PTJ: Physical Therapy & Rehabilitation Journal | Physical Therapy, 2022;102:1–12

https://doi.org/10.1093/ptj/pzab271
Advance access publication date December 23, 2021
Perspective

From Fear to Safety: A Roadmap to Recovery From

Musculoskeletal Pain
JP Caneiro , PT, FACP, PhD1 ,2 ,* , Anne Smith, PT, PhD1 , Samantha Bunzli, PT, PhD3 ,
Steven Linton, Psych, PhD4 , G. Lorimer Moseley, PT, DSc, PhD, FACP, FFPMANZCA, FAAHMS5 ,
Peter O’Sullivan, PT, FACP, PhD1 ,2
1 Curtin University, School of Allied Health, Faculty of Health Sciences, Perth, Western Australia, Australia

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2 Body Logic Physiotherapy Perth, Western Australia, Australia
3 University of Melbourne Department Surgery, St. Vincent’s Hospital, Melbourne, Australia
4 Örebro University, Center for Health and Medical Psychology (CHAMP), Örebro, Sweden
5 IIMPACT in Health, University of South Australia, Adelaide, Australia

*Address all correspondence to Dr Caneiro at: jp.caneiro@curtin.edu.au; Follow the author(s): @jpcaneiro

Abstract
Contemporary conceptualizations of pain emphasize its protective function. The meaning assigned to pain drives cognitive,
emotional, and behavioral responses. When pain is threatening and a person lacks control over their pain experience, it can
become distressing, self-perpetuating, and disabling. Although the pathway to disability is well established, the pathway to
recovery is less researched and understood. This Perspective draws on recent data on the lived experience of people with
pain-related fear to discuss both fear and safety-learning processes and their implications for recovery for people living with
pain. Recovery is here defined as achievement of control over pain as well as improvement in functional capacity and quality
of life. Based on the common-sense model, this Perspective proposes a framework utilizing Cognitive Functional Therapy
to promote safety learning. A process is described in which experiential learning combined with “sense making” disrupts
a person’s unhelpful cognitive representation and behavioral and emotional response to pain, leading them on a journey to
recovery. This framework incorporates principles of inhibitory processing that are fundamental to pain-related fear and safety
learning.
Keywords: Fear of Movement, Musculoskeletal Pain, Recovery, Rehabilitation

Received: February 16, 2021. Revised: November 11, 2021. Accepted: November 23, 2021
© The Author(s) 2022. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved.
For permissions, please email: journals.permissions@oup.com
2 Fear and Safety Learning in Musculoskeletal Pain

Background and disability, we consider this framework applicable across

Chronic musculoskeletal pain is now a leading cause of dis- a range of musculoskeletal pain conditions.15,28
ability worldwide, with the disability burden predicted to To illustrate the utility of this framework, we present a case
grow exponentially in the next 2 decades, placing unsustain- study where CFT is used to guide a person with disabling
able strain on health systems.1 back pain and high pain-related fear on a journey to recovery.
Once serious pathology has been excluded, a person’s mus- Recovery is here defined as a person developing control over
culoskeletal pain experience is influenced by a varying inter- pain, confident engagement with valued activities, and quality
play of multidimensional factors, including, physical, patho- of life.29
anatomical, lifestyle, psychological, social, culture, past his-
tory, sensory, comorbid health, genetics, sex, and life stage.2–5 Fear Learning
The dynamic interplay and the relative contribution from Societal Beliefs About the Body and Pain
each factor is variable, interrelated, and fluctuates temporally,
In Western society, people of all ages, both with pain and
making chronic pain a unique experience to each individual.4
without pain in geographically diverse settings, commonly
These interactions influence tissue sensitivity and continually
hold unhelpful beliefs about the body and pain.30–33 The

