What are fear avoidance beliefs?

Fear Avoidance Beliefs: Definition and Clinical Significance

Fear avoidance beliefs (FABs) are cognitions and emotions representing concerns and fears that physical activities will produce pain and cause further harm to the body, particularly the spine. 1

Core Components

Fear avoidance beliefs comprise two distinct but related elements:

• Emotionally-based fears of pain and injury that drive avoidance behavior 1
• Information-based beliefs about the vulnerability of the affected body part, causes of tissue degeneration, and the meaning of pain 1

These beliefs are central to the Fear-Avoidance Model, which describes a cascade of events where pain perceived as threatening leads to avoidance of valued and meaningful life activities. 2

Clinical Manifestations

In chronic pain conditions, particularly low back pain, FABs manifest as:

• Pain catastrophizing - viewing pain as serious and threatening despite absence of ongoing tissue damage, coupled with feelings of helplessness over managing the pain 3
• Hypervigilance - constantly checking for pain occurrence after activities like meals or bowel movements 3
• Activity avoidance - refusing to engage in important activities due to fear that symptoms will occur 3
• Overfocusing on finding a cause or solution, which represents psychological inflexibility and interferes with pain acceptance and treatment response 3

Impact on Patient Outcomes

Excessive FABs result in:

• Heightened disability and delayed recovery from acute, subacute, and chronic pain 1
• Lower levels of physical activity and poorer work outcomes 4
• Increased healthcare utilization and risk of opioid misuse 3
• Significant interference with normal routine, occupational functioning, and social activities 1

Assessment Tools

FABs are commonly measured using validated questionnaires:

• Fear Avoidance Beliefs Questionnaire (FABQ) - includes separate scales for physical activity (FABQ-PA) and work activities (FABQ-W), with minimal clinically important differences of 4 points and 7 points respectively 3, 4, 5
• Tampa Scale of Kinesiophobia (TSK) - quantifies fear of movement and (re)injury 3, 4, 6
• Pain Catastrophizing Scale (PCS) - measures catastrophic thinking about pain 3

Clinical Subtypes

Patients with FABs can be categorized into three subgroups that guide treatment:

• Misinformed avoiders - require FAB-reducing information and education 1
• Learned pain avoiders - need pain desensitization treatments 1
• Affective avoiders - benefit from fear desensitization and counseling to address negative cognitions 1

Pathophysiology

FABs operate through brain networks that influence pain processing:

• Increased stress responsiveness leads to greater engagement of emotional arousal (threat appraisal) and central autonomic nervous systems even to mild stressors 3
• These beliefs amplify pain severity, interfere with pain inhibitory responses, and prevent self-correction of fear responses 3
• The generalization of fear to other settings increases avoidance behavior and functional impairment 3

Common Pitfall

A critical caveat: FABs can be present in healthcare providers themselves, not just patients. Provider-held FABs negatively impact treatment outcomes by delaying recovery and heightening patient disability. 1 Clinicians should avoid catastrophizing language such as telling patients they "shouldn't be in so much pain" or continuing to order tests to find the "cause" of chronic pain when tissue damage is not present. 3