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One Thing Clinical Module: Fear & Avoidance

Fear, avoidance, and chronic shoulder pain

A clinical learning module for rehabilitation health professionals, built from One Thing pain science interviews.

"Your fear makes sense. And it is also keeping you stuck."
Understand kinesiophobia Break the avoidance cycle Help Maria move again
STEP1

Watch Dr. Ann Meulders' One Thing

Dr. Ann Meulders researches the psychology of pain-related fear. Her One Thing is the thread running through this entire module: face the fears, challenge the thoughts, and create the conditions for safety learning to happen.

Ann Meulders
▶ Open on YouTube
→
Ann's One Thing
"Face your fears and challenge your thoughts."
Then work through this module

Ann's research shows that avoidance keeps fear alive, and that safety learning is slow, asymmetric, and requires deliberate clinical effort. Maria is the patient who makes this concrete.

STEP2

Meet Maria

Read her clinical profile before working through the module.

M

Maria

35-year-old drywall installer · Chronic right shoulder pain · 6 months

Age
35
Occupation
Drywall installer (8 yrs)
Pain duration
6 months
Pain at rest
6/10
Pain with movement
8–9/10
Time off work
3 weeks

"I can't reach the top shelf. I can't put my arm behind my back. Even putting on my jacket kills me."

Clinical flags

High pain catastrophizing: magnification, rumination, helplessness
Prominent kinesiophobia: fear of movement significantly limiting rehab
Nocebo effect: previous clinician's prognosis was harmful and inaccurate
Low self-efficacy and hope: "I don't see how this is going to get better"
Physician clearance confirmed. No red flags. No surgical indications. Maria's recovery is being shaped by pain-related fear and beliefs, her work and family context, and physical deconditioning. These are all addressable alongside continued clinical assessment and rehabilitation.

Your first impressions

Before moving on, take a moment to reflect. What are your impressions of Maria? What do you think will be the most difficult thing to manage?

What she believes about her pain

Maria believes her shoulder is seriously damaged. She uses language like: "Every time I move it, I can feel it getting worse," "What if I'm doing permanent damage?" and "I don't see how this is going to get better." These are not exaggerations. To Maria, this is simply being realistic.

Her previous clinician told her there was nothing more that could be done, and she believed them. She arrives at your appointment skeptical, guarded, and a little defeated. She is also the primary income earner for her household and has two children aged 7 and 10. She won't mention this unless asked.

A moment to reflect

As you move through the rest of this module, consider what Dr Meulders' One Thing might encourage or challenge you to do differently with Maria. Does anything come to mind? Enter it here.

Your writing stays in this browser tab until you download it. It is not saved to this website—avoid entering patient-identifying information.

STEP3

Understand the science

This will help you explain Maria's pain in a way that reduces fear and builds realistic hope. Select each idea to expand.

Maria says: "Every time I move my shoulder, I can feel it getting worse. It's been 6 months and nothing is healing."

What is the most important thing to understand about why her pain has persisted?

Pain is a personal, protective experience influenced by biological, psychological, and social factors. It is not a direct measure of tissue damage. With Maria’s assessment and physician clearance in mind, it is reasonable to explore whether sensitivity, fear, and avoidance are contributing to her pain and disability—while remaining alert to changes that need reassessment.

Useful analogy for Maria: "Pain is real, and it can be influenced by many things—not just what a scan can show. We can use gentle, supported movement to learn what feels manageable and build from there."

In some persistent pain presentations, altered pain sensitivity can contribute to pain and movement difficulty. It cannot be diagnosed from duration alone, and people can have more than one pain mechanism at the same time. For Maria, this is a useful working hypothesis to explore alongside ongoing assessment, not a reason to dismiss her symptoms.

Key message for Maria: "Your shoulder and your pain system can both be part of the picture. We can start with movements that feel manageable, keep checking in, and build confidence step by step."

Chronic pain is best understood through a biopsychosocial lens: biological factors (tissue, neurology), psychological factors (fear, beliefs, mood), and social factors (work stress, financial pressure, past clinical experiences) all contribute to the pain experience. For Maria, the psychosocial contributors (kinesiophobia, catastrophizing, and the nocebic message from her previous clinician) are highly clinically significant and must be addressed directly alongside physical rehabilitation.

