Fear Of Movement-related Pain Research Articles

Kinesiophobia among health professionals' interventions: a scoping review.

Health professionals are regularly confronted with patients suffering from a fear of movement-related pain (unknown as kinesiophobia). The fear-avoidance attitudes and beliefs of healthcare professionals are likely to play a key role in their patients' therapeutic approach. However, kinesiophobia among health professionals is a relatively young topic. This scoping review aims to explore and catalogue the extent of scientific research that identifies the causes and consequences of kinesiophobia among health professionals while they perform their interventions. The review was based on the Joanna Briggs Institute manual and the PRISMA method for a scoping review. The research was conducted in May 2024 using CINHAL, Medline and Sportdiscus databases with the search terms "fear-avoidance", "kinesiophobia", "pain-related" and "physical therapist". Out of 2,162 potential studies, thirteen articles were included. No study directly mentioned kinesiophobia among health professionals, but it was studied through fear-avoidance beliefs. Two-thirds of the articles indicate that professionals with fear-avoidance beliefs tend to refer their patients to other specialists less frequently and limit their patients' activity, despite treatment guidelines. Most of the studies found were physiotherapists' interventions for chronic back pain patients. The current review emphasizes the need for additional studies involving more healthcare professionals and diverse health conditions.

Virtual reality to understand pain-associated approach behaviour: a proof-of-concept study

Pain-associated approach and avoidance behaviours are critically involved in the development and maintenance of chronic pain. Empirical research suggests a key role of operant learning mechanisms, and first experimental paradigms were developed for their investigation within a controlled laboratory setting. We introduce a new Virtual Reality paradigm to the study of pain-related behaviour and investigate pain experiences on multiple dimensions. The paradigm evaluates the effects of three-tiered heat-pain stimuli applied contingent versus non-contingent with three types of arm movements in naturalistic virtual sceneries. Behaviour, self-reported pain-related fear, pain expectancy and electrodermal activity were assessed in 42 healthy participants during an acquisition phase (contingent movement-pain association) and a modification phase (no contingent movement-pain association). Pain-associated approach behaviour, as measured by arm movements followed by a severe heat stimulus, quickly decreased in-line with the arm movement-pain contingency. Slower effects were observed in fear of movement-related pain and pain expectancy ratings. During the subsequent modification phase, the removal of the pain contingencies modified all three indices. In both phases, skin conductance responses resemble the pattern observed for approach behaviour, while skin conductance levels equal the pattern observed for the self-ratings. Our findings highlight a fast reduction in approach behaviour in the face of acute pain and inform about accompanying psychological and physiological processes. We discuss strength and limitations of our paradigm for future investigations with the ultimate goal of gaining a comprehensive understanding of the mechanisms involved in chronic pain development, maintenance, and its therapy.

The efficacy of graded motor imagery in post-traumatic stiffness of elbow: a randomized controlled trial.

Physiotherapy improves the movement range after the onset of post-traumatic elbow stiffness and reduces the pain, which is a factor limiting elbow range of motion. However, no results have been reported for motor-cognitive intervention programs in post-traumatic elbow stiffness management. The objective was to investigate the efficacy of graded motor imagery (GMI) in post-traumatic elbow stiffness. Fifty patients with post-traumatic elbow stiffness (18 female; mean age, 41.9±10.9 years) were divided into 2 groups. The GMI group (n=25) received a program consisting of left-right discrimination, motor imagery, and mirror therapy (twice a week for 6 weeks); the structured exercise (SE) group (n=25) received a program consisting of range-of-motion, stretching, and strengthening exercises (twice a week for 6 weeks). Both groups received a 6-week home exercise program. The primary outcome was the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. The secondary outcomes were the active range of motion (AROM), visual analog scale (VAS), Tampa Scale for Kinesiophobia (TSK), muscle strength of elbow flexors and extensors, grip strength, left-right discrimination, and Global Rating of Change. Patients were assessed at baseline, at the end of treatment (12 sessions), and a 6-week follow-up. The results indicated that both GMI and SE interventions significantly improved outcomes (P<.05). After a 6-week intervention, the DASH score was significantly improved with a medium effect size in the GMI group compared with the SE group, and improvement continued at the 6-week follow-up (F1,45=3.10, P=.01). The results with a medium to large effect size were also significant for elbow flexion AROM (P=.02), elbow extension AROM (P=.03), VAS-activity (P=.001), TSK (P=.01), and muscle strength of elbow flexors and elbow extensors (P=.03) in favor of the GMI group. The GMI is an effective motor-cognitive intervention program that might be applied to the rehabilitation of post-traumatic elbow stiffness to improve function, elbow AROM, pain, fear of movement-related pain, and muscle strength.

