- Psychological factors have been shown to be among the best predictors of worse outcomes post-concussion. (1-8)
- As psychological factors have been implicated in both post-concussion syndrome’s development and maintenance, then assessing and helping a patient’s psychological approach to rehabilitation early on could improve outcomes. (9)
Fear-based activity avoidance
- Avoidance is a natural response to aversive stimuli.
- Patients tend to restrict what they do or modify how they do it to prevent physical or psychological discomfort.
- Too much avoidance prevents one’s ability:
- to get used to the symptom/activity (i.e., desensitization, this is how allergy shots work)
- to challenge unhelpful beliefs (if you think going out is dangerous, then you will never give yourself the opportunity to possibly learn that you can pull it off safely, if that possibility exists).
- Like this, continued fear avoidance keeps sensory sensitivity and activity intolerance alive.
- By restricting activities to avoid symptom exacerbations, patients can become quite disabled.
- Avoidant patients are typically ‘‘on the lookout’’ for symptoms (i.e., hypervigilant, which makes them more likely to notice symptoms, and interpret them as serious, dangerous, and uncontrollable) (12, 40, 41); and this becomes a vicious cycle of fear-hypervigilance-avoidance.
- This fear avoidance predicts chronic disability. (10-12)
- Fear avoidance has been established as a maladaptive form of coping with body pain (13), headaches (14), fatigue (15), dizziness (16), anxiety (17) and concussion (18).
- It likely also contributes to disability in a variety of health conditions with similar and overlapping symptoms with mTBI including headache, tinnitus, and dizziness (12, 26, 42, 43, 44).
- In post-concussion syndrome patients, fear avoidance predicts worse symptoms, anxiety and disability months later (18).
- Preliminary work suggests that fear avoidance behaviour is also associated with adverse outcomes from mTBI (40, 12, 18).
- Fear avoidance after mTBI might also limit therapy gains from active rehabilitation (45).
- Pre-existing mental health conditions such as anxiety disorders are prevalent in those with mTBI (32, 46) and are strong predictors of persistent symptoms after mTBI (47, 48).
- A cycle of overexertion and recuperation – of plowing through what you have to do, and then crashing – may represent an alternative pathway to chronic disability after injury (19-23).
- It has also been shown to predict prolonged post-concussion symptoms, anxiety and disability after mTBI. (18, 24)
- There are many ways to answer this question.
- It can be explained from may psychological models: positive psychology; mindfulness; cognitive behavioural therapy; learning theory; etc.
- However, to put it simply, soon after a concussion, patients often start feeling worse with physical and mental exertion. (25)
- So, patients get “punished” when they do something (e.g., read off a computer screen). And who would like that? So we avoid it. But therein lies the rub…research shows avoiding it doesn’t help…and neither does soldiering through it.
Fear-avoidance behaviours examples
- Because of fear of re-injury, people may avoid a lot of activities, with the goal of “reducing” the risk of the same.
- Avoiding headache triggers may eventually result in sensitization such that triggers more easily provoke headaches. (26)
- Avoiding movement limits opportunities to habituate the vestibular system in patients with dizziness. (27)
- Inactivity may result in physiological deconditioning and, in turn, fatigue and other concussion-like symptoms. (13, 28)
- Avoiding thoughts or emotions can contribute to psychopathology. (29, 30)
- Fear of not being able to perform pre-concussion activities like one once could, and the consequences they may face because of that may motivate people to avoid doing those activities, or reminders of those activities. This can lead to lower self-esteem, anxiety, and avoidance of cognitively demanding activities. (31-33)
- Fear of the discomfort of the symptoms of post-concussion syndrome can cause avoiding anything that causes symptom discomfort. This can lead to a hyperawareness of symptoms by the principle of ironic process theory.
- Nowadays, there is so much emphasis on goals. While goals, generally sound like a good idea, their application are fraught with challenges.
- Obviously, plowing through your symptoms to achieve goals, on average, predicts worse outcomes.
