Fear, Anxiety, and Kinesiophobia: Part I


Fear:

What scares you? It’s an interesting question, isn’t it, because we are all scared of something, whether it’s the monsters under the bed, snakes, awkward social situations, or something deeper, fear is part of the human condition, which isn’t a bad thing. The sensation of fear exists to alert us when danger is present; in fact, fear circuits are present in other mammals, and even single celled organisms have the ability to detect and respond to significant events (1).

Individuals with high risk tolerance, i.e., higher thresholds before the fear response kicks in, stay calm under pressure longer than someone who has a lower threshold for fear. These individuals may also take higher risks than the average person. Alex Hannold, the world renowned free climber who soloed half dome is an example of someone who, according to brain imaging, has an unusually high threshold for fear (2). The lack of activity in his amygdala, the part of the brain that triggers the physiological responses associated with fear and sends information to higher processing parts of the brain that say, “hey. This is scary. Maybe this isn’t such a good idea,” might explain part of his success. His lack of response may allow him to do things like stay calm longer while climbing up the face of a rock without ropes, thousands of feet above the ground. Many would argue that his hobby/career/life’s purpose is, indeed, a high risk behavior, though he pursues it in an analytical, calculated way designed to minimize errors.

You can deal with fear a number of ways, including

  • Ignoring it and doing the thing that scares you anyway. This is often referred to as facing your fear. When you do something that scares you and nothing bad happens, it reinforces the fact that maybe the thing that brings you fear isn’t as harmful as you think. This works best in situations where the fear may be blown out of proportion and the situation is generally safe, such as walking into a room full of people you don’t know, flying in an airplane, or giving a public talk. It should also be done on a small scale first—don’t walk into a room of one hundred people you don’t know, walk into a room of ten people you don’t know and see how it goes.

  • Preparing for the thing that scares you to maximize your chance of success. Alex Hannold uses preparation to maximize his chance of scaling a rock face, sans ropes, without falling. He prepares in the fullest way possible through repetition, visualization, and physical conditioning. Most of us don’t aspire to free solo huge rock faces, but all of us can learn from his commitment to preparedness. If you have fear of balancing on rails that are three feet off of the ground, start with a rail that’s two inches off of the ground. If you are giving a talk to 50 professionals, spend time researching, putting together the presentation, and then practice. Practice so much you barely need to look at your slides because you know the material and what you want to say. Gain confidence through preparation.

  • Create small steps towards facing your fear. Rather than ignoring your fear, this mindset requires acknowledging that you are scared and finding small opportunities that allow you to take steps towards your fears without creating an anxiety provoking feeling that causes you to freeze, disconnect, or flee. If talking in front of groups gives you anxiety, the next time you are in a group, introduce yourself to one person you don’t know and offer a piece of information about yourself. Or, if you are afraid of heights, if there is a footbridge near your house that gives you trepidation, take two steps across it and then return to the starting position. Maybe the next time you approach the bridge, you can take three steps, but begin with one step at a time.

Kinesiophobia:

What does any of this have to do with exercise and fitness, you may be wondering? Often fear prevents people from exploring movement and developing strength and flexibility. It may even stop people from beginning an exercise program. Fear in an exercise setting can be specific, (“I’m scared of placing weight on my hands so I’m not going to do anything that places weight on my hands,”), or it can be more general.

Kinesiophobia, or excessive fear of movement, occurs when people feel vulnerable to injuring themselves during movement because of a previous injury (3). Kinesiophobia contributes to pain becoming a chronic condition—individuals believe that physical activity will result in more pain/re-injury, leading to avoidance of physical activity, disuse, and depression.

Fear of injury can come from many sources. If someone reads in an interview with a postural expert that bending over is bad for the back and this individual has experienced back pain, he may avoid bending over at all costs. His spine will become stiff as he protects the back from injury because an expert said it was potentially harmful, leading to muscle guarding, altered body perception, and, ultimately, more pain.

Patellofemoral pain (PFP) is the experience of nerve sensitivity in the soft tissues and bones around the kneecap. The sensitivity can become chronic, despite the fact the ligaments and menisci supporting the knee are intact. It affects 23% of the general population and long term prognosis is poor—two thirds of individuals diagnosed with PFP still have knee persistent knee pain one year after the initial diagnosis (4).

You probably know someone with “bad knees.” It’s the person who makes off handed comments while watching you squat and crawl around on the floor that her knee could never do that, or who tells you that her right knee is bad and that’s why she avoids walking downhill. She feels most things that require knee bending, actually, are going to injure her right knee and make it hurt worse than it already does.

Here is the crazy thing about interventions for chronic pain: a number of studies show temporarily aggravating symptoms using exercise therapies actually leads to an overall decrease in pain. It’s as though exposing the body to the very thing it’s become fearful of reduces sensitivity.

So, the person with a chronically painful right knee with no structural damage would benefit from walking downhill, or squatting with weight, or maybe even performing single leg squats on a regular basis. The short bouts of discomfort lead to stronger tissues (i.e., the muscles, ligaments, and bones get stronger), and a shift in mindset—exercise is no longer viewed as something to be avoided because it will injure the joint more.