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shape a person’s interpretation of their pain experience.2,5,6
body is often perceived as fragile and vulnerable to harm,
Contemporary conceptualizations of pain emphasize its
and the experience of pain is interpreted as threatening and
protective function.2,5,7 The meaning assigned to pain is
often understood as a sign of structural damage. As such,
potentially a powerful cognitive contributor to the need for
there is a perception that the painful body part always needs
protection and therefore influences both the pain itself and
to be protected and “fixed.”30–33 There are examples of this
the person’s individual experience and response to pain. For
in people suffering from pain in the back,30,34 knee,35 and
instance, a recent trial randomized patients to receive threat-
hip.36 Our own clinical studies have demonstrated that people
ening and non-threatening information from MRI reports.
with and without back pain, as well as physical therapists
Compared with those who received non-threatening informa-
who manage people with back pain, show an implicit (non-
tion, patients randomized to threatening information were
conscious) bias about the vulnerability of the back even when
more likely to perceive a need for interventions that carry
they explicitly report otherwise.37–39 This suggests that as a
greater risk and lower benefit such as opioids, injection, and
society, we are biased towards information that supports fear
surgery, while also reporting worse pain intensity, disabil-
beliefs about the body and pain.40
ity, pain cognitions, mental health, and self-efficacy.8 This
highlights how both threatening and safety messages can
Lived Experience of Pain-Related Fear
influence a person’s pain experience and trajectory in the
health system.9 The meaning of pain also influences emotional A body of qualitative work31,34,41,42 exploring the lives of
(ie, pain-related fear) and behavioral responses (ie, protection people living with chronic pain and high fear provides com-
and avoidance).4 Thus, pain-related fear can be defined as a pelling evidence that pain-related fear can be understood as
cognitive and emotional response to an evaluation that the a common-sense response to a threatening pain experience
body is in danger and needs protecting.10 described as severe, uncontrollable, and unpredictable. For
Pain-related fear, psychological distress, and self-efficacy example, when a person believes that performing a painful
have all been shown to mediate the relationship between activity will hurt and/or cause harm to their body, avoid-
pain and disability.11 High levels of pain-related fear ing or modifying that activity is common sense. Although
predict increased disability and poorer outcomes in people avoidance may reduce fear and or pain in the short term, it also
with chronic musculoskeletal pain.12,13 Pain-related fear is prevents the person from having positive learning experiences
modifiable,12 and targeting protective (eg, slow and guarded that would disconfirm their expectations and beliefs. Failed
task performance) and avoidance (eg, not performing a task) attempts to gain control over the pain experience and its
behavior may be an opportunity to reduce disability and the impact can reinforce fear learning and result in increased
burden of chronic musculoskeletal pain.14 disability in the long term.26,27 Qualitative26,27 and experi-
In this paper, we draw on recent data on the lived expe- mental43,44 data highlighted several factors that can reinforce
rience of people with pain-related fear to discuss both fear pain-related fear and behaviors, including diagnostic uncer-
and safety-learning processes and their implications for the tainty, threatening radiological reports coupled with negative
management of musculoskeletal pain. There is now com- advice (explicit or implicit) received from clinicians during
pelling evidence that management of chronic musculoskeletal health care encounters, conflicting advice from different clini-
pain should integrate biological, psychological, and social cians, and societal beliefs about the structural vulnerability of
perspectives.15–19 However, there is a lack of clear directions the body. For some, threatening social contexts such as abu-
for clinicians, particularly physical therapists, on how to sive relationships, bullying, stressful life events, and negative
implement psychologically informed approaches into prac- health care encounters promote a salient learning experience
tice.20–24 The paper aims to provide physical therapists with and may also play a role in facilitating fear learning.45
a clinical framework that describes how Cognitive Functional
Therapy (CFT) 25 can be implemented through the lens of Pain-related Fear, Protection, and Avoidance of
the common-sense model26,27 to promote safety learning Movement
in people with musculoskeletal pain. CFT is an exposure- A large proportion of people with chronic back pain believe
based physical therapy-led approach25 that was developed to that a wrong movement could result in serious negative con-
reduce disability in people with chronic musculoskeletal pain. sequences to their back.46 This belief potentially increases
Because chronic musculoskeletal pain across different body pain expectation, pain experience, and fear, shaping people’s
regions shares common biopsychosocial risk profiles for pain behavior34,47 towards activity avoidance, protective muscle
Caneiro et al 3

guarding, and restricted movement.48,49 It has been proposed experiences pain, their cognitive representation helps them
(but not yet empirically established) that overprotective motor make sense of pain based on 5 dimensions: identity (What
responses can be pro-nociceptive, leading to abnormal stress is this pain?), cause (What caused this pain?), consequences
on sensitized spinal structures and, in turn, increased pain (What are the consequences of having this pain?), timeline
intensity and pain persistence50,51 Other studies highlight the (For how long will this pain last?), and cure/controllability
role of cognitions and emotions as potential mechanisms that (Can this pain be cured or controlled?).57 How a person
may underlie co-occurrence of pain and fear and modulate a makes sense of their pain will influence how they respond to
person’s pain experience.52–54 it from both a behavioral and emotional perspective.26,27 The
dynamic process that includes a person’s understanding and
Generalization of Fear, Protection, and Avoidance their behavioral and emotional responses is here defined as
The inability to distinguish what is safe from what is danger- “learning schema.”
ous has been proposed as a core mechanism in the generaliza- For example, when a person with back pain believes that
tion of protective responses that lead to disability.14,55 This “spinal flexion will cause pain,” the action taken is to avoid
can result in pain being triggered by more functionally dissimi- and guard against flexion, and therefore the predicted out-

