Fear, avoidance, and getting moving again.

What is the fear-avoidance model of pain?

The model was developed largely by Johan Vlaeyen, Steven Linton, Geert Crombez and colleagues. In their 2016 summary they describe how a painful experience can lead in two directions (Vlaeyen et al., 2016). If pain is interpreted as temporary and not especially threatening, people tend to stay active and recover. If it is interpreted catastrophically, as a sign of serious harm, it can trigger pain-related fear. Fear leads to vigilance and avoidance of movement. Avoidance leads to deconditioning, disability, low mood and often more pain, which feeds back into the cycle.

Earlier reviews tracked the evidence for each link in the chain (Vlaeyen and Linton, 2000; Leeuw et al., 2007; Vlaeyen and Linton, 2012), and later work proposed refinements (Crombez et al., 2012). The model is not a complete explanation of chronic pain, and researchers continue to debate its details. But it gives clinicians a practical map: if fear and avoidance are keeping someone stuck, those are things that can be worked on. Our guide to kinesiophobia describes how that fear is measured.

How much does fear explain disability?

A 2015 systematic review looked at mediation studies in people with back and neck pain to ask how pain leads to disability (Lee et al., 2015). Mediation studies examine which factors sit on the pathway between pain and outcomes. Pooling 12 studies with nearly 3,000 participants, the authors found that self-efficacy, psychological distress and fear each partly explained how pain led to disability, while catastrophizing did not reach significance.

The underlying studies were of low methodological quality, which the authors say plainly. Their conclusion still stands as a practical one: these factors are worth targeting directly in treatment, rather than focusing on pain intensity alone.

What is graded exposure for pain?

If fear drives avoidance, one solution borrowed from anxiety treatment is exposure. In graded exposure in vivo, a clinician and patient identify the movements or activities the person fears, rank them from least to most threatening, and work through them step by step. The goal is not to push through pain. It is to test predictions. Someone who expects that bending will damage their back learns, through repeated safe experiences, that it does not.

Randomized trials have tested the approach in chronic low back pain. Leeuw and colleagues compared exposure in vivo with operant graded activity (Leeuw et al., 2008), Woods and Asmundson evaluated graded exposure for pain-related fear (Woods and Asmundson, 2008), and an economic evaluation asked whether exposure was cost-effective (Goossens et al., 2015). Together they establish exposure as a credible option, particularly for people whose fear of movement is high.

What did the RESTORE trial find?

Cognitive functional therapy, or CFT, was developed by Peter O'Sullivan, Peter Kent and colleagues in Australia and combines several of these ideas. It helps people make sense of their pain, challenges unhelpful beliefs, and uses guided movement experiments to build confidence, while also attending to sleep, stress and activity.

The RESTORE trial tested CFT in 492 adults with chronic, disabling low back pain across 20 primary care physiotherapy clinics in Australia (Kent et al., 2023). People received up to seven sessions over 12 weeks. Both CFT alone and CFT with movement sensor biofeedback reduced activity limitation compared with usual care by about 4.6 points on the 24-point Roland Morris Disability Questionnaire at 13 weeks, with similar effects at one year. CFT was also less costly from a societal perspective. Three-year follow-up results have since been published (Hancock et al., 2025).

What does breaking the fear-avoidance cycle look like in practice?

For clinicians, the steps are consistent across these approaches:

• Ask what the person believes is happening in their body, and what they fear will happen if they move.
• Explain pain in a way that lowers threat, drawing on pain neuroscience education.
• Build a hierarchy of feared activities and work through it together.
• Frame each step as an experiment: what do you predict, and what actually happened?
• Measure function and confidence, not only pain scores.

For people living with pain, it may help to know that fear is a normal response and not a personal failing. Gradually re-engaging with the activities you value, ideally with someone alongside you, is one of the best tested routes out of the cycle. Karuna's program applies the same sequence: understand first, then move in graded steps, with a coach each week. See how it works.