How fear-avoidance can lead to back pain


As mentioned in a previous blog post (7 things to avoid when you have back pain), people react differently to face the pain coming from the back. Some people ignore the pain completely and force themselves to keep going (I don’t recommend this!). Other people feel paralyzed and are scared to make any movement (Don’t recommend this either!). They are unsure what they can or cannot do and they avoid anything that may cause (more) pain.

This psychological consequence of back pain, where you are scared to move at all, prevents you from doing physical activity or exercise. This has both a negative impact on your recovery and on your overall (physical) health.

In this blog post I will explain what this fear of movement is by using the fear-avoidance model. After you get an idea of what the fear-avoidance model is, I will explain how fear-avoidance can lead to chronic back pain and other consequences, and, finally, I will discuss how to get rid of your fear of moving.

What is kinesiophobia?

Kinesiophobia, or in easy terms, an excessive and irrational fear of movement, means (quite obvious) having a fear to cause (more) pain when performing certain movements or exercises or doing any physical activity. This is a common response in people struggling with (chronic) back pain. The reason for this is explained in the fear-avoidance model (see figure 1). The fear-avoidance model explains that after an injury, people experience pain, but perceive that pain differently. There are two different ways, one leading to recovery, while the other one may lead to a more chronic presentation of the original injury1. Let’s zoom in on the different aspects of the fear-avoidance model after an injury occurs.
fear avoidance model
Figure 1: Fear-avoidance model. Source: Vlaeyen JWS & Linton SJ. Fearavoidance and its consequences in chronic musculoskeletal pain: A state of the art. Pain 2000;85(3):317-332.

Pain experience

Experiencing pain is something we all have in common, but the intensity, impact, and how we cope with the pain definitely differs between people.

As explained, people take two different approaches according to the fear-avoidance model.


People may experience pain, but have no or little fear of making it worse by doing daily life activities. These people will confront the pain and do physical exercises according to their ability. They don’t have negative beliefs around the injury and how it will impact their life, but rather accept the pain and have a quicker recovery in the end2.


Other people may experience an increased fear because of the pain. They are scared to make the pain or the injury worse by continuing doing what they were doing. Their reaction is to start avoiding certain things to avoid the (thought of) pain. Avoidance, unfortunately, can have both physical and psychological consequences, like loss of muscle mass, reduced mobility and flexibility, reduced fitness level, passive coping strategies, reinforcement of invalidity status, …). People in this category experience an exaggerated pain perception and an increased disability2.

Pain Catastrophizing

When following path n°2 as explained above, you get in the negative cycle starting with pain catastrophizing. One reason some people end up on this path may be lack of sufficient education about the given diagnosis3.

The mind is a powerful source. It can drive people to do great things and to persist, but it can also take over in a negative way. When a person is starting to have negative beliefs about the outcome of the injury, due to the pain they’re experiencing, the mind might start catastrophizing the pain1,4. These people see the pain as something debilitating their quality of life rather than the signal function it has to take care of the problem.

Fear of movement/(re)injury

With catastrophizing the pain people start fearing. They fear certain movements that might incur more pain and definitely fear worsening the injury. In a study conducted in 2022 it was shown that even though participants logically understand the evidence-based guidelines for their lower back pain (which is to stay physically active), they still feel in doubt about executing the guidelines. This is because they are still concerned and feeling insecure that doing so might lead to worsening the back pain5. As suggested before, it’s mostly lack of education about back pain, exercising, and treatment that make people fear the pain and their prognosis.

Avoidance/escape, hypervigilance

Fear can have a big impact on people’s lives. Just like pain, fear has a signaling function to the body to react to a perceived threat. The pain stimulus is in this seen as the threat. Our brain will react to fear with a fight, flight, or freeze reaction. In this pathway people start to flight (or avoid) anything that may worsen the pain. They start avoiding certain movements, postures, exercises. People also become hypervigilant in the way they move or what they do, all in an attempt to avoid a ‘threat’4,6.

They eventually change their behaviors when it comes to daily life activities like working or cleaning the house. The downside is that whenever new behavior is taught it is very hard to get rid of this behavior. Their new behavior is also reinforced by the fact that the threat (the pain) didn’t happen because of avoidance7.

Of course we need to make a difference between avoidance out of fear and avoidance because what you’re doing is bad for your back. Read more about things to avoid when you have back pain here to see the difference or read about how your lifestyle causes back pain here.

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Disuse, disability, depression

All the previous steps (the pain experience, catastrophizing the pain and then avoiding daily life activities or exercises to prevent pain) will prevent people from using the back in their normal daily life activities. People will stop exercising (or avoid certain exercises), they might even stop going out and meeting up with people out of fear for more pain. This will lead to disuse of the back muscles. When muscles aren’t used anymore they get weaker which in turn will create a disability to use them. Of course this makes the recovery a longer process. There’s a possibility your acute back pain will turn into a chronic back pain because of the weak and unused muscles1.

Let’s look at all the consequences there are when you start avoiding activities or exercises out of fear of movement.

