Rethinking relationships between fear, avoidance and pain-related disability

Working as a physical therapist, I have sometimes struggled to understand why some of my patients with seemingly similar musculoskeletal injuries recover and why others develop chronic pain and disability. This question, as well as a range of others, ultimately prompted me to delve into the world of pain (research, that is) and explore how psychosocial and physiological factors shape the rehabilitation process. Some of my recent research has focused on the Fear Avoidance Model of pain (FAM), which suggests that the solution to my clinical quandary is rooted in how my patients interpret and respond to their pain. In a nutshell, the FAM suggests that individuals who don’t fear their pain will continue to engage in physical activities and therefore recover without difficulty. On the other hand, people that catastrophically interpret their pain (think, magnified threat, persistent negative thoughts and feeling helpless) begin to fear, and then avoid, movements and activities associated with their pain. The model suggests that over time these individuals avoid increasingly more activities, become physically deconditioned (a process known as Disuse Syndrome) and depressed, and that all of this nastiness helps perpetuate a downward spiral of increasing disability and pain.

In our recent Topical Review (Wideman et al., Pain 154 (11), pp. 2262-5) we reviewed some of the literature and theoretical assumptions related to the FAM and explore ideas for model advancement. One aspect that we explore is the cyclical relationships in the model (i.e. pain leads to catastrophic thoughts, which lead to fear, which leads to disuse, depression and disability, which lead to increased pain; repeat). There have only been a handful of studies that have systematically evaluated these cyclical relationships over time and, thus far, have largely failed to support them. On the other hand, there has been preliminary support for alternate, cumulative, relationships among the psychological risk factors in the FAM (i.e. catastrophizing, fear, depression). This work suggests that people with a greater number of elevated risk factors (e.g. those with elevated catastrophizing and fear and depression) have a worse prognosis than those with fewer risk factors. In my opinion, this alternate conceptualization of risk has enormous clinical appeal. The patients that we see in clinical settings often simultaneously face multiple factors that might impair recovery. Thinking about risk in this manner also facilitates the integration of risk-stratified interventions (such as the STarT Back approach) that can be matched to patients’ levels of cumulative risk.

A second aspect that we consider is the model’s dichotomous trajectories: one leading to pain and disability, the other leading to recovery from pain and disability. Research that samples non-clinical populations suggests that these two pathways don’t fully account for the variability between chronic pain and disability. This work suggests that many individuals live with chronic pain without experiencing pronounced disability or psychological distress. Related research suggests that these individuals may have resilience factors (think, high optimism, deep sense of purpose) that act as a buffer to the potentially detrimental aspects of pain. Consideration of both risk and resilience factors might therefore enable us to explain a wider range of recovery trajectories.

A third aspect of the FAM that we explore is Disuse Syndrome, the proposed mechanism through which fear-avoidance causes disability. Despite its intuitive appeal, there is very little research supporting the notion that avoidance of specific feared movements translates into widespread inactivity. Surprisingly, there is also inconsistent evidence supporting the notion that individuals with chronic pain are more deconditioned than their pain-free counterparts. While this lack of evidence may strike fear in the hearts of activity-endorsing rehabilitation professionals (such as myself), we need not (necessarily) despair. One alternate – and at this point speculative – hypothesis to Disuse/Deconditioning Syndrome is a type of Sensitization Syndrome in which disengagement from (or over-engagement with) physical activity is linked to increased pain sensitivity. This is broadly consistent with our conceptualization of how pain changes during central sensitization and with emerging research exploring how pain associated with physical activity can summate (e.g. check out Pain 2010; 151(2): 440-446). If supported, this alternate conceptualization may also help us shift the way that we think about activity-based interventions for individuals with musculoskeletal pain, from targeting deconditioning processes to targeting sensitization processes.