The brain and nervous system are plastic: they change in response to experience. Graded, meaningful movement can be one way to build confidence and function over time. This supports realistic hope without making promises about a particular pain outcome.

Key message for Maria: "We can take this one step at a time, learn what feels manageable, and use that information to guide the next step."
STEP4

Recognize the barriers

Think back to what you noticed about Maria. Each of these barriers connects directly to something in her profile. Select each to explore the clinical science behind it.

Kinesiophobia is an excessive, irrational, and debilitating fear of physical movement resulting from a belief that movement will cause harm or re-injury. It is one of the strongest predictors of chronic pain disability.

In Maria's case, a previous clinician told her to "listen to your body" and interpreted it as: stop when it hurts. She has been doing progressively less. She is especially afraid of overhead movement, reaching across her body, and lifting with her right arm.

Guarding and protective posturing during assessment
Reluctance to attempt prescribed exercises
Catastrophic language when discussing movement
Hypervigilance to normal pain sensations during activity

Pain catastrophizing involves three components: magnification (overestimating severity: "something is tearing"), rumination (unable to stop thinking about pain), and helplessness (believing nothing will help, "I don't see how this is going to get better"). Maria rates as a high catastrophizer. Catastrophizing amplifies the pain experience and is associated with poorer rehabilitation outcomes, unless directly and compassionately addressed.

The nocebo effect is the negative counterpart to the placebo effect. When a trusted clinician says "you won't get better," this expectation can worsen outcomes, increasing pain, reducing function, and deterring rehabilitation. Maria's previous clinician delivered a deeply nocebic prognosis. This must be gently but confidently reframed.

Example reframe: "I can see you've been given some really discouraging information. I want to share what the current research tells us, because the picture is actually a lot more hopeful than what you've heard."

Self-efficacy is a person's belief in their capacity to achieve a specific outcome through their own actions. Maria's is severely eroded. A clinician has told her nothing more can be done, she has been off work for weeks, and her shoulder still hurts despite rest. From her perspective, there is no evidence that effort produces improvement.

Low self-efficacy is one of the strongest independent predictors of poor rehabilitation outcomes. A patient who does not believe recovery is possible engages less, avoids challenge, and interprets setbacks as confirmation of hopelessness rather than a normal part of the process.

Clinical implication: Early wins matter disproportionately for Maria. When she completes a movement she feared, the clinical value extends well beyond range of motion. It directly rebuilds self-efficacy. Acknowledge it explicitly: "You just did something you thought you couldn't do. That's not a small thing."

These barriers don't operate in isolation. Together, kinesiophobia, catastrophizing, nocebo expectations, and low self-efficacy feed into a documented clinical cycle. You may have encountered this model before, but it's worth seeing it in the context of Maria's presentation.

The fear-avoidance model

Vlaeyen & Linton (2012) describe two paths following an injury. Which path a patient takes depends largely on how threatening they find the experience. Maria is firmly on the left. Graded exposure is designed to shift her toward the right.

Vlaeyen and Linton fear-avoidance model diagram

Active rehabilitation interrupts the left path by gradually reintroducing safe movement, building positive experiences, and updating the nervous system's prediction that movement equals harm.

Why avoidance is self-sustaining

Remember Dr. Ann Meulders' One Thing from the video: learning matters. What you are about to read is where that principle hits the clinical ground. The fear-avoidance cycle persists specifically because avoidance prevents the learning that would break it.

A key reason the fear-avoidance cycle is so difficult to break is that avoidance is self-reinforcing by design. When Maria avoids a movement and nothing bad happens, she does not conclude the movement was safe. She concludes her avoidance protected her. The feared outcome is never tested, so the fear is never disconfirmed.

Exconsequential reasoning (Meulders, 2019): People with high kinesiophobia often use their own avoidance as evidence of threat: "I must be avoiding this because it's harmful." For Maria, months of protecting her shoulder may have deepened her belief that it is fragile, not because of what she experienced, but because of what she never allowed herself to test.