- So, let’s talk a bit more about goals.
- A common goal paradigm are SMART goals; that is, that goals should be specific, measurable, attainable, relevant, and time-bound.
- Now, this sounds fairly reasonable. But rarely is any given ideology is a panacea; they have relative strengths and relative weakness.
- Educating one on about the strengths and shortcomings of any psychological construct helps one in developing mastery in using these tools.
- Some of the criticism of setting goals are outlined below.
“Don’t aim at success. The more you aim at it and make it a target, the more you are going to miss it. For success, like happiness, cannot be pursued; it must ensue, and it only does so as the unintended side effect of one’s personal dedication to a cause greater than oneself or as the by-product of one’s surrender to a person other than oneself. Happiness must happen, and the same holds for success: you have to let it happen by not caring about it. I want you to listen to what your conscience commands you to do and go on to carry it out to the best of your knowledge. Then you will live to see that in the long-run—in the long-run, I say!—success will follow you precisely because you had forgotten to think about it”
– Viktor E. Frankl, Man’s Search for Meaning
“Another problem with goal-setting is that it creates a certain amount of inflexibility. When you’re focused on a goal, you tend to miss opportunities that present themselves when you take a different direction”.
– Jack Trout, Power of Simplicity (1999)
- Inviting people to build a description of the life that fits with the emergence of their best hopes, like children with bright dreams do, has proponents too.
- So, here, unlike S.M.A.R.T. goals that call for very specific and measurable goals, visualizing a description of the life you prefer to lead calls for a much broader and generous point-of-view.
- This has the effect of highlighting the answer the question “what difference would it make to you to leading that life?”; that is, it highlights your bottom line – your life’s values.
- Putting less emphasis on goals takes a lot of stress off people.
- Stress (podcast episode 5), and its effect on recovery from concussion are well known.
- What difference does reducing stress make? It helps with relaxation and focusing our attention on the moment, and living in a way that resonates with our values; in a sense, it is a form of resiliency training.
- There are several questionnaires that can screen for fear avoidance and endurance behaviours.
- Also, observing patients’ approach to their rehabilitation and lifestyle provides a robust measure of these behaviours.
- Exposure-based treatment that targets fear of movement is best suited to patients who display fear avoidance; pacing is better for the endurance behaviour patients. (34-37)
- Fear avoidance behaviours were associated with lower education (18), hence our strong emphasis on educating patients’ about post-concussion syndrome.
- The sooner one can transition to an “approach” behaviour (think of goldilocks and the three bears, and the porridge that was “just right”), the better they align their psychology with better outcomes.
- For example, avoiding exercise in the 48 h after mTBI is considered a good idea, after which point gradual activity resumption is advised. (28, 38, 39)
1. Hellstrøm, T., Kaufmann, T., Andelic, N., Soberg, H.L., Sigurdardottir, S., Helseth, E., Andreassen, O.A., and Westlye, L.T. (2017). Predicting outcome 12 months after mild traumatic brain injury in patients ad- mitted to a neurosurgery service. Front. Neurol. 8, 125.
2. Ponsford, J., Cameron, P., Fitzgerald, M., Grant, M., Mikocka-Walus, A., and Scho¨nberger, M. (2012). Predictors of postconcussive symp- toms 3 months after mild traumatic brain injury. Neuropsychology 26, 304–313.
3. Silverberg, N.D., and Iverson, G.L. (2011). Etiology of the post- concussion syndrome: physiogenesis and psychogenesis revisited. NeuroRehabilitation 29, 317–329.
4. Silverberg, N.D., Gardner, A., Brubacher, J.R., Panenka, W., Li, J.J., and Iverson, G.L. (2015). Systematic review of multivariable prognostic models for mild traumatic brain injury. J. Neurotrauma 32, 517–526.
