factors in the experience of pain. Physical Therapy. 2011;91:700-711.

Moons WG, Eisenberg NI, Taylor SE. Anger and fear responses to stress have different biological profiles. Brain Behav Immun. 2010;24(2):215-­‐9.

About the Author:

Mark is a Specialist Musculoskeletal Physiotherapist who consults at both Insight Physiotherapy and Pain Options, in Perth, Western Australia. He specialises in the assessment and management of persistent/chronic musculoskeletal pain. In addition to his clinical role he maintains regular involvement in education of the profession having held a Teaching Fellow position at the University of Western Australia for 10 years and regularly presenting at courses and seminars through the Australian Physiotherapy Association and private education sector. Mark is also a Facilitator for the Australian College of Physiotherapists Specialisation Training Program and a Sessional Academic at Curtin University. The views expressed on this blog are his own.

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