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lar stimuli,11 meaning that people are more likely to disengage come is that pain is avoided. If this occurs, it appears that there
from a wider range of movements and activities. For example, is coherence between prediction and outcome even though
when the original painful trigger is associated with bending the coherence actually relates to an opposing prediction and
and lifting, this may result in generalization of fear, avoidance, its outcome. Nonetheless, the original cognitive representa-
and pain to similar (eg, vacuuming, putting on shoes) and tion (that flexion will cause pain) is reinforced by inference,
dissimilar (eg, walking, washing dishes) movements and activ- and the behavior is maintained (ie, the experience does not
ities.11 This generalization of fear and avoidance reduces the promote learning). If the prediction then becomes “avoiding
opportunities to challenge and disconfirm a person’s feared flexion prevents pain” but this does not occur (ie, pain is
expectations, reinforcing fear as a driver of unhelpful behavior experienced despite avoidance of flexion), there is incoherence
and perpetuating disability.10,34 This sustained perceived lack between prediction and outcome and learning occurs sensibly
of safety may play a role in the maintenance of pain-related toward the notion that the cognitive representation does not
fear.55 work and things are even worse than they first appeared.
A person’s inability to predict what makes their pain worse
and the lack of control over their pain experience results
Models of Fear Avoidance in Musculoskeletal in an inability to make sense of pain, which is in turn self-
Pain perpetuating, distressing and disabling, and reinforces fear
The Fear Avoidance Model learning (fear learning schema).10,27,52
A prevailing model explaining the pathway to disability asso-
ciated with chronic musculoskeletal pain is the fear avoidance
model.10,14,56 The model describes how a threatening pain
Safety Learning
experience can lead to an unhelpful cycle of catastrophic Extinction research highlights the importance of learning
thoughts, pain-related fear, avoidance of movement and activ- of a new experience of safety as the primary underlying
ity, and subsequent disability and depressed mood, which in mechanism in fear reduction.58 Fear reduction is related to
turn heightens the pain experience.10,56 Although the fear people’s ability to form new safety memories that compete
avoidance model proposes the return to normal activity in the with old fear memories, thus regulating their emotional and
absence of catastrophizing leads to recovery,10,56 the pathway behavioral response to the source of their fear.7,59 This con-
to recovery is less researched and understood. cept is grounded in the inhibitory learning theory from the
field of anxiety management, which proposes a shift from
The Common-Sense Model and Fear Learning models that use cognitive restructuring and fear habituation
Sense-making is the process by which an individual makes (ie, exposure until fear reduces) as an index of corrective
sense of their pain and what it means now and moving for- learning, towards developing safe associations (ie, new expe-
ward. Insights from qualitative research suggest that “sense- rience of safety).59–61 Inhibitory learning strategies have been
making” processes, beyond pain catastrophizing, play a role proposed to maximize learning of new safe memories.59,60
in pain-related fear learning and disability.31,34 Sense-making Figure 1 provides a summary of the information presented
is at the heart of the common-sense model.57 Bunzli et al pro- in this section, outlining “how to” principles for clinicians to
posed the utility of the common-sense model as a framework promote safety learning in clinical practice.
to assist health care professionals to understand the sense-
making processes involved in the fear avoidance cycle and Common-Sense Model and Safety Learning
how these processes can be targeted to facilitate fear reduc- The common-sense model can also assist clinicians to under-
tion in people with chronic musculoskeletal pain (see safety stand the sense-making processes involved in safety learning
learning section).27 The model describes a dynamic process in people with chronic musculoskeletal pain.27 Take the same
that constitutes a person’s “cognitive representation” of their person with back pain who is fearful, guarded, and avoidant
pain condition, which is formed by memory structures of their of lumbar flexion. If they are reassured that “spinal flexion is
normal functioning self, past experiences of pain, treatments, safe” and they experience that flexing their back in a graded
lifestyle, and social activities. This is updated based on new and relaxed manner does not result in an increase in back pain
information that is heard (eg, media, family, encounters with (or indeed a reduction in pain), there is incoherence between
health care professionals), observed (eg, vicarious experience prediction and outcome; subsequently, learning occurs.
from friends, family, work colleagues), and felt (eg, bodily Expectancy violation is at the heart of inhibitory learn-
sensations, a perceived painful sensation). Once a person ing (or safety learning), meaning that new safe memories
4 Fear and Safety Learning in Musculoskeletal Pain