5. Stein, M.B., Ursano, R.J., Campbell-Sills, L., Colpe, L.J., Fullerton, C.S., Heeringa, S.G., Nock, M.K., Sampson, N.A., Schoenbaum, M., Sun, X., Jain, S., and Kessler, R.C. (2016). Prognostic Indicators of persistent post-concussive symptoms after deployment-related mild traumatic brain injury: a prospective longitudinal study in U.S. Army soldiers. J. Neurotrauma 33, 2125–2132.
5. Stulemeijer, M., van der Werf, S., Borm, G.F., and Vos, P.E. (2008). Early prediction of favourable recovery 6 months after mild traumatic brain injury. J. Neurol. Neurosurg. Psychiatry 79, 936–942.
7. van der Naalt, J., Timmerman, M.E., de Koning, M.E., van der Horn, H.J., Scheenen, M.E., Jacobs, B., Hageman, G., Yilmaz, T., Roks, G., and Spikman, J.M. (2017). Early predictors of outcome after mild traumatic brain injury (UPFRONT): an observational cohort study. Lancet. Neurol. 16, 532–540.
8. Vikane, E., Hellstrøm, T., Røe, C., Bautz-Holter, E., Aßmus, J., and Skouen, J.S. (2016). Predictors for return to work in subjects with mild traumatic brain injury. Behav. Neurol. 2016, 8026414.
9. Silverberg, N.D., Hallam, B.J., Rose, A., Underwood, H., Whitfield, K., Thornton, A.E., and Whittal, M.L. (2013). Cognitive-behavioral prevention of postconcussion syndrome in at-risk patients: a pilot randomized controlled trial. J. Head Trauma Rehabil. 28, 313–322.
10. Nederhand, M.J., IJzerman, M.J., Hermens, H.J., Turk, D.C., and Zilvold, G. (2004). Predictive value of fear avoidance in developing chronic neck pain disability: consequences for clinical decision making. Arch. Phys. Med. Rehabil. 85, 496–501.
11. Pincus, T., Smeets, R.J.E.M., Simmonds, M.J., and Sullivan, M.J.L. (2010). The fear avoidance model disentangled: improving the clinical utility of the fear avoidance model. Clin. J. Pain 26, 739–746.
12. Wertli, M.M., Rasmussen-Barr, E., Weiser, S., Bachmann, L.M., and Brunner, F. (2014). The role of fear avoidance beliefs as a prognostic factor for outcome in patients with nonspecific low back pain: a systematic review. Spine J. 14, 816–36.e4.
13. Vlaeyen, J.W., and Linton, S.J. (2000). Fear-avoidance and its con- sequences in chronic musculoskeletal pain: a state of the art. Pain 85, 317–332.
14. Martin, P. (2000). Headache triggers: To avoid or not to avoid, that is the question. Psychol. Health 15, 801–809.
15. Vercoulen, J.H., Swanink, C.M., Galama, J.M., Fennis, J.F., Jongen, P.J., Hommes, O.R., van der Meer, J.W., and Bleijenberg, G. (1998). The persistence of fatigue in chronic fatigue syndrome and multiple sclerosis: development of a model. J. Psychosom. Res. 45, 507–517.
16. Whalley, M.G., and Cane, D.A. (2017). A cognitive-behavioral model of persistent postural-perceptual dizziness. Cogn. Behav. Pract. 24, 72–89.
17. Hayes, S.C., Wilson, K.G., Gifford, E. V, Follette, V.M., and Strosahl, K. (1996). Experimental avoidance and behavioral disorders: a func- tional dimensional approach to diagnosis and treatment. J. Consult. Clin. Psychol. 64, 1152–1168.
18. Silverberg ND, Panenka WJ, Iverson GL. Fear Avoidance and Clinical Outcomes from Mild Traumatic Brain Injury. J Neurotrauma. 2018;35(16):1864-1873. doi:10.1089/neu.2018.5662
19. Edwards, R.R., Dworkin, R.H., Sullivan, M.D., Turk, D.C., and Wasan, A.D. (2016). The role of psychosocial processes in the de- velopment and maintenance of chronic pain. J. Pain 17, Suppl 9, T70–T92.