Consequences of fear-avoidance

In the second pathway of the fear-avoidance model people may experience some short-term effects of the avoidance and hypervigilance. It will reduce their anxiety and they feel less pain (because they are not confronting the pain, but rather avoiding anything that might cause it). In the long run, however, this will have a negative effect on many aspects of life6. See below what the consequences are of this avoidance3,8:

Physical consequences

Mental consequences


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How to get rid of your fear of moving

To get out of this negative cycle of catastrophizing, fearing, and avoiding, all making the injury worse, one research done in 2021 recommended doing multimodal therapy3. The multimodal therapy consisted of physical therapy as well as psychological therapy, but with a preference for psychological therapy. The same study also suggested to combine the psychological treatment with neuromuscular control exercise programs specifically3. When dealing with higher levels of kinesiophobia, a regular exercise program was found to be more effective than standard medical care6.

Psychological therapy

In psychological therapy, patients learn new coping strategies for their perceived pain6. Common psychological therapies to help with the fear-avoidance are cognitive behavioral therapy and in-vivo exposure therapy5,6.

The cognitive behavioral therapy will go deeper into situations that the patient sees as dangerous or a threat and will give the patient proper education on the fear-avoidance model. This way the patient can make new links between their thoughts and their behavior, getting rid of the excessive fear.

In-vivo exposure therapy means gradually exposing the patient to whatever causes the patient to fear excessively (like with other phobias). They progress in levels of difficulty so by the end the patient won’t fear the activity anymore6.

Lastly, but also important, is the way health care professionals act around patients. This might influence their behavior when it comes to movements and it is something health care professionals need to be aware of5.

Physical therapy

Physical therapy is aimed to prevent weakening of the muscles around the injured area. Depending on the level of fitness of the patient, one can suggest interventions focused on improving daily life skills or, for more active patients, focus on sport-related, exercise practices. Doing these interventions will impact the level of pain, kinesiophobia, and function3. Physical activity will strengthen your muscles and will benefit your health, thus helping you to recover quicker. The positive effects on kinesiophobia, in one study, was seen the longest and most visible in the group where patients had to do more demanding exercises6. A personal trainer can help you by giving professional and customized guidance so you are still able to do physical activity to your ability. According to a recent study (2022), patients even requested professional guidance to find suitable exercises for them5. My blog about 5 easy exercises to do with back pain, will give you a general idea of safe exercises you can try.

Let's go beyond the fear of moving

In this blog post I’ve talked about the fear that comes when some people get injured. The fear will lead to avoidance which in turn can lead to chronic pain. The fear-avoidance model explains how an injury can trigger different pain experiences where one can lead to confrontation and recovery, where the other one leads to pain catastrophizing, fear, avoidance and disuse of the particular area. This has negative consequences on the quality of life, both mental and physical. It is therefore important to address this fear by combining psychological and physical therapy.

Know that this is based on scientific research, but in no way replaces medical advice from your physician.
If you want to read more about back pain, check out my other blog posts.
If you’re interested in working with me, book a free consultation and together we see how I can help you reach your goals. I specialize in back strengthening programs.
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  1. Physiopedia 2022. https://www.physio-pedia.com/Fear_Avoidance_Model
  2. Health Education and Improvement Wales. https://gpcpd.heiw.wales/clinical/low-back-pain/fear-avoidance-model/
  3. Purva G, Vaishnavi W, Neha C, Sakshi P. A, Pratik P, 2021. “Fear avoidance model of kinesiophobia and rehabilitation”. Jour. of Med. P’ceutical & Allied. Sci. V 10 – I 5, 1267 P-3529-3533. doi: 10.22270/jmpas.V10I5.1267.
  4. Diogo Carvalho Felício; José Elias Filho; Daniele Sirineu Pereira; Barbara Zille de Queiroz; Amanda Aparecida Oliveira Leopoldino; Vitor Tigre Martins Rocha; Leani Souza Máximo Pereira.
    The effect of kinesiophobia in older people with acute low back pain: longitudinal data from Back Complaints in the Elders (BACE). Cad. Saúde Pública 2021; 37(12):e00232920. doi: 10.1590/0102-311X00232920.
  5. Maria André 1 ,2 , Mari Lundberg 2 ,3*. Thoughts on Pain, Physical Activity, and Body in
    Patients With Recurrent Low Back Pain and Fear: An Interview Study. PTJ: Physical Therapy & Rehabilitation Journal | Physical Therapy, 2022;102:1–9. https://doi.org/10.1093/ptj/pzab275.
  6. Filipczyk, P.; Filipczyk, K.; Saulicz, E. Influence of Stabilization Techniques Used in the Treatment of Kinesiophobia. Int. J. Environ. Res. Public Health 2021, 18, 6393. https://doi.org/10.3390/ijerph18126393.
  7. Johan W.S. Vlaeyen*, Geert Crombez, Steven J. Linton. The fear-avoidance model of pain. Painjournalonline.com. 157 (2016) 1588–1589. http://dx.doi.org/10.1097/j.pain.0000000000000574.
  8. Aleena Agnus Tom, Eslavath Rajkumar, Romate John & Allen Joshua George (2022) Determinants of quality of life in individuals with chronic low back pain: a systematic review, Health Psychology and Behavioral Medicine, 10:1, 124-144, DOI:10.1080/21642850.2021.2022487.


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