Do these FAM shortcomings mean that fear and avoidance aren’t important? Far from it. There is lots of literature supporting both the relationship between these two factors and their importance for clinical populations. That said, within our review we do outline a number of recommendations for advancing our thinking about these relationships. First, we recommend moving on from the cyclical relationships of the FAM. I’m personally inclined to conceptualize risk as cumulative rather than cyclical and am eager to explore the additive impact of both resilience and risk factors. Second, the historic conceptualization of pain-related fear as phobia (i.e. kinesiophobia; think, irrational and debilitating distress when confronted with painful activities) is out of sink with how we typically measure fear (for instance, the Tampa Scale of Kinesiophobia tends to focus on beliefs and behaviours while overlooking distress, a defining quality of phobia) and with the clinical presentation of most of our patients (aside from folks struggling with PTSD, I have yet to see a truly phobic response to potentially painful behaviours). Instead of using a term like kinesiophobia, I’m personally inclined to think more broadly about the potential threat-value that my patients might assign to different pain-related activities and movements. Third, we need to consider multiple pathways to disability, not only those associated with fear and avoidance. The recent extensions of the FAM (e.g. see recent review papers by Crombez et al and Vlaeyen et al) have done an excellent job of addressing this issue by integrating a wider range of behaviors that are contextualized within patient goals (e.g. approach goals, avoidance without fear). Fourth, we are still in need of an overarching framework to guide our thinking about pain-related disability. Our previous models have overwhelmingly focused on the psychological interpretation of, and behavioral response to, pain. While these processes are essential in explaining pain-related disability, so are biological, social, cultural, environmental and developmental factors. Developing a framework that integrates a more comprehensive range of these factors is consistent with both our current conceptualization of pain and with the World Health Organization’s classification of disability, and will hopefully prompt us to think about new ways to advance the clinical management of pain-related disability. While we may still be years away from developing such a framework, I think it’s an exciting and meaningful initiative that will hopefully prompt collaboration across a range of different research specialties and help clinicians who, like me, are eager to better understand what drives patient recovery.

About Tim Wideman

Timothy WidemanTimothy Wideman is a licensed physical therapist and post-doctoral fellow at Johns Hopkins University in Baltimore. His research broadly explores the different biopsychosocial aspects of pain-related disability and is generously supported through the Canadian and Quebec governments (CIHR and FRQS). His current research focuses on the relationships between pain sensitization, psychological factors and physical activity. Dr. Wideman is also the current Chair of the Canadian Physiotherapy Association’s Pain Science Division, a position that offers him the distinct privilege of working with an incredibly dedicated group of physiotherapists toward the advancement of pain management in Canada. Thoughts? Questions? Feel free to email him, twidema1 at


Wideman TH, Asmundson GG, Smeets RJ, Zautra AJ, Simmonds MJ, Sullivan MJ, Haythornthwaite JA, & Edwards RR (2013). Rethinking the fear avoidance model: toward a multidimensional framework of pain-related disability. Pain, 154 (11), 2262-5 PMID: 23748115

Sullivan MJ, Larivière C, & Simmonds M (2010). Activity-related summation of pain and functional disability in patients with whiplash injuries. Pain, 151 (2), 440-6 PMID: 20797819


  1. Tim Wideman says

    Thanks Lesley for these comments and questions. Yes, there is emerging research that explores how clinicians can do exactly what you’re suggesting – address resilience within clinical settings. Alex Zautra is doing some interesting work in this area, which was a main motivation for me to reach out to him to contribute to our topical review. I encourage you to check out one of his review articles that gets into the theory and some of the clinical applications of resilience (Sturgeon, J. A., & Zautra, A. J. (2010). Resilience: a new paradigm for adaptation to chronic pain. Current pain and headache reports, 14(2), 105–112.) To the best of knowledge, these ideas have yet to percolate into the rehab/PT world, but I’m hoping to that we are heading in that direction…

    Regarding addressing sensitization processes in clinical settings, there are a bunch of approaches that have been advanced for neuropathic/CRPS pain conditions (Lorimer has done a bunch of this work). In the msk world things are still in the early days. Similar to the cited work above, we have started to explore new sensitization measures. We just published a paper that explores these measures within a knee OA sample (Wideman, T. H., Finan, P. H., Edwards, R. R., Quartana, P. J., Buenaver, L. F., Haythornthwaite, J. A., & Smith, M. T. (2013). Increased Sensitivity to Physical Activity Among Individuals with Knee Osteoarthritis: Relation to Pain Outcomes, Psychological Factors and Responses to Quantitative Sensory Testing. Pain.). While it’s still too early to advocate any specific interventions, we’re interested in exploring whether people with high sensitivity might be better suited to different approaches to activity-based interventions – I’ll keep you posted as we make progress toward this goal (but please give me a couple of years!). I hope that all is well with you.