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Figure 1. Key principles to promote safety learning in clinical practice (once serious and specific pathology has been screened). a These principles are
described in detail elsewhere.67,25

(eg, “flexing my spine is safe”) are developed and com- Utilizing CFT to Implement Safety Learning
pete with the original fear memory (eg, “flexing my spine
causes pain”).59 The development of a strategy that effectively We propose a framework that considers the person’s journey
controls the pain experience combined with an explanation into pain and disability but focuses on the process of
that helps a person make sense of their pain challenges the change in which safety learning can lead to recovery. This
original fear schema,4 which is sensibly updated towards framework enables clinicians to capture the patient’s story,
an experience that is deemed safe (safety learning schema). identify targets for recovery, and assist patients to acquire
The repetition of an experience of safety integrated to the a new understanding through an alternative experience of
person’s life is thought to reduce pain-related fear, disability, safety. The experiential learning and sense-making process
and distress.26,27 outlined in this framework aims to equip patients with
Caneiro et al 5

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Figure 2. Schematic illustration of the proposed clinical framework. (A) Person’s common-sense response to a pain experience interpreted as threatening
(fear schema). (B) Core elements of Cognitive Functional Therapy as a vehicle to promote safety learning. The experience may confirm or violate the
original schema. Confirmation of pain as a threatening experience (ie, learning does not occur) leads to the reinforcement of the person’s fear response.
Violation of pain as a threatening experience (ie, learning of safety occurs) can powerfully disconfirm fear-avoidance beliefs while reinforcing that valued
activities can be safely confronted when performed without safety behaviors and reduced pain vigilance. This leads to an update of the person’s
response that promotes generalization of safety. (C) Person’s common-sense response to an experience interpreted as safe (Safety schema). (D)
Response to a pain flare, which may reinforce fear or safety learning. This is a crucial learning opportunity that influences a person’s process to recovery.

effective strategies to independently control pain and prevent providing opportunity for targeted exploration of their
flare-ups in pain intensity and/or control the impact of pain in concerns within the interview66 (Fig. 1 provides examples
their lives and emotional responses to pain. The combination of screening tools).
of a new cognitive representation and an effective set of Clinicians are encouraged to use the common-sense model
strategies enables patients to problem solve the best course to explore the patient’s pain representation, emotions. and
of action in any given context so they can confidently engage behavioral responses to pain. Patients can be prompted to
in valued life activities.25,27,31 This framework endorses best- reflect on experiences that led to their understanding of pain
practice recommendations,15 providing clinicians with a clear and how this impacts their behavior.27,67 Insight into the
roadmap of how to implement exposure to promote change person’s feared, avoided, and pain-provoking activities that
clinically. are aligned to their goals provides clear targets for expo-
Not all patients in pain are fearful. Acknowledging that sure.25,67 This approach encourages greater partnership in
avoidance can also occur as a commonsense response to an clinical encounters.63,68
unhelpful pain representation based on what they have been
told or experienced; we propose that our framework may also Exposure
be helpful in patients who report low levels of fear. Behavioral exposure specifically targets pain-related fear and
The proposed clinical framework is schematically illus- avoidance by gradually exposing the person to the tasks
trated in Figure 2. It displays a pathway to recovery from pain- they fear or avoid while challenging unhelpful cognitions and
related fear using CFT as a vehicle to promote safety learning. disconfirming threat expectations (ie, task performance with-
out the occurrence of the expected catastrophic outcome).69
The Therapeutic Relationship Traditionally, exposure therapy targets erroneous harm beliefs
For patients in pain, the use of a communication style that is (eg, “lifting will damage my disc”) rather than pain itself.69
open, non-judgmental, reflective, and provides validation of However, the basis of avoidance and the cognitive representa-
the person’s emotions, beliefs, and experiences is paramount tion of pain vary between people (ie, fear of damage, fear of
to safety learning.62 This communication style decreases pain, fear of the consequences of being in pain, or a common-
arousal, facilitates disclosure, and encourages problem- sense response to what they have been told or experienced).27
solving.63,64 Communication practices that foster a strong, For patients who avoid lifting because they fear an increase in
trusting therapeutic alliance create an environment of reduced pain and its consequences, exposure to repeated lifting when
distress that sets the stage for safety learning and behavioral it leads to an increase in pain and distress may inadvertently
change.63,65 The use of a screening questionnaire prior to reinforce fear learning.
the interview provides the clinician with a perspective on the In contrast, exposure with control is a process of behav-
person’s pain and disability levels, cognitions, and emotions, ioral change that explicitly targets the pain experience itself
6 Fear and Safety Learning in Musculoskeletal Pain

