Safety behaviours – do they maintain kinesiophobia?
Let me start by saying this post is conjecture, but based both on observing patients, and after reading an interesting paper on ‘subtle avoidance and safety behaviours relevant to social anxiety’.

First some definitions: I hope you’re all familiar with the term ‘kinesiophobia’, or ‘fear of movement’ – it’s the fear and avoidance of movements that an individual believes will hurt or harm them.

Safety behaviours: are strategies that may be used to reduce the anxiety of carrying out a behaviour – and are usually ‘logically’ linked to the underlying belief about the movement.  For example, using ‘safe lifting techniques’ can be a safety behaviour in someone who is fearful of bending; taking a deep breath in and breathing out prior to doing a movement may also be a safety behaviour, as can moving very slowly while carrying out the movement.

The reason safety behaviours are important in the treatment of phobia is that they are ‘subtle forms of avoidance that are employed during feared movements’, and as such the prevent the ‘unambiguous disconfirmation of unrealistic beliefs about danger’  (note that I’ve inserted the words ‘movements’ and ‘danger’ in these quotes that I’ve drawn from the paper by Cuming, Rapee, Kemp, Abbott, Peters and Gaston, 2009).

Let’s unpack that sentence: in a phobia, a person holds an unconfirmed and (usually) unrealistic belief that some sort of disaster will occur if they encounter the feared stimulus.  In kinesiophobia, this belief can be complicated by the degree of meaning that people hold about experiencing pain – not only are individuals probably correct in their belief that if they move they may experience pain, but from childhood we have been trained to avoid experiencing pain because it is equal to harm or damage.  The problem for people with chronic pain who also have kinesiophobia is that the movements may exacerbate pain but the pain they experience no longer represents harm or damage.  But it doesn’t feel like this!

As a result, people with high levels of fear and avoidance will avoid movements that they believe will cause pain in the belief that some sort of harm will befall them – the harm may be their belief that some sort of damage will occur in their bodies (their backs will ‘fall apart’ or ‘go out’), or it may be much more subtle, perhaps a belief that ‘I can’t cope if the pain increases’, or ‘I will have an awful day and I won’t sleep if my pain goes up’.

As in social phobia, safety behaviours in kinesiophobia prevent the person from experiencing or verifying that the feared outcome will not occur.  The person may instead believe that the awful thing hasn’t occurred because they have used a protective safety behaviour – so they still believe that the movement will cause harm (think of ‘safe lifting’ techniques supposedly reducing the risk of back ‘injury’); or safety behaviours may actually increase the likelihood of experiencing the negative outcome – by tensing and moving very carefully, the person may increase muscle tension and inefficient movement patterns, thereby increasing pain after the movement is complete.  By carrying out safety behaviours, the person never confronts his or her fear that something horrible will inevitably occur – either increased pain that they ‘can’t cope with’, or ‘damage’.

The paper I read that triggered my pondering today suggests that subtle avoidance and safety behaviours are prevalent in individuals with social anxiety.  The subtle behaviours allow the person to remain in a feared social situation – but only if they carry out these ‘special’ behaviours, for example speaking very slowly or quietly, mentally rehearsing what to say, holding onto a utensil very tightly causing it to shake and so on.  The problem is, these behaviours may make the negative outcome more likely (people will get frustrated listening to someone who speaks very slowly or hesitantly!), and they therefore maintain the fear that ‘people will ignore me and I’ll make a fool of myself’.

Can you see the similarities between these behaviours and maybe what we ask patients to do while getting people to carry out movements?

Maybe we ask people to review their footing and posture before they do a manual handling task – suggesting, in effect, that if they do the task ‘this way’ they will be ‘safe’.

Maybe we encourage patients to breathe in a special way, or pre-plan their movements or ‘wait until you’re warmed up’ before doing movements.

Maybe we get them to do special stretches or breathing exercises at certain times of the day, maybe even ask them to rate their pain and if they report any increase in pain, we reduce the demands on them, or try to identify ‘what has caused the pain’ so we can modify the way they do the activity.

Some patients use medication as a way to avoid experiencing fluctuations in pain – experiencing relief almost immediately after swallowing a tablet and way before it can have had a pharmacologic action.  Some patients use splints or hotties or rubs.

What are we reinforcing in our patients when we encourage them to notice their pain, report on their pain, medicate their pain – maybe we’re actually reinforcing their fear that something awful will happen if they experience a fluctuation in their pain?  Or maybe we are fearful of seeing someone experiencing pain?

The authors of this paper describe the development of a self-report measure of safety behaviours – maybe it’s time we started to develop something similar for people experiencing kinesiophobia.  Of course, in social phobia, and indeed in most phobia, the fear is out of proportion to the threat, the avoidance interferes with daily life, and most phobia are recognised as being ‘unrealistic’ .  I wonder if we can say the same about pain-related fear and avoidance – or do we have mixed feelings about how OK it is for people to experience pain?

I think our job is to help people reduce their level of suffering, to minimise the interference that pain has on their lives, and to encourage full participation in life.  I’m not so sure that we always do this when we encourage people to avoid experiencing pain by medicating or avoiding movements or carrying out movements in special ways.  What do you think?

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Cuming, S., Rapee, R., Kemp, N., Abbott, M., Peters, L., & Gaston, J. (2009). A self-report measure of subtle avoidance and safety behaviors relevant to social anxiety: Development and psychometric properties Journal of Anxiety Disorders DOI: 10.1016/j.janxdis.2009.05.002

One comment

  1. I do think that this can be the case—that the fear of pain becomes more of a problem than the pain itself.
    I’ve heard the advice (from an MD) to listen to my pain, and to stop when it hurts. Too much focus on the pain and not enough on rehabilitation.
    But what to do if not what is usually done? It reminded me of “magic spray” to chase away the monsters under the bed of a fearful child. Sometimes it works!
    Better might be to see how much activity is tolerated and suggest that as baseline and encourage just a little more each day. Check in to keep encouraging.

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