Generalization of fear of movement-related pain and avoidance behavior as predictors of work resumption after back surgery: a study protocol for a prospective study (WABS)

BackgroundPrevious studies indicated that about 20% of the individuals undergoing back surgery are unable to return to work 3 months to 1 year after surgery. The specific factors that predict individual trajectories in postoperative pain, recovery, and work resumption are largely unknown. The aim of this study is to identify modifiable predictors of work resumption after back surgery.MethodsIn this multisite, prospective, longitudinal study, 300 individuals with radicular pain undergoing a lumbar decompression will be followed until 1-year post-surgery. Prior to surgery, participants will perform a computer task to assess fear of movement-related pain, avoidance behavior, and their generalization to novel situations. Before and immediately after surgery, participants will additionally complete questionnaires to assess fear of movement-related pain, avoidance behavior, optimism, expectancies towards recovery and work resumption, and the duration and severity of the pain. Six weeks, 3 months, 6 months, and 12 months after surgery, they will again complete questionnaires to assess sustainable work resumption, pain severity, disability, and quality of life. The primary hypothesis is that (generalization of) fear of movement-related pain and avoidance behavior will negatively affect sustainable work resumption after back surgery. Second, we hypothesize that (generalization of) fear of movement-related pain and avoidance behavior, negative expectancies towards recovery and work resumption, longer pain duration, and more severe pain before the surgery will negatively affect work resumption, pain severity, disability, and quality of life after back surgery. In contrast, optimism and positive expectancies towards recovery and work resumption are expected to predict more favorable work resumption, better quality of life, and lower levels of pain severity and disability after back surgery.DiscussionWith the results of this research, we hope to contribute to the development of strategies for early identification of risk factors and appropriate guidance and interventions before and after back surgery.Trial registration The study was preregistered on ClinicalTrials.gov: NCT04747860 on February 9, 2021.

Fear of movement-related pain disturbs cortical preparatory activity after becoming aware of motor intention

Fear of movement-related pain is known to disturb the process of motor preparation in patients with chronic pain. In the present study, we aimed to clarify the neural mechanisms underlying the influence of fear movement-related pain on motor preparatory brain activity using Libet’s clock and electroencephalography (EEG). Healthy participants were asked to press a button while watching a rotating Libet’s clock-hand, and report the number on the clock (“W time”) when they made the “decision” to press the button with their right index finger. Immediately after pressing the button, a painful electrical stimulus was delivered to the dorsum of the left hand, causing participants to feel fear of movement (button press-related pain). We found that fear of movement-related pain caused the W time to be early, and that the amplitudes of readiness potentials (RPs) increased after awareness of motor intention emerged. In addition, fear of movement-related pain caused over-activation of the medial frontal cortex, supplementary motor area, cingulate motor area, and primary motor cortex after participants became aware of their motor intention. Such over-activation might result from conflict between the unrealized desire to escape from a painful experience and motivation to perform a required motor task.

Placebo analgesia induced by verbal suggestion in the context of experimentally induced fear and anxiety.

The role of state anxiety and state fear in placebo effects is still to be determined. We aimed to investigate the effect of fear of movement-related pain (FMRP) and contextual pain related anxiety (CPRA) on the magnitude of placebo analgesia induced by verbal suggestion. Fifty-six female participants completed a modified voluntary joystick movement paradigm (VJMP) where half participated in a predictable pain condition (PC), in which one of the joystick movements is always followed by pain and the other movement is never followed by pain, and half in an unpredictable pain condition (UC), in which pain was delivered unpredictably. By varying the level of pain predictability, FMRP and CPRA were induced in PC and UC respectively. Colour stimuli were presented at the beginning of each trail. Half of the participants were verbally informed that the green or red colour indicated less painful stimuli (experimental groups), the other half did not receive any suggestion (control groups). We measured self-reported pain intensity, expectancy of pain intensity (PC only), pain related fear and anxiety (eyeblink startle response and self-ratings) and avoidance behaviour (movement-onset latency and duration). The results indicate that the placebo effect was successfully induced in both experimental conditions. In the PC, the placebo effect was predicted by expectancy. Despite the fact that FMRP and CPRA were successfully induced, no difference was found in the magnitude of the placebo effect between PC and UC. Concluding, we did not find a divergent effect of fear and anxiety on placebo analgesia.