(where possible), using pain as a hypothesis for testing during patient in this process. They also need to be skilled to manage
behavioral experiments (eg, “lifting will increase my pain”). potential emotional responses, because exposure can elicit
Behavioral experiments during exposure provide an experi- strong emotional responses, anxiety, and occasionally panic in
ence in which learned associations between threatening tasks a patient. An awareness of the clinician’s own pain and move-
and increased pain or harm may be corrected (ie, that new ment/activity beliefs, as well as specific training, appears to
“safety” associations are formed). This strategy derives from be important when implementing this approach. This reflects
the premise that the mismatch between expectancy and expe- a process of exposure training for both the clinician and the
rience is helpful for new learning60 (see Tab. 1; and row 3 in patient.24,25,67,73
Suppl. Tab. 1 for an example illustrated by the case study).
Whereas for some patients the goal is to experience less pain Making Sense of Pain
during task performance, for others, it may be engaging with
The process of making sense of pain is reflective and uses a
the feared and avoided tasks without damage. In this process,
persons’ own story combined with their experiences during
sympathetic responses and safety-seeking behaviors that occur
behavioral exposure to gain a new understanding of their
during the performance of painful, feared, or avoided func-
pain and build self-efficacy to achieve their goals.25 The

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tional tasks are explicitly targeted and controlled to create a
common-sense model can be used to explain this process.27
discrepancy between the patient’s expected and actual pain
Qualitative31 and clinical71 data of people with disabling back
responses (ie, prior patient expectation: “I expect my pain
pain undergoing CFT found that clinical improvement was
will get worse with repeated bending”; behavioral experiment:
attributed to a person’s ability to make sense of their pain
patient experience “When I relax, breathe and bend my back
experience in a non-threatening way and their ability to gain
without protecting it, my pain does not get worse—it in fact
control over the pain experience and/or the effects of pain in
reduces”). This includes promotion of body relaxation prior
their life. This was achieved through developing a new and
to exposure, reduction of protective behaviors, facilitation of
coherent cognitive representation of pain that guides effective
body awareness, and control that enables the person to experi-
behavior.
ence the performance of functional activities in non-protective
Based on the common-sense model, a coherent represen-
way.25,70,71 For instance, lifting in a relaxed manner and mod-
tation includes diagnostic certainty from a biopsychosocial
ifying how the person physically performs the task without
perspective (identity) that can explain a person’s symptoms in
unhelpful protective responses (ie, breath holding, bracing,
a meaningful way (cause), replacing erroneous beliefs about
avoidance of spinal flexion) may result in a positive experi-
pain and its damaging or disabling effects (consequences) and
ence that promotes safety learning.25,70 A recent case series
provides strategies for controlling symptoms and emotions
demonstrated that for the people in whom improvements in
in a manner that re-engages them with living (timeline and
pain were related to changes in movement, they adopted a
control).27 The development of a new cognitive representation
new behavior considered “less protective” (ie, greater range
is an interactive learning process that is achieved via reflecting
and speed of movement and more relaxed back muscles).70
on the person’s own narrative, experience, self-reflection, and
In another case series, people with high pain-related fear
education. This process disconfirms previously held unhelpful
reengaged with previously feared and avoided activities after
beliefs and allows a person to reconceptualize and understand
undergoing a 12-week CFT intervention.71 Exposure that
their pain symptoms and emotional and behavioral responses
promotes “control” of emotional and behavioral responses
to pain in a new way through a biopsychosocial lens, with the
to pain provides a potential pathway to return a person to
aim to gain self-efficacy.25
their valued activities without pain escalation and associated
distress.25
Safety learning is consolidated by asking patients to reflect The Journey to Recovery
on what they learned regarding the non-occurrence of the The experience of “safety” is key for the recovery of a person
feared event, discrepancies between what was predicted and who is protective and/or avoidant. The pathway by which a
what occurred, and the degree of “surprise” from the exposure person recovers is unique for each person. This was previously
practice.60 The experience and this reflection process chal- illustrated in Caneiro et al.71 Although for some this process
lenge the person’s implicit and explicit beliefs.4 This process is can occur in a few weeks, for others it may take longer
repeated for reinforcement of the new experience, and expo- (3–6 months).25 A study investigating how changes in pain-
sure is progressed to further disconfirm unhelpful beliefs. The related fear unfolded over the course of a 12-week CFT
new learned strategies are immediately integrated into daily intervention demonstrated that changes in pain intensity, pain
activities to build self-efficacy and promote generalization controllability, and pain-related fear were associated with
across contexts and activities. changes in disability. The factors that changed, and the rate
When pain control is not achievable during this process, the and pattern of change, differed for each person, highlighting
focus is placed away from pain and toward non-protection individual variability in the process of change.71 A qualita-
and reassurance that the activity is safe while undergoing the tive study found that people with chronic back pain who
process of graded exposure to personally relevant functional gained control over pain by modifying the way they move
and lifestyle goals. In these cases, the journey towards living reported an ability to self-manage pain and flare-ups while
is the experiment itself.25,72 engaging in valued goals.27 Among those who did not achieve
Exposure can be very challenging for the patient as well pain control, some reported poorer outcomes at follow-up,
as the clinician who needs to support the patient along the whereas others reported that accepting the unpredictability
journey. To guide their patient to engage in painful, feared, and uncontrollability of pain or adopting a new and more
and/or avoided movements and activities, clinicians need to positive mindset about the causes and consequences of pain
be confident they have adequately screened for specific and enabled them to control their worry and engage in valued
underlying pathology and that they will not “harm” the activities.27 This suggests the likelihood of multiple individual
Table 1. Qualitative Reports Based on the CSM Before and After an Exposure-Based Approacha [[ImEquation#]][[ImEquation#]]