This is why verbal reassurance alone is rarely sufficient. Maria needs repeated, direct experiences of safe movement, each one serving as evidence that contradicts her prediction of harm.

Safety learning is specifically impaired in chronic pain

Dr. Ann Meulders' research shows that people with persistent pain are not just slow to lose fear: they are specifically impaired at learning which activities are safe. Fear can be acquired after a single painful episode, but safety learning requires far more experiences and takes much longer.

This has a direct clinical implication: one good session is not enough. Multiple, varied, and repeated positive movement experiences are needed to build lasting safety associations.

If Maria's fear doesn't reduce as quickly as expected, this is not resistance or non-compliance. It reflects a genuine learning asymmetry that requires patient, systematic repetition to overcome.
STEP5

Communicate with care

How you talk with Maria is as important as what you prescribe. Select each principle to expand.

Many people in pain have already been doubted, dismissed, or made to feel they have to prove themselves. When you make belief explicit, you reduce the need for the patient to keep defending their experience. That changes the tone of the interaction immediately.

Once Maria feels believed, pain education and collaborative planning land better. Validation creates enough safety for new information to be heard. Without it, even good science can sound like another dismissal.

Make it explicit: "Your pain is real and I believe you." Don’t assume she knows—say it clearly.

Never imply Maria's pain isn't real, or that she's exaggerating. Instead, validate the pain while gently reframing its meaning: pain can be influenced by a sensitive protective system as well as by the body and the person’s context. Honour her experience while updating her understanding.

Example: "Your pain is real. The scan and assessment do not tell the whole story of how pain is affecting you, and we can work together on what helps you move forward."

The clinical target is not only "less pain." Ask Maria what returning to work, reaching overhead, or doing daily tasks without fear means to her. Connecting rehabilitation to personally meaningful goals: getting back to her kids without wincing when they hug her, getting back on the tools, dramatically improves engagement. Set achievable early goals, celebrate small improvements, and consistently reinforce her capacity to change.

Explain that discomfort during rehabilitation can be expected, but should be monitored in the context of the person’s presentation and agreed plan. Help Maria distinguish manageable symptoms from unexpected or concerning changes, and encourage her to report the latter. Use graded exposure principles to expand her comfort zone.

Example: "Some discomfort can be part of practising a movement. Let’s agree what feels manageable today, notice how you respond, and adjust the plan if something feels unexpected or concerning."

Rather than telling Maria her fears are wrong, invite her to test them directly. Frame movements as experiments: "You believe reaching this high will cause lasting harm. Let's try it together and see what actually happens."

When her prediction doesn't come true, that direct experience is far more powerful than verbal reassurance. It violates her harm expectancy through evidence she generates herself. Consider documenting her predictions and outcomes together so she builds an evidence base she can refer back to between sessions.

STEP6

Design the program

You are three weeks into Maria's rehabilitation. The science is in place, the relationship is building. Now a moment of clinical decision-making.

Week 3 of rehabilitation. Maria has received pain science education and a fear hierarchy has been established. Today you ask her to reach overhead to place a light object on a shelf. She hesitates, then says: "I'm scared. What if I tear something? My last physio said I might be doing permanent damage."

What is your next move?

Knowledge check

Five questions with adaptive feedback. Each answer leads somewhere useful: specific feedback for every choice, hints after the first wrong attempt, and deeper explanation if needed. Answer correctly to master each question.

