Fear Avoidance

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

By Frank M. Painter|September 3, 2025|Chronic Low Back Pain, Fear Avoidance, Neurology|

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

SOURCE: J Pain 2018 (Nov); 19 (11): 1352–1365

Dan-Mikael Ellingsen • Vitaly Napadow • Ekaterina Protsenko • Ishtiaq Mawla • Matthew H Kowalski • David Swensen • Deanna O’Dwyer-Swensen • Robert R Edwards • Norman Kettner • Marco L Loggia

A. A. Martinos Center for Biomedical Imaging,
Department of Radiology,
Massachusetts General Hospital,
Harvard Medical School,
Boston, Massachusetts.

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. PERSPECTIVE: This 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.

Keywords: Expectation; Fear-avoidance; Pain anticipation; Physical exercise; Spinal Manipulative Therapy; chronic Low Back Pain; functional Magnetic Resonance Imaging.

From the FULL TEXT Article:

Background

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Pain-Related Fear-Dissociable Neural Sources

By Frank M. Painter|January 15, 2019|Fear Avoidance, Outcome Assessment, Pain Management|

Pain-Related Fear-Dissociable Neural Sources of Different Fear Constructs

The Chiro.Org Blog

SOURCE: eNeuro. 2019 (Jan 3); 5 (6) pii: ENEURO.0107-18.2018

Michael Lukas Meier, Andrea Vrana, Barry Kim Humphreys, Erich Seifritz, Philipp Stämpfli, and Petra Schweinhardt

Integrative Spinal Research,
Department of Chiropractic Medicine,
Balgrist University Hospital,
8008 Zurich, Switzerland.

Fear of pain demonstrates significant prognostic value regarding the development of persistent musculoskeletal pain and disability. Its assessment often relies on self-report measures of pain-related fear by a variety of questionnaires. However, based either on “fear of movement/(re)injury/kinesiophobia,” “fear avoidance beliefs,” or “pain anxiety,” pain-related fear constructs plausibly differ while it is unclear how specific the questionnaires are in assessing these different constructs. Furthermore, the relationship of pain-related fear to other anxiety measures such as state or trait anxiety remains ambiguous. Advances in neuroimaging such as machine learning on brain activity patterns recorded by functional magnetic resonance imaging might help to dissect commonalities or differences across pain-related fear constructs. We applied a pattern regression approach in 20 human patients with nonspecific chronic low back pain to reveal predictive relationships between fear-related neural pattern information and different pain-related fear questionnaires.

More specifically, the applied multiple kernel learning approach allowed the generation of models to predict the questionnaire scores based on a hierarchical ranking of fear-related neural patterns induced by viewing videos of activities potentially harmful for the back. We sought to find evidence for or against overlapping pain-related fear constructs by comparing the questionnaire prediction models according to their predictive abilities and associated neural contributors. By demonstrating evidence of nonoverlapping neural predictors within fear-processing regions, the results underpin the diversity of pain-related fear constructs. This neuroscientific approach might ultimately help to further understand and dissect psychological pain-related fear constructs.

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Rethinking the Fear Avoidance Model

By Frank M. Painter|June 12, 2017|Biopsychosocial Model, Fear Avoidance|

Rethinking the Fear Avoidance Model: Toward a Multidimensional Framework of Pain-related Disability

The Chiro.Org Blog

SOURCE: Pain. 2013 (Nov); 154 (11): 2262–2265

Timothy H. Wideman, Gordon G. J. Asmundson, Rob J. E. M Smeets, Alex J. Zautra,

School of Medicine,
Johns Hopkins University,
Baltimore, MD, USA.

Introduction

Nearly 20 years ago the Fear Avoidance Model (FAM) was advanced to explain the development and persistence of disabling low back pain. The model has since inspired productive research and has become the leading paradigm for understanding disability associated with musculoskeletal pain conditions. The model has also undergone recent expansion by addressing learning, motivation and self-regulation theory [10, 34]. In contrast to these extensions, however, one relatively constant aspect of the model is the recursive series of fear-related cognitive, affective, and behavioral processes shown in Figure 1 [31, 32, 34].

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