Baseline Management Follow-Up

Caneiro et al

CSM Constructs
(8 wk Pretreatment) (12 wk) (6 mo)
Representation Identity Tissue damage (ie, An individualized, exposure-based behavioral approach (Cognitive Functional Therapy) 25 “The fear of doing things
muscles, ligaments, disc, including the following key components: that would make me sore,
and nerves) The story: an interview centered in the person’s narrative to explore their story and experiences and the tension that
of pain. This sets the scene for targeted behavioral experiments and exposure. comes with it . . . and me
Exposure with “control”: a process of behavioral change through experiential learning following disengaging from family,
a “graded exposure” model designed to violate expectations of pain and damage via guided work and all that I
behavioral experiments. wanted to do . . . . it was a
The movements and activities that she feared and avoided were explored and revealed vicious cycle really.”
breath-holding, muscle guarding, and avoidance of flexion of the lumbar spine during sitting,
bending, and lifting.
Behavioral experiments revealed that visualization of bending and lifting increased pain and
muscle tension. Slow diaphragmatic breathing and relaxation of spine posture in sitting reduced
pain.
Graduated exposure to lumbar flexion with control (ie, relaxed spinal flexion) led to less pain
than she expected. This positive experience confronted her beliefs about bending, pain, and
damage, allowing her to experience pain control during feared and provocative tasks.
Repeated exposure to relaxed bending and lifting was gradually progressed (from 0 kg to 15 kg)
over 12 wk reinforcing that these movements were safe.
The strategies learned were integrated with daily activities to reinforce safety learning and
promote generalization.
Making sense of pain: reconceptualization of pain via self-reflection, behavioral learning, and
personalized education linked to her story.
Explained how negative beliefs, distress, poor sleep, fear, worry, lack of confidence, activity
avoidance, and protective muscle guarding set up a vicious cycle that sensitizes the spinal
structures that lead to pain and disability.
The positive experience during guided behavioral experiments reinforced that her back was
structurally sound, that pain does not equal harm, and that relaxed movement is healthy and safe.
Generalization: integration of strategies in her daily life enabled self-learning and self-discovery
during the rehabilitation that guided subsequent progression across different sessions in a
goal-orientated manner.
Lifestyle change: behavioral modification addressing unhelpful lifestyle factors, including: (1)
advice to improve sleep hygiene (7 h/night, regular sleep time, breathing techniques to relax); (2)
encouragement to gradually reengage in family activities including walking, bike riding, and
beach walking. She was advised to perform these activities on a time contingent manner rather
than contingent on pain; (3) perform body and mind relaxation strategies daily.
Flare–up plan: that equipped her with effective strategies to independently prevent or manage
pain flare-ups, unhelpful responses to pain, and/or control the impact of pain in her life, which
allowed her to engage in valued life activities.
Treatment dose: 8 sessions over 12 wk. The initial session was 1 h and the follow ups were
30–45 min. This patient was seen on a weekly basis for the first 3 sessions and then progressed to
1 session every 2–3 wk.
An individualized self-management program was provided that included behavioral strategies,
progressive functional exercises, and lifestyle changes tailored to personal goals.