20. Hasenbring, M.I., Hallner, D., and Rusu, A.C. (2009). Fear-avoidance- and endurance-related responses to pain: Development and validation of the Avoidance-Endurance Questionnaire (AEQ). Eur. J. Pain 13, 620–628.
21. Hasenbring, M.I., Hallner, D., Klasen, B., Streitlein-Bo¨hme, I., Will- burger, R., and Rusche, H. (2012). Pain-related avoidance versus en- durance in primary care patients with subacute back pain: Psychological characteristics and outcome at a 6-month follow- up. Pain 153, 211–217.
22. Plaas, H., Sudhaus, S., Willburger, R., and Hasenbring, M.I. (2014). Physical activity and low back pain: the role of subgroups based on the avoidance-endurance model. Disabil. Rehabil. 36, 749–755.
23. Band, R., Barrowclough, C., Caldwell, K., Emsley, R., and Wearden, A. (2017). Activity patterns in response to symptoms in patients being treated for chronic fatigue syndrome: an experience sampling meth- odology study. Health Psychol. 36, 264–269.
24. Hou, R., Moss-Morris, R., Peveler, R., Mogg, K., Bradley, B.P., and Belli, A. (2012). When a minor head injury results in enduring symptoms: a prospective investigation of risk factors for post- concussional syndrome after mild traumatic brain injury. J. Neurol. Neurosurg. Psychiatry 83, 217–223.
25. Symonds, C. (1928). The differential diagnosis and treatment of ce- rebral states consequent upon head injuries. Br. Med. J. 2, 829–832.
26. Martin, P.R., and MacLeod, C. (2009). Behavioral management of headache triggers: avoidance of triggers is an inadequate strategy. Clin. Psychol. Rev. 29, 483–495.
27. Whalley, M.G., and Cane, D.A. (2017). A cognitive-behavioral model of persistent postural-perceptual dizziness. Cogn. Behav. Pract. 24, 72–89.
28. Silverberg, N.D., and Iverson, G.L. (2013). Is rest after concussion ‘‘the best medicine?’’: recommendations for activity resumption fol- lowing concussion in athletes, civilians, and military service members. J. Head Trauma Rehabil. 28, 250–259.
29. Scheenen, M.E., Spikman, J.M., de Koning, M.E., van der Horn, H.J., Roks, G., Hageman, G., and van der Naalt, J. (2016). Patients ‘‘At Risk’’ of Suffering from Persistent Complaints after Mild Traumatic Brain Injury: The Role of Coping, Mood Disorders, and Post- Traumatic Stress. J. Neurotrauma, neu.2015.4381.
30. Maestas, K.L., Sander, A.M., Clark, A.N., van Veldhoven, L.M., Struchen, M.A, Sherer, M., and Hannay, H.J. (2014). Preinjury coping, emotional functioning, and quality of life following uncomplicated and complicated mild traumatic brain injury. J. Head Trauma Rehabil. 29, 407–417.
31. Potter, S., and Brown, R.G. (2012). Cognitive behavioural therapy and persistent post-concussional symptoms: integrating conceptual issues and practical aspects in treatment. Neuropsychol. Rehabil. 22, 1–25.
32. Klonoff, P.S., Lage, G.A., and Chiapello, D.A. (1993). Varieties of the catastrophic reaction to brain injury: A self psychology perspective., in: Bulletin of the Menninger Clinic. pps. 227–241.
33. Kay, T., Newman, B., Cavallo, M., and Ezrachi, O. (1992). Toward a neuropsychological model of functional disability after mild traumatic brain injury. Neuropsychology 6, 371–384.
34. Van Damme, S., and Kindermans, H. (2015). A self-regulation per- spective on avoidance and persistence behavior in chronic pain: new theories, new challenges? Clin. J. Pain 31, 115–122.