The effect of differential spatiotopic information on the acquisition and generalization of fear of movement-related pain.

Fear of movement-related pain significantly contributes to musculoskeletal chronic pain disability. Previous research has shown that fear of movement-related pain can be classically conditioned. That is, in a differential fear conditioning paradigm, after (repeatedly) pairing a neutral joystick movement (conditioned stimulus; CS+) with a painful stimulus (unconditioned stimulus; pain-US), that movement in itself starts to elicit self-reported fear and elevated psychophysiological arousal compared to a control joystick movement (CS−) that was never paired with pain. Further, it has been demonstrated that novel movements that are more similar to the original CS+ elicit more fear than novel movements that are more similar to the CS−, an adaptive process referred to as stimulus generalization. By default, movement/action takes place in reference to the three-dimensional space: a movement thus not only involves proprioceptive information, but it also contains spatiotopic information. Therefore, the aim of this study was to investigate to what extent spatiotopic information (i.e., endpoint location of movement) contributes to the acquisition and generalization of such fear of movement-related pain besides proprioception (i.e., movement direction). In a between-subjects design, the location group performed joystick movements from the middle position to left and right; the movement group moved the joystick from left and right to the middle. One movement (CS+) was paired with pain, another not (CS−). Feature overlap between CSs typically reduces differential learning. The endpoint of both CSs in the movement group is an overlapping feature whereas in the location group the endpoint of both CSs is distinct; therefore we hypothesized that there would be less differential fear learning in the movement group compared to the location group. We also tested generalization to movements with similar proprioceptive features but different endpoint location. Following the principle of stimulus generalization, we expected that novel movements in the same direction as the CS+ but with a different endpoint would elicit more fear than novel movement in the same direction of the CS− but with a different endpoint. Main outcome variables were self-reported fear and pain-US expectancy and eyeblink startle responses (electromyographic). Corroborating the feature overlap hypothesis, the location group showed greater differential fear acquisition. Fear generalization emerged for both groups in the verbal ratings, suggesting that fear indeed accrued to proprioceptive CS features; these effects, however, were not replicated in the startle measures.

Brain Mechanisms of Anticipated Painful Movements and Their Modulation by Manual Therapy in Chronic Low Back Pain

Heightened anticipation and fear of movement-related pain has been linked to detrimental fear-avoidance behavior in chronic low back pain (cLBP). Spinal manipulative therapy (SMT) has been proposed to work partly by exposing patients to nonharmful but forceful mobilization of the painful joint, thereby disrupting the relationship among pain anticipation, fear, and movement. Here, we investigated the brain processes underpinning pain anticipation and fear of movement in cLBP, and their modulation by SMT, using functional magnetic resonance imaging. Fifteen cLBP patients and 16 healthy control (HC) subjects were scanned while observing and rating video clips depicting back-straining or neutral physical exercises, which they knew they would have to perform at the end of the visit. This task was repeated after a single session of spinal manipulation (cLBP and HC group) or mobilization (cLBP group only), in separate visits. Compared with HC subjects, cLBP patients reported higher expected pain and fear of performing the observed exercises. These ratings, along with clinical pain, were reduced by SMT. Moreover, cLBP, relative to HC subjects, demonstrated higher blood oxygen level–dependent signal in brain circuitry that has previously been implicated in salience, social cognition, and mentalizing, while observing back straining compared with neutral exercises. The engagement of this circuitry was reduced after SMT, and especially the spinal manipulation session, proportionally to the magnitude of SMT-induced reduction in anticipated pain and fear. This study sheds light on the brain processing of anticipated pain and fear of back-straining movement in cLBP, and suggests that SMT may reduce cognitive and affective-motivational aspects of fear-avoidance behavior, along with corresponding brain processes. PerspectiveThis study of cLBP patients investigated how SMT affects clinical pain, expected pain, and fear of physical exercises. The results indicate that one of the mechanisms of SMT may be to reduce pain expectancy, fear of movement, and associated brain responses.

