Kinesiophobia
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By Ashley Pena, DPT Student

Patients with re-occurring injuries that become chronic conditions such as chronic low back pain or chronic ankle sprains can be a challenge for medical professionals for many reasons. Risk factors for the array of chronic conditions have been studied and identified. However, one problem in this population that is less frequently discussed is that of Kinesiophobia. Kinesiophobia (KPB), or Fear Avoidance Beliefs, are defined as “excessive, irrational, and debilitating fear of physical movement and activity resulting from a feeling of vulnerability to painful injury or re-injury.”8 While this may sound like an extraordinary occurrence, these beliefs to some degree are often a factor in chronic conditions.

To summarize, KPB can be broken down into “Harmful factors” (HF) which reflect the patient’s belief that something is seriously wrong with the body; and “Activity avoidance factors” (AAF) which represent the belief that avoiding exercise/activity will prevent an increase in pain. These beliefs generally lead to a vicious cycle involving an avoidance of movement or any activities that might cause pain or reinjury (see Figure above). Over time, the inactivity that stems from this fear leads to physical consequences such as muscle atrophy, loss of spinal range of motion, and psychological consequences. Psychological consequences include reduced calibration to painful stimuli and behavioral changes. This in turn can affect patient prognosis and healing times.10

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Figure 2

The physiological and psychological changes that occur in chronic pain conditions are well- studied and is described in David Butler’s “Explain Pain.”1 Essentially, your body adapts to what is being sent it’s way, so if pain or “danger” messages keep being sent to the brain, the sensory neurons become more sensitive to incoming excitatory chemicals, the sensors stay open longer, eventually more sensors are produced and neuronal sprouting can occur. Another change which occurs in the brain is homunculus “smudging”. With this occurrence, the area of the cerebral cortex which is devoted to sensation and representation of the involved body part becomes larger, with less distinct outlines and overlaps with surrounding areas of the cortex. All of these things can contribute to perpetuating pain.

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Figure 3

The good news: many of these changes are reversible. As depicted below, after injury the body has a new tissue tolerance level (Figure 2). The key to combating this over-sensitivity is pacing and graded exposure (Figure 3). Finding a Baseline tolerance to a task which you can perform without a flare up is essential, since your body will alert you of the need to stop at the “New Protect By Pain” line (Figure 2). By exercising just below the “Flare Up” line one can begin to slowly make changes in their tolerance and eventually resume to their original Tissue Tolerance.1

ashleyBlog Post written by Ashley Pena, DPT Student from Cal State Northridge. Ashley is currently in her final clinical rotation with me at Catz PTI.

References:

1. Butler DS, Moseley GL. Explain pain. Adelaide: Noigroup Publications; 2015
2. Crombez G, Vlaeyen JWS, Goubert L. Muscle Pain, Fear-Avoidance Model. Encyclopedia of Pain 2013:1963–1966. doi:10.1007/978-3-642-28753-4_2531.
3. Crombez G, Vlaeyen JW, Heuts PH, Lysens R. Pain-related fear is more disabling than pain itself: evidence on the role of pain-related fear in chronic back pain disability. Pain 1999;80(1):329–339. doi:10.1016/s0304-3959(98)00229-2.
4. Feitosa AS, Lopes JB, Bonfa E, Halpern AS. A prospective study predicting the outcome of chronic low back pain and physical therapy: the role of fear-avoidance beliefs and extraspinal pain. Revista Brasileira de Reumatologia (English Edition) 2016. doi:10.1016/j.rbre.2016.03.002.
5. Guclu DG, Guclu O, Ozaner A, Senormanci O, Konkan R. The relationship between disability, quality of life and fear- avoidance beliefs in patients with chronic low back pain. Turkish Neurosurgery . 2012. doi:10.5137/1019-5149.jtn.6156-12.1.
6. Heymans MW, Ford JJ, McMeeken JM, Chan A, de Vet HC, van Mechelen W. Exploring the contribution of patient-reported and clinician based variables for the prediction of low back work status. Journal of Occupational Rehabilitation 2007; 17(): 383-397. doi:10.1007/s10926-007-9084-1.
7. Lethem J, Slade P, Troup J, Bentley G. Outline of a fear-avoidance model of exaggerated pain perception—I. Behaviour Research and Therapy 1983;21(4):401–408. doi:10.1016/0005-7967(83)90009-8.
8. Neblett R, Hartzell M, Mayer T, Bradford E, Gatchel R. Establishing clinically meaningful severity levels for the Tampa Scale for Kinesiophobia (TSK-13). Eur J Pain European Journal of Pain 2015;20(5):1–10. doi:10.1002/ejp.795.
9. Peña A, Plotkin L, Eagle M, Riehl J, Mathiyakom W. American Physical Therapy Association: Combined Sections Meeting. In: San Antonio; 2017.
10. Vlaeyen JW, Kole-Snijders AM, Boeren RG, Eek HV. Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance. Pain 1995;62(3):363–372.