(Continued)
7

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 8

Table 1. Continued

Baseline Management Follow-Up

CSM Constructs
(8 wk Pretreatment) (12 wk) (6 mo)
Cause “A car accident 23 years “The fact that I avoided doing a lot of things and moving because I
ago made my back weak, was fearful of making it worse is the reason why I got worse.”
and then having kids
made it worse.”
Consequences “The pain is worsening “A big thing for me has been having the physical therapist
( . . . ) It affects my life alongside me, guiding me. Another big thing was having a positive
every day. I’m not able to experience.”
do things that I
like . . . things like
gardening . . . what normal
people do.”
Control/curability “There’s not much I can “Definitely much more control than I had before. I still get
do to control it ( . . . ) occasional periods of pain, but they are a lot more manageable. I
Avoidance is my control.” do things differently, more relaxed, breathing and using my legs
and that reduces the pain.”
Timeline “That’s just how it is, and “Definitely improving, and it’s kind of surprised me as well,
I have to learn to accept because coming down off the Opioids was very hard.”
it.”
Behavioral response Action “Just anything that “There was a process of teaching me how to move differently (in a
involves bending, just relaxed manner). This gave me a sense of control over my pain, my
puts that thought in my life really.”
mind. ‘Can I or can I
not?’ And the majority of
the time I’ll just avoid.”
Appraisal “Nothing that I have “This process gave me confidence I can do most things. Now, I
done so far, chiropractor, have strategies and a plan, and they work.”
physical therapist,
massage, Pilates,
injections, has been
effective—only avoidance
is effective.”
Coherency “There is a lot of “A lot of it now, feels like it’s common sense, but it was actually
conflicting advice . . . . I quite empowering for me to learn.”
follow it, but I don’t get
better . . . .it is confusing
really.”
Emotional response Emotion “It’s upsetting, it makes “I’m not fearful of bending and lifting. I know I can change it and
you feel useless, not being that makes me feel in control, empowered.”
able to do what other
people can do ( . . . ) It is
frightening.”
a CSM = common-sense model.
Fear and Safety Learning in Musculoskeletal Pain

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Caneiro et al 9

Figure 3. Roadmap to recovery.