Questions mastered 0 / 5
1
Not yet mastered
Maria says: "Every time I move it, I can feel it getting worse." What does this most likely reflect in her clinical presentation?
Consider Maria's psychological profile. She uses phrases like "something is tearing" and "I'm making it worse." Which psychological construct, catastrophizing, red flag, or malingering. Which of these does this language most closely describe?
Clinical explanation: Pain catastrophizing involves magnification (overestimating severity), rumination, and helplessness. Maria's language, "can feel it getting worse," "what if I'm doing permanent damage", reflects magnification of threat. This is not dishonesty or a red flag. It is a genuine but unhelpful cognitive pattern that responds well to compassionate, evidence-based education and graded exposure.
2
Not yet mastered
Maria has avoided overhead movements for 6 months and nothing bad has happened. What is she most likely concluding, and why does this matter?
Think about the self-sustaining nature of avoidance. When Maria avoids a movement and nothing bad happens, who gets the credit, the avoidance behaviour, or the movement being safe?
Clinical explanation: Meulders describes this as a self-sustaining loop: avoidance prevents the disconfirmation of fear. Maria may also be engaging in exconsequential reasoning, using her avoidance as unconscious evidence that the movement is dangerous ("I must be avoiding this because it's harmful"). Breaking this cycle requires direct movement experiences with outcomes that contradict her predictions, not more reassurance or more rest.
3
Not yet mastered
Maria's previous clinician told her: "There isn't much we can do, you'll need to accept living with pain." Your first response should be:
Think about Joletta Belton's message. What does a person who has already been dismissed most need to hear first, before any science, any plan, or any reassurance?
Clinical explanation: The sequence matters: validate → educate → activate. Maria has already been dismissed by a clinician she trusted. Her guard is up. Explicit belief ("your pain is real and I believe you") and acknowledgment of what she's been through creates psychological safety for new information. Without that foundation, even excellent pain science education can sound like another dismissal.
4
Not yet mastered
Maria successfully reaches overhead with moderate discomfort (3/10) in your second session and says she's "a bit less scared." What is the most important next clinical consideration?
Think about Dr. Ann Meulders' research on safety learning. How many positive movement experiences are typically needed before safety associations become reliable in someone with chronic pain?
Clinical explanation: Meulders' research highlights a critical asymmetry: fear is acquired fast but safety is learned slowly. One good session is not enough to change a sensitized fear system. Plan for multiple, varied, repeated exposures. If progress is slower than expected, this is the nature of impaired safety learning, not a failure of the patient or the program.
5
Not yet mastered
Which of the following BEST describes an effective first session approach for Maria?
Think about the sequence: validate → educate → activate. What does the very first session need to establish above everything else?
Clinical explanation: The first session with a patient like Maria is about alliance and orientation, not assessment or exercise. Validate. Listen. Begin to gently update her beliefs. Map the landscape of her fears without triggering them. Everything else, graded exposure, exercise prescription, goal-setting, builds on the foundation of trust and psychological safety established in that first session.
STEP7

Practice with Maria

Copy the prompt below into an AI chatbot for a fictional communication rehearsal. Never include patient-identifying information or use it as a substitute for supervision or clinical judgement.

How to use this simulation

Paste the prompt below as your first message in a new AI conversation. Once you start, speak as yourself, the rehabilitation health professional. Maria is fictional and will respond based on how you communicate with her.

When you are ready to end the session and receive feedback on your performance, type: //FEEDBACK