  2. Tim Wideman says

    Thanks Betsan, it’s really great to have your perspective on these questions! I remember a conversation that I had years ago with a corrections officer who helped advance a sewing program for prison inmates with, apparently, quite strong therapeutic and rehabilitating effects. I don’t doubt the benefits of the program that you’re involved with! I seems that you’re sitting on a very interesting qualitative database that effectively taps both clinical and non-clincial populations. Have you ever thought about publishing your findings? Your proposed themes seem quite insightful. I’m curious if you’ve also considered the flip-side perspective: what are the positive attributes of participants that effectively cope with seemingly insurmountable challenges?

  3. Tim Wideman says

    Thanks Bronnie for these thoughtful comments. I agree that better distinguishing and contextualizing both fear and avoidance will be important for future research. Thank you as well for the references, I’m looking forward to looking more closely at this research. I’d also be interested in checking out your PhD research; do you have a publication or abstract that you could send my way?

  4. Tim Wideman says

    Thank you Neil for these great comments. I really hope that you subscribe to the ‘better late than never’ adage; I just climbed out from under a mountain of work and am only now getting a chance to respond to these thoughtful insights.

    Yes, I fully agree with your suggestions that fear/threat/motivation should be considered within a broader context. Regarding your latter thoughts on sensitization and patients that over-engage in physical activity, I think that you’re right in suggesting that we have yet to put a quantitative finger on this clinical phenomenon. I think Hasenbring and Verbunt’s avoidance/endurance model (see Clinical journal of pain, 26(9), 747–753) does touch on patients with this presentation. However, I am personally inclined to think of a sensitization mechanism instead of the proposed deconditioning process… Fodder for future research I suppose.

  5. Lesley Singer says

    Hi Tim
    i have always been interested in the concept of resilience with respect to chronic pain. Is resilience the reason some people do better than others. What is resilience? does it have anything to do with the FAM? We seem to work on the things we find dysfunctional to help people. Why do we not try to increase things such as resilience. Can this be worked on? It seems not to be a trait so it seems to be able to be better or worse with different stress. I would also like to know clinically how do we work on sensitization processes?

  6. As part of my research into using the creative, meditative and social benefits of knitting as a healthcare tool, I’ve been collecting narratives from people around the globe. I now have around 600. Most of these narratives give a life story -some brief, others at length. Some of the writers have no medical problems, others have a wide range of medical conditions. Those with no medical problems talk of dealing with a wide range of life issues, some of which involve great trauma and difficult situations. Whilst reading these stories I became intrigued as to why some people stay afloat and even thrive despite numerous hardships (non-medical and medical related) whilst others sink under a seemingly small amount of pressure. Certain core issues began to emerge and these appear to be common across the board – whether the writer suffers chronic pain, mental health issues or traumatic/ stressful life events. In conversation with experts in conditions such as dyslexia or those who work with disruptive teenagers or prisoners, I’ve realised that these core issues are also common to these groups as well as to the newly retired or bereaved.

    Core issues are –
    1) Fear, Worry, Stress
    2) Low Self Esteem, feelings of worthlessness in society / family
    3) Social isolation / loneliness
    4) Lack of rewarding occupation. Few positive life experiences
    5) Lost or changed identity

  7. Clinically, I have found the same issues with people fearing not simply pain-as-harm but pain-limitations-representing-loss-of-identity.
    I don’t think all people who avoid doing things (thus have high levels of disability) do so for the same reasons. Some might be afraid that pain=harm, while some might be afraid that they can’t do things “as normal” or that they’ll end up “paying for it tomorrow” or a myriad of other reasons.
    Some people even achieve a low score on the TSK but are highly avoidant because intellectually they “know” that hurt doesn’t equal harm, but at the same time they just don’t want to (are afraid of) going through the pain because they become distressed, or feel exhausted, or want to focus on other more important things that they can do.
    When working within a CBT or ACT model, the specific concerns of an individual need to be identified rather than assumed, and certainly this is what Johan Vlaeyen advocates (see Johan’s book “Pain-Related Fear: Exposure-Based Treatment for Chronic Pain”
    I think one of the risks of the Avoidance model is that it conflates fear AND avoidance. It’s entirely possible to be fearful of something, yet go ahead and do it – in fact, that’s the basis of graded exposure with response prevention. It’s also possible to avoid doing something, but not because of fear of pain – instead it could be fear of other people’s responses, loss of income, or competing priorities.