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pathways to reducing disability related to chronic pain in frequently offers reimbursements for imaging, medication,
people with pain-related fear. and surgery (when not indicated by guidelines), but not
Booster sessions may be necessary for when/if pain again for person-centered physical and psychological interven-
becomes uncontrollable, distressing, and/or disabling. Dur- tions.75,76 The biomedical model of care provides a fertile
ing pain flares, the old cognitive representation can resurge context for fear learning, which can lead a person to believe
strongly, often re-activating unhelpful behavioral and emo- their body is fragile and damaged and needs protection.3
tional responses. In the study by Caneiro et al, all participants The beliefs of both clinicians and patients that pain is asso-
experienced pain flare-ups of variable intensities and duration ciated with damage (in the absence of trauma or indicators of
that provided opportunities to reinforce safety learning.71 serious/specific pathology), that scans identify the source of
Providing patients with an individualized management plan pain, and that symptoms occur as a consequence of structural
for pain flare-ups with the potential to re-engage with care is and biomechanical abnormalities are pervasive.9,34,77,78 This
important (see “flare-up plan” in Tab. 1). commonly leads to the view that targeting the structure or
The following clinical case illustrates the processes of fear body “abnormalities” will fix pain, which in turn often leads
learning and disability, and safety learning as a roadmap to to overmedicalization, unnecessary and potentially unhelp-
recovery (Fig. 3). ful tests, and limited effectiveness of interventions for most
chronic musculoskeletal pain conditions.3 Threatening advice
Case Study to patients such as “let pain guide you,” “your pain is due
Patient’s Story to wear and tear,” “if it hurts avoid it,” “engage your core
when you move,” and “lift with a straight back” suggest
A 45-year-old woman had a 23-year history of (non-specific)
vulnerability of the body and reinforces an unhelpful cognitive
back pain. A mother of 2, she is married and works part-time
representation that can lead to or reinforce avoidance/protec-
from home. She has seen several health care professionals,
tive behaviors.77–79 In this way, physical therapists have the
including general practitioners, chiropractors, massage ther-
capacity to influence patients into fear or safety learning.
apists, physical therapists, spinal surgeons, and pain physi-
There is a need for change in how we communicate about
cians. She manages her pain with rest, heat packs, massage,
the body and pain to people with and without pain to reduce
light stretches, non-steroidal anti-inflammatories, gabapentin,
fear learning, promote safety messages, and minimize or
several spinal injections, and opioids (including Oxycodone
prevent the impact of pain in people’s lives.67,80 To promote
for many years). Her goals are to be able to participate in
safety learning, it is imperative to disseminate messages
her family activities and be healthier, fitter, and stronger. Key
broadly in society that instill positive perceptions about the
contributing factors for this patient’s presentation are unhelp-
body and pain, that build confidence in the body in its capacity
ful damage beliefs, high pain-related fear (of pain/flare-ups
to heal and adapt, and that encourage the adoption of healthy
and damage), high pain catastrophizing, guarded movement
behaviors, including movement and physical activity, as safe
and avoidance behavior, poor sleep, activity avoidance, low
and helpful.43,44,75 Having a unified narrative among family
physical conditioning, and hyperalgesia to touch and move-
members, friends, carers, workplace colleagues, and advisors
ment. Table 1 outlines this patient’s cognitive representation
is critical because they play an important role in a person’s
of her pain and her behavioral and emotional responses to
journey to recovery. In contrast, conflicting advice, unhelpful
pain before and after a CFT intervention (key elements of the
carers, social stress, mental health, and co-morbidities can be
intervention are outlined in the table). Supplementary Table 1
obstacles for recovery.76 This highlights the importance of co-
outlines how inhibitory learning strategies can be integrated
care and communication with community services to support
to the management of musculoskeletal pain conditions, using
a person’s path to recovery.
the case patient in this paper as an example.
Clinical pathways that align with evidence and clinical
practice guidelines are optimal, but not always delivered.15 To
Challenges and Implications for Clinical facilitate safety learning in patients with pain who are fearful
Practice and/or avoidant, clinicians require excellent communication
Despite the promotion and awareness of a biopsychosocial skills that are reflective, validating, and empowering.25,62,76
approach to pain, a biomedical model commonly underpins Clinicians also need to be specifically trained and mentored
current education and practice.74 Health system models to achieve competency to perform exposure with control,25
can limit access to best practice, where health funding and changes to physical therapy curriculum are needed to
10 Fear and Safety Learning in Musculoskeletal Pain

upskill clinicians on the understanding and delivery of person- bodies have reimbursed him for travel costs related to presentation of
centered care. research on pain at scientific conferences/symposia. He has received
Public health initiatives are needed to change the pervasive speaker fees for lectures on pain and rehabilitation. He receives book
societal belief that the body (the back,30,34 the knee,35 and the royalties from NOIgroup publications, Dancing Giraffe Press, and
hip36 ) is vulnerable.67 Community outreach initiatives such OPTP for books on pain and rehabilitation. Steven Linton, Anne Smith,
and Samantha Bunzli declare no conflict of interest.
as the Pain Revolution (https://www.painrevolution.org/), the
painHEALTH (https://painhealth.csse.uwa.edu.au/), the joint
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review. Spine J. 2014b;14:816–836.e814.
Concept/idea/research design: JP Caneiro, A. Smith, S. Bunzli, 13. Zale EL, Lange KL, Fields SA, Ditre JW. The relation between
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Funding J Sports Med. 2020;54:79–86.
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JP Caneiro and Peter O’Sullivan deliver educational workshops on agement of low back pain: future directions in practice and
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Health; ConnectHealth UK; Seqirus; Kaiser Permanente; Workers’ tis: randomized controlled trial. Arthritis Care Res. 2016;68:
Compensation Boards in Australia, Europe, and North America; 590–602.
AIA Australia, the International Olympic Committee; Port Adelaide 19. van Erp RMA, Huijnen IPJ, Jakobs MLG, Kleijnen J, Smeets R.
Football Club; and Arsenal Football Club. Professional and scientific Effectiveness of primary care interventions using a biopsychosocial
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