The //FEEDBACK command will assess: Did you validate before educating? · Did you explain pain accessibly and without fear-inducing language? · Did you address kinesiophobia directly? · Did you counter the nocebo messaging? · Did you distinguish discomfort from harm?
Maria: AI Simulation Prompt
You are Maria, a fictional 35-year-old drywall worker roleplaying as a simulated patient for clinical training purposes. A rehabilitation health professional (e.g., physiotherapist, occupational therapist, kinesiologist, nurse, or psychologist) will be practising their therapeutic communication and pain education skills with you. Stay in character throughout the conversation unless the clinician types "//FEEDBACK", at which point you should break character and provide detailed, honest feedback on their clinical approach. Do not provide medical diagnosis or treatment advice. YOUR BACKGROUND: You are a 35-year-old woman who has worked in drywall installation for 8 years. You take pride in your work and your ability to keep up with your predominantly male colleagues. You are the primary income earner for your household and have two kids (ages 7 and 10). Being off work is causing significant financial and emotional stress, but you don't volunteer this unless asked directly. YOUR CLINICAL PRESENTATION: - Constant right shoulder pain for 6 months following a busy period of overhead drywalling - Pain 6/10 at rest, spiking to 8-9/10 with movement (especially overhead, across the body, behind the back) - Significant limitations in shoulder flexion, internal and external rotation - You describe this in everyday terms: "I can't reach the top shelf," "I can't put my arm behind my back," "Even putting on my jacket kills me" - Off work for 3 weeks; largely sedentary; even vacuuming and lifting groceries worry you - Referred by your physician for active rehabilitation, you don't fully understand what this means or why YOUR PSYCHOLOGICAL STATE: Pain catastrophizing (high): You genuinely believe your shoulder is seriously damaged. You use language like "Every time I move it, I can feel it getting worse," "What if I'm doing permanent damage?" You don't realise this is catastrophizing, to you, it feels like being realistic. Kinesiophobia (prominent): You are genuinely afraid of movement. Your last clinician told you to "listen to your body" and you interpreted this as: stop when it hurts. You've been doing less and less. You are especially afraid of overhead movement, reaching across your body, and lifting with your right arm. Low hope and low self-efficacy: Your previous clinician told you "There isn't much we can do. You're not likely to get much better, you'll need to accept that living with pain will be normal for you." You arrived skeptical and guarded. Guarded initially: In the first part of the conversation, give short answers unless the clinician asks follow-up questions or makes you feel heard. Don't volunteer emotional information easily. HOW YOU RESPOND: - If the clinician validates your experience before giving information: gradually become more open and engaged. Show small signs of softening, longer answers, asking a question back. - If the clinician dismisses your fears or jumps straight to exercise: become more guarded. "That's what the last person said." - If the clinician uses scary anatomical language (e.g., "inflamed," "impingement," "torn"): become more anxious. "So something is actually torn in there?" - If the clinician explains pain in a nervous-system way: show genuine curiosity. "So it's not actually getting worse when I move it?" - If the clinician threatens or coerces: shut down. Become monosyllabic. - If the clinician asks about your life, your kids, or what getting better would mean to you: open up noticeably. YOUR LANGUAGE: Speak plainly and practically. No medical or clinical terminology. Occasionally make dry, self-deprecating comments (e.g., "I've been hanging drywall for 8 years, you'd think I could handle a bit of pain"). Sometimes minimise how much things bother you emotionally before eventually admitting more. OPENING LINE (use this exactly): "Hi. I'm Maria. I'm not really sure why I'm here exactly, my doctor said to come, so... here I am. I've already been told there's not much that can be done, so I'm not sure what you're going to be able to do differently." FEEDBACK (when clinician types //FEEDBACK): Break character completely. Provide structured feedback covering: 1. Therapeutic alliance, Did they validate Maria's experience before delivering information? Did she feel heard? 2. Pain science communication, Did they explain pain in a way that was accurate, accessible, and non-threatening? 3. Management of kinesiophobia, Did they address Maria's fear of movement directly and appropriately? 4. Nocebo reframing, Did they address or counter the harmful messaging from the previous clinician? 5. Language, Did they avoid damage-based or fear-inducing language? 6. Strengths, Two or three specific things the clinician did well. 7. Areas for growth, Two or three specific, actionable suggestions for improvement. For each of the first five areas, rate the attempt as emerging, developing, or ready to try in practice. Be honest but constructive. The goal is to help the clinician improve their communication skills.

Tips for getting the most from this simulation

Don't rush to educate. Maria needs to feel heard first. Try validating her experience in the first 2–3 exchanges before introducing any pain science concepts.

Ask open-ended questions. "What does a typical day look like for you right now?" will open up far more than "Does it hurt at rest?"

Notice when Maria softens. If she starts asking questions back or giving longer answers, that's a sign your communication is landing well.

Try different approaches. If Maria shuts down, reflect on why and try a different strategy. The //FEEDBACK report is tailored to your actual conversation, making it a genuine learning tool, not a generic debrief.

Patient take-home note

Read the first few lines together with Maria before she leaves. Then take a screenshot or print it for her to keep.

For the days pain gets loud

Your pain is real.
You do not have to prove it here.
You are believed.

  • You have already shown strength by getting through hard days and still turning up.
  • Discomfort during movement does not mean damage is happening. Your nervous system is learning that it is safe to move again, and that takes practice and time.
  • Small steps toward what matters are real progress.
  • You still have capacity for change, even if things feel stuck right now.

You already carry persistence, adaptability, and courage.
Care can build on those strengths.