  8. I was really heartened to see your reference to contextualisation – we need to ask ourselves what it is that individuals intend to achieve when they engage in certain behaviours that lead to disability.
    Drawing from functional contextualism, and ACT, perhaps what happens is that the coping repertoire in some individuals is limited, therefore they’re restricted in how to go about doing what is important. If, at the same time, they’re concerned that pain = threat, it’s not surprising they draw upon ways of coping that attempt to solve the problem of pain intensity while interfering with engaging in important occupation (using the term in the context of occupational science).
    ACT uses this approach to understand and influence how individuals do what they do. It seems an eminently pragmatic approach to explain why some people have pain but are not bothered by it, while others are distinctly disabled. It certainly has been supported in my PhD study of people who cope well with pain – these people use all those strategies I learned were “maladaptive”, along with all those I learned were “adaptive” – and they don’t think pain is a threat, therefore they carry on with what’s important in their lives.
    If you’re looking for an overarching explanatory model for disability and chronic pain, I think there’s merit in considering the functional contextual perspective.
    Biglan, Anthony, & Hayes, Steven C. (1996). Should the behavioral sciences become more pragmatic? The case for functional contextualism in research on human behavior. Applied & Preventive Psychology, 5(1), 47-57.
    Hayes, Steven C., Levin, Michael E., Plumb-Vilardaga, Jennifer, Villatte, Jennifer L., & Pistorello, Jacqueline. (2013). Acceptance and commitment therapy and contextual behavioral science: Examining the progress of a distinctive model of behavioral and cognitive therapy. Behavior Therapy, 44(2), 180-198.
    Lauwerier, Emelien, Damme, Stefaan, Goubert, Liesbet, Paemeleire, Koen, Devulder, Jacques, & Crombez, Geert. (2012). To control or not? A motivational perspective on coping with pain. Acta Neurologica Belgica, 112(1), 3-7. doi: 10.1007/s13760-012-0020-6
    Wetherell, Julie Loebach, Afari, Niloofar, Rutledge, Thomas, Sorrell, John T., Stoddard, Jill A., Petkus, Andrew J., . . . Hampton Atkinson, J. (2011). A randomized, controlled trial of acceptance and commitment therapy and cognitive-behavioral therapy for chronic pain. PAIN, 152(9), 2098-2107. doi:

  9. Neil Pearson says

    Hey Tim – well stated. I think I have shared this with you before, and thought it would make sense to add it here. The FAM, as stated, treats fear as if all people are fearful of the same thing(s), and as if fear only leads to avoidance of activity. Maybe we need to discuss fear as the complex human experience that it is, rather than as if it is a simple measurable input such as 8 grams of mechanical pressure. From a neuromatrix perspective, fear, like pain, is both an output, and an input. From a systems view, fear and pain and activity all interact multi directionally and non-linearly. The original diagrams of the FAM may need to be redrawn before we can shift our paradigm of the interactions of fear, pain and activity.
    Many people who continue to function apparently well AND have pain and signs of sensitization seem to be more fearful of losing their competence, or identity, or job, or respect of others, or spouse, … . I don’t think they have no fear of pain or reinjury, but I expect that fear of pain and reinjury are contextualized just as nociceptive input is. I also don’t think they never avoid activities that would increase their pain, but that, the activity they perform is situationally dependent. As a clinician, I hear the story of ‘enduring’ the pain as much as I hear the story of avoiding activities that increase the pain. As a reader of research, I wonder if the lack of discussions about people who ‘push through the pain as best as they can AND shows signs of sensitization’ is a problem with my filters, or whether research methodologies are somehow filtering out these people, these aspects of fear, or these responses to fear. Thanks for the paper and opening the discussion here.