35. Andrews, N.E., Strong, J., and Meredith, P.J. (2016). The relationship between approach to activity engagement, specific aspects of physical function, and pain duration in chronic pain. Clin. J. Pain 32, 20–31.
36. Nielson, W.R., Jensen, M.P., Karsdorp, P.A., and Vlaeyen, J.W.S. (2013). Activity pacing in chronic pain: concepts, evidence, and future directions. Clin. J. Pain 29, 461–468.
37. Hasenbring, M.I., and Verbunt, J.A. (2010). Fear-avoidance and endurance-related responses to pain: new models of behavior and their consequences for clinical practice. Clin. J. Pain 26, 747–753
38. Grool, A.M., Aglipay, M., Momoli, F., Meehan, W.P., Freedman, S.B., Yeates, K.O., Gravel, J., Gagnon, I., Boutis, K., Meeuwisse, W., Barrowman, N., Ledoux, A.A., Osmond, M.H., and Zemek, R. (2016). Association between early participation in physical activity following acute concussion and persistent postconcussive symptoms in children and adolescents. JAMA 316, 2504–2514.
39. Schneider, K.J., Leddy, J.J., Guskiewicz, K.M., Seifert, T., McCrea, M., Silverberg, N.D., Feddermann-Demont, N., Iverson, G.L., Hay- den, A., and Makdissi, M. (2017). Rest and treatment/rehabilitation following sport-related concussion: a systematic review. Br. J. Sports Med. 51, 930–934.
40. Silverberg, N., Iverson, G., and Panenka, W. (2017). Cogniphobia in mild traumatic brain injury. J. Neurotrauma 34, 2141–2146.
41. Nakao, M. and Barsky, A. (2007). Clinical application of somato- sensory amplification in psychosomatic medicine. Biopsychosoc. Med. 1.
42. Asmundson, G., Norton, P., and Norton, G. (1999). Beyond pain: the role of fear and avoidance in chronicity. Clin. Psychol. Rev. 19, 97–119.
43. Nijs, J., Roussel, N., Van Oosterwijck, J., De Kooning, M., Ickmans, K., Struyf, F., Meeus, M., and Lundberg, M. (2013). Fear of move- ment and avoidance behaviour toward physical activity in chronic- fatigue syndrome and fibromyalgia: state of the art and implications for clinical practice. Clin. Rheumatol. 32, 1121–1129.
44. Kleinstauber, M., Jasper, K., Schweda, I., Hiller, W., Andersson, G., and Weise, C. (2013). The role of fear-avoidance cognitions and be- haviors in patients with chronic tinnitus. Cogn. Behav. Ther. 42, 84–99.
45. Chrisman, S., Whitlock, K., Mendoza, J., Burton, M., Somers, E., Hsu, A., Fay, L., Palermo, T., and Rivara, F. (2019). Pilot randomized con- trolled trial of an exercise program requiring minimal in-person visits for youth with persistent sport-related concussion. Front. Neurol. 10, 623.
46. Broshek, D., De Marco, A., and Freeman, J. (2015). A review of post- concussion syndrome and psychological factors associated with con- cussion. Brain Inj. 29, 228–237.
47. Mallya, S., Sutherland, J., Pongracic, S., Mainland, B., and Ornstein, T. (2015). The manifestation of anxiety disorders after traumatic brain injury: a review. J. Neurotrauma 32, 411–421.
48. Wood, R., O’Hagan, G., Williams, C., McCabe, M., and Chadwisk, N. (2014). Anxiety sensitivity and alexithymia as mediators of post- concussion syndrome following mild traumatic brain injury. J. Head Trauma Rehabil. 29, E9–E17.
49. Snell DL, Siegert RJ, Debert C, Cairncross M, Silverberg ND. Evaluation of the Fear Avoidance Behavior after Traumatic Brain Injury Questionnaire. J Neurotrauma. 2020;1573:1566-1573. doi:10.1089/neu.2019.6729.
Research & writing: Dr. Taher Chugh
Last update: July 2020