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Fear Avoidance (What you Resist, Persists…) by Chris Shorter

Evening folks! Hope you’re all keeping warm in the snow!

I’ve got a real winter warmer for today’s #Advent blog series: a guest blog from my colleague at North Light Physio, the multi-talented Christopher Shorter.  He’s done a great piece about what we in the #pain management business refer to as “Fear-Avoidance”!

Check out Chris’s website:

Without further ado, over to Chris! Enjoy!

What do #backpain and #dizziness have in common? Answer: Fear

More notably fear avoidance of movement.

I work with a number of different conditions in the public and private sector and despite the large variety of cases I see, there are many common themes. Fear avoidance is a big one, it was first defined by Lethem et al. in 1983 but I’m guessing it was around much longer than that.

Fear keeps us safe, fear holds us back from injury and shoots us with a boost of adrenaline when needed. However when fear turns into a chronic apprehension of movement it begins to work against us.

You can acronym fear down to this: (I’m not claiming this, I heard it on a podcast a long time ago!)

  • F  = FALSE.


  • A = APPEARS.

  • R = REAL.

So we can fear something that is not real. Some evidence may suggest it is, such as the belief that pain is always a sign of damage or symptoms occurring when we move, but in a huge amount of cases it is our beliefs that need changing…it is basically just false evidence.

Let’s apply the fear avoidance pattern to dizziness (aka vertigo/ labarynthitis/neuritis). Dizziness can be due to problems with the balance control system of inner ears. It is in fact very common and a high proportion of A and E visits can be due to this. The dizziness linked to the inner ears / nerve pathways of the ears is called a vestibular problem. In some people you can get a short lived vestibular problems just like most of us will get an episode of back pain once in our lives, the causes can be diverse (but that’s for another blog maybe),  both can resolve can quickly. Some facts about dizziness are:

  • Almost 1 in 4 adults under 65 report dizziness or vertigo, often causing occupational difficulties or preventing employment, but less than 25 per cent had received treatment (Collertan et al 2012).

  • Dizziness is one of most frequently reported symptoms for people over 75 seeking medical assistance (Sloane & Dallara 1999).

Sometimes the dizziness symptoms persist. They may not be as intense as the initial episode but they are enough for us to start to limit our movement and cause us some anxiety about keeping the dizziness at bay. Medication can also be prescribed as a dizziness sedative, but patients should be encouraged to wean off this. So a typical coping mechanism is commonly to self-restrict neck and head movements, limiting activities around the home or out and about. Classically busy places such as supermarkets become tricky to move around in. Our movements can change, when we turn the head we tend to turn the whole body in a robotic manner. Stiffness can also develop in the muscles and joints of the neck, as well as neck pain and headaches. This is where the importance of education comes in and I commonly tell my patients the following:

  • For the vestibular (balance) system to reset itself (to recover) it needs to experience normal movement of the head and neck. It also needs to experience error signals (i.e  – dizziness). It is OK to move the head and neck and it is also OK to feel some dizziness when doing this (this helps to re-calibrate the system).

Being told to move normally again is often quite anxiety-inducing in patients but believe me it works and it can be done at a pace comfortable for the patient (known as graded exposure to movement, not “in at the deep end” stuff!).

If we now look at this pattern in back pain. As physio’s we often find the patient is very apprehensive when bending forwards. For example and they may use mal-adaptive movement patterns (not moving normally), such as keeping the back entirely straight or arched when bending to pick an item from the floor. This is fear avoidance due to fear of pain, or fear of damage, or both. I accept that in the first few days, sometimes weeks of back pain we maybe move less to protect our self but if this goes on for many weeks, months, even years in some cases, it can become very disabling.  So just like a dizziness problem the area affected can become stiff, tense, very sensitive and weaker, not to mention in a lot of cases the pain persists. So again for clinicians; education and listening skills are vital. Hearing from the patient why they have changed their way of moving and what they are fearing is very important and can lead to a lot of clinical reassurance and confidence building. Movements restriction are often due to outdated beliefs, for example thinking our back remains damaged long after the time for healing has occurred. So just like for vestibular rehab, movement is encouraged, with bags of reassurance when needed.

In vestibular rehab when we start to move our head again it can invoke some discomfort or dizziness, remember this is normal. Similarly when moving our back again it can induce some pain or stretching type discomfort. Beginning to move normally again may initially feel stiff or painful, but this is hurt not harm.

A great line which also applies on many levels in life is ‘what you resist persists’. So if you are resisting movements due to dizziness or pain linked to fear of worsening symptoms, be open to the fact that your self-restriction may be holding you back.

This blog is a guide to give an idea of the concept of fear avoidance on how it applies to subsets of two conditions. This may not be the definitive answer but in some cases it is. A full assessment is always required.  Pain and dizziness have many more factors feeding into them, anxiety is a big feeder, as is our emotional health.

Contact me for a more detailed consultation.   I offer consultations and treatment for vestibular rehabilitation and assessments for chronic and acute pain.


Chris Shorter is a Chartered Physiotherapist with North Light Physiotherapy Associates, Huddersfield, UK.  Find out more about Chris and his work at at


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