Pain in context: Cues predicting a reward decrease fear of movement related pain and avoidance behavior

Previous research shows that goal-directed behavior might be modulated by cues that predict (dis)similar outcomes. However, the literature investigating this modulation with pain outcomes is scarce. Therefore, this experiment investigated whether environmental cues predicting pain or reward modulate defensive pain responding. Forty-eight healthy participants completed a joystick movement task with two different movement orientations. Performing one movement was associated with a painful stimulus, whereas performance of another movement was associated with reward, i.e. lottery tickets. In a subsequent task, participants learned to associate three different cues withpain, reward, or neither of the two. Next, these cues were integrated in the movement task. This study demonstrates that in general, aversive cues enhance and appetitive cues reduce pain-related fear. Furthermore, we found that incongruence between the outcomes predicted by the movement and the cue results in more oscillatory behavior, i.e., participants were more willing to perform a painful movement when a cue predicting reward was simultaneously presented, and vice versa. Similarly, when given a choice, participants preferred to perform the reward movement, unless there was an incongruence between the outcomes predicted by the movements and cues. Taken together, these results provide experimental evidence that environmental cues are capable of modulating pain-related fear and avoidance behavior.

Mere Intention to Perform Painful Movements Elicits Fear of Movement-Related Pain: An Experimental Study on Fear Acquisition Beyond Actual Movements

Fresh empirical evidence supports the notion that fear of movement-related pain can be acquired through associative learning. In the context of these findings, 2 ideas are appealing, yet uninvestigated. The first is that merely the intention to perform a painful movement acts as a covert conditioned stimulus (CS) inducing defensive fear responses (ie, gaining excitatory properties following Pavlovian acquisition). The second idea is that after extinction, fear of movement-related pain can easily be reinstated after unexpected painful stimuli (ie, reinstatement). In a voluntary differential conditioning movement paradigm with movements as CSs and a painful electrocutaneous stimulus as the unconditioned stimulus (pain-US), 2 groups were included (Experimental/Control). One movement (CS+) was followed by the pain-US and another movement (CS−) was not during acquisition, while the CS+ was no longer reinforced during extinction. Next, the Experimental group received 2 reinstating pain-USs, whereas the Control group did not. The CS+ but not the CS− evoked fear of movement-related pain in self-reports and eye-blink startles. Intriguingly, the mere intention to perform the painful movement produced higher eye-blink startle responses than the intention to perform the nonpainful movement. We also demonstrated nondifferential reinstatement in the verbal fear ratings in the Experimental group only. PerspectiveThis study demonstrates that the mere intention to perform a painful movement prior to the actual painful movement itself can come to elicit conditioned fear responses. These results suggest that actual movement may not be necessary to elicit pain-related fear responses, maintaining chronic pain-related fear, avoidance, and disability.

Safety behavior can hamper the extinction of fear of movement-related pain: An experimental investigation in healthy participants

Excessive fear of movement-related pain (FMRP), and its associated avoidance behavior, is considered a major risk factor for disability in chronic musculoskeletal pain. The current study aimed to investigate whether engaging in safety behavior, conceptualized as an avoidance response, hampers the extinction of FMRP. In a differential conditioning paradigm, we used joystick movements as conditioned stimuli (CSs) and a painful electrocutaneous stimulus as the unconditioned stimulus (US). In the Safety group, participants received the opportunity to avoid the pain-US by pressing a safety button during the extinction phase, whereas in the Control group, this option was not included. In a subsequent test phase, this safety button was no longer available. In two experiments, results demonstrate successful acquisition and extinction. Retrospective FMRP ratings in both experiments revealed a return of fear of pain in the test phase in the Safety group, but not in the Control group. In Experiment 1, mean eyeblink startle reflex amplitudes partly corroborated the self-report findings on fear of pain. The present results suggest that performing safety behavior during cognitive-behavioral interventions, i.e., exposure, might increase the risk of a return of FMRP.