Clinical Reflections and Updates on the Fear-Avoidance Model (FAM): Beyond the Fear of Movement

Recently, I’ve revisited the Fear-Avoidance Model (FAM), one of the most widely used theoretical frameworks in chronic pain management. For those unfamiliar with it, the model describes a process in which individuals interpret pain as a sign of damage or danger, which leads to fear of movement or physical activity associated with pain. This fear can trigger avoidance behaviors, which may in turn lead to physical deconditioning, disability, and pain chronicity.

While I’ve always found the FAM useful for framing certain dysfunctional behaviors related to pain, I’ve also often perceived its limitations—especially its reductionist view of highly complex psychophysical phenomena (a view echoed by recent literature and commentary here).

This impression is increasingly supported by scientific research that calls for a re-evaluation of the FAM, advocating for more multidimensional and context-sensitive understandings of pain and disability.

Here are some recent insights from the literature that I believe are especially relevant for physiotherapy practice.

1. FAM and Chronic Pain: How Strong Is the Link?

Longitudinal studies show that fear of movement and fear-avoidance beliefs have a low to moderate impact on disability, and an even weaker influence on pain intensity (1–4).
More robust systematic reviews reveal limited evidence supporting a direct causal relationship between fear-avoidance and the development of chronic pain (5).
Furthermore, no consistent link has been found between fear of movement and reduced levels of physical activity in daily life (1).

2. The Role of Other Psychosocial Factors

Fear is rarely the only factor at play. Other elements—such as depression, catastrophizing, and low self-efficacy, parents' intolerance of uncertainty (in youth)—often coexist and exert a cumulative effect on avoidance and the risk of disability. Focusing solely on "fear of movement" may oversimplify the emotional and cognitive complexity often present in persistent pain (6–8).

3. Beyond Avoidance: Overuse and Compensatory Strategies

Interestingly, some individuals respond to pain and fear not with avoidance, but with the opposite behavior: compensatory hyperactivity. These individuals continue moving or working, potentially overloading other body regions, which may perpetuate pain over time.

Such behaviors can contribute to what is described as a “sensitization syndrome”, where both avoidance and overuse may enhance nociceptive sensitivity and drive chronicity (9).

4. Fear Alone Doesn’t Explain Behavior

Later studies suggest that it’s not just fear itself, but rather the ability to inhibit automatic behavioral response—such as avoidance/withdrawal reflex—that better predicts patient outcomes.

Moreover, even the intention or thought of moving can activate defensive responses before fear is consciously felt. This shifts our therapeutic focus from emotion alone to the cognitive mechanisms of regulation and control (10–11).

5. Attentional Biases: Beyond Fear, Beyond Thought

Prof. Judy Veldhuijzen highlights how attentional biases—the automatic tendency to direct attention toward pain-related signals—may develop independently of fear (12).

Hypervigilance, also interpreted as an ongoing embodied prediction of threat (13), triggered by sensory or environmental pain-related cues, may reinforce dysfunctional behavior even in the absence of catastrophizing or conscious fear. Intervening directly on these mechanisms—for instance, through:

Attentional Bias Modification (ABM)
Awareness and attentional focus techniques

—can open up new clinical opportunities. (For more information, see the blog here.)

Personal Clinical Reflection

In my experience, patients don’t just experience fear. Avoidance behaviors may also stem from shame, sadness, frustration, guilt, or lack of motivation. Reducing everything to fear risks oversimplifying a deeply personal and multifaceted experience.

Likewise, not all patients avoid—some overcompensate, push through the pain, or ignore it entirely to avoid stopping. Understanding and normalizing these behaviors is part of our role.

Finally, as Tim Wademan points out, the socio-cultural context matters greatly: economic resources, social support, access to care, and upbringing all profoundly shape how a person experiences and manages pain.

Conclusion

As physiotherapists, our role is not limited to correcting movement, but also to recognizing and working with the complex cognitive, emotional, and contextual factors that influence the pain experience. The FAM has been useful, but today we can (and should) go further—toward more nuanced, personalized, and integrated approaches.

REFERENCES:

Carvalho et al. Fear of Movement Is Not Associated With Objective and Subjective Physical Activity Levels in Chronic Nonspecific Low Back Pain. Arch Phys Med Rehabil 2017;98:96-104.
Jensen J, Karpatschof B, Labriola M, Albertsen K. Do fear-avoidance beliefs play a role in the association between low back pain and sickness absence? A prospective cohort study among female health workers. J Occup Environ Med 2010;52:85–90.
Lamoth CJC, Daffertshofer A, Meijer OG, Moseley GL, Wuisman P, Beek PJ. Effects of experimentally induced pain and fear of pain on trunk coordination and back muscle activity during walking. Clin Biomech 2004;19:551–63.
Wideman T, Adams H, Sullivan M. A prospective sequential analysis of the fear avoidance model of pain. Pain 2009;145:45–51.
Pincus T, Vogel S, Burton AK, Santos R, Field AP. Fear avoidance and prognosis in back pain – a systematic review and synthesis of current evidence. Arthritis Rheum 2006;54:3999–4010.
Westman et al. Fear-avoidance beliefs, catastrophizing, and distress: a longitudinal subgroup analysis on patients with musculoskeletal pain. Clin J Pain 2011;27:567-77.
Wideman TH, Sullivan MJ. Development of a cumulative psychosocial factor index for problematic recovery following work-related musculoskeletal injuries. Phys Ther 2012;92:58-68.
Neville A, Kopala-Sibley DC, Soltani S, Asmundson GJ, Jordan A, Carleton RN, Yeates KO, Schulte F, Noel M. A longitudinal examination of the interpersonal fear avoidance model of pain: the role of intolerance of uncertainty. Pain. 2021 Jan 1;162(1):152-60.
Hasenbring MI, Verbunt JA. Fear-avoidance and endurance-related responses to pain: new models of behavior and their consequences for clinical practice. Clin J Pain 2010;26:747-53.
Meulders A, & Vlaeyen JW (2013). Mere intention to perform painful movements elicits fear of movement-related pain: an experimental study on fear acquisition beyond actual movements. J Pain, 14 (4), 412-23 PMID: 23453562
Karsdorp PA, Geenen R, & Vlaeyen JW (2013). Response inhibition predicts painful task duration and performance in healthy individuals performing a cold pressor task in a motivational context. Eur J Pain PMID: 23788405
Crombez G, Van Ryckeghem DM, Eccleston C, & Van Damme S (2013). Attentional bias to pain-related information: a meta-analysis. Pain, 154 (4), 497-510 PMID: 23333054
Varangot-Reille C, Pezzulo G, Thacker M. The fear-avoidance model as an embodied prediction of threat. Cognitive, Affective, & Behavioral Neuroscience. 2024 Oct;24(5):781-92.