Anxiety:

Fear and anxiety are similar. Anxiety is defined as constant worry, and worry is fear of actual or potential problems. (Interestingly, dictionary.com also defines worry as a verb specific to carnivorous animals. It means to tear at or gnaw on, like what a dog does with a bone.) Fear is the sensation that arises when you are unsure of a situation’s outcome, so a state of anxiety could be thought of as being fearful of what could happen in most situations.

Fear, which occurs when a potential threat has been identified, can result in passive or active responses. There may be an initial freeze response, while the severity of the threat is determined. If the threat is life-threatening and there is no obvious escape route, the heart rate may slow, blood pressure may drop, and the animal may “play dead” until the threat passes (5). If the animal moves into a fight or flight response, heart rate increases. Respiration rate increases. Breathing becomes shallow, and blood moves away from the digestive system to the global muscles, which tense.

The DSM-5, which is the decider of all psychological disorders, defines generalized anxiety disorder as symptoms that include: feeling restless, getting tired easily, having difficulty concentrating and sleeping, irritability, and muscle tension (6). The persistency of worry leads to chronic physiological responses, affecting an individual’s heart rate and respiration (7, 8).

It’s no surprise panic attacks are often mistaken for heart attacks—one prevailing hypothesis is that panic attacks (which result in anxiety), are provoked by misinterpretations of bodily sensations. If you don’t trust that your body is strong, things like elevated heart rate and shortness of breath suggest a potential weakness that could potentially be life threatening (9).

When you first begin an exercise program, your body responds by revving up, mimicking the same symptoms that a person may fear cause harm. The increase in heart rate and rapid breathing stops when exercise is over. This can be a teaching tool, similar to the way using the knee to perform strength based exercises is a teaching tool for the person with PFP. The realization that, “my heart was beating fast and for a short time, my breath was shorter, but I’m okay,” can help someone re-write the story they tell themselves about the fragility of their body.*

When you learn new physical skills, sensations arise. These sensations can be unpleasant while you figure out how to hold the limbs a specific way or coordinate the limbs to move in specific pattern. New movements require muscular work that feels foreign and the sensations can be overwhelming as your nervous system goes into overdrive, figuring out what it’s being asked to do and how many motor units should be sent to the muscles to accommodate the new position. The experience can be overwhelming and scary, and can be enough for a person who is concerned exercise may be a source of pain to decide it’s not a good idea to ever be in that particular position again. Interestingly, the second time you try the same new skill, it will feel less uncomfortable. Novelty is never as interesting the second time, and the neuromuscular system’s response to new positions is no exception.

New positions can also cause sensation in the joints, particularly if the joints aren’t used to dealing with specific types of load. The sensation in the joints can almost always be altered by focusing on the connection of the entire kinetic chain, so if you’re doing a wall sit position and you feel it in the knee, focusing on actions in the feet or pelvis will change what you are experiencing, usually for the better. This requires knowing how to alter focus, so unless someone suggests you change how you are supporting the movement, you may not realize there are less pain provoking ways to perform the skill, reinforcing fear of exercise and movement.

Finally, exposing the body to new positions can cause more noise in the nervous system while it struggles to understand the most efficient way to accomplish the task. These sensations are often quick, sharp, nerve-like sensations that disappear as the neuromuscular system figures out the best way to coordinate the movement. Have you ever had a sudden twinge when you reach for something, only to have the twinge disappear when you reach again? That’s noise. If the twinge persists with repeated exposure, then you should definitely get it checked out, but more often than not, it simply disappears.

If you struggle with anxiety, perhaps the most important thing you can do when you begin an exercise program is expose yourself gradually. The guidelines for exercise make it seem like the average person should be able to do 30 minutes of sustained cardiovascular activity and 3 sets of 10 repetitions on the first day after a long exercise hiatus. The reality is if you have been inactive for a long time or you have struggled to be successful in an exercise program, either because it caused discomfort or felt overwhelming, less is more. Begin with a seven or eight minute walk instead of a thirty minute walk. Do one set of squats, four times, instead of three sets of ten. If something hurts, take a break for a minute or two and then try the same move again. Give the body and nervous system a chance to adapt to what you are asking. Feel the different parts of the body interacting with the floor when you begin strength training so you feel a sense of security. Don’t focus on how much you think you should do, focus on what you can do. Gradual, repeated exposure is what will set you up for long term success and give you an opportunity to feel stronger, more capable, and more emotionally and physically resilient.

Thank you for reading part one. Part two will take a deeper look at other factors that can contribute to anxiety, such as traditional gym and class settings, what happens if you exercise and still experience anxiety, and the importance of self efficacy.

*This is a reference to Brene Brown’s Netflix special, “The Call to Courage.” If vulnerability interests you, you should watch it.

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References:

  1. LeDoux, J.E., (2012). Evolution of human emotion: a view through fear. Progressive Brain Research, 195 (431-442). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3600914/

  2. Mackinnon, J.B., (2016). The strange brain of the world’s greatest solo climber. Nautilus, 39 (https://nautil.us/issue/39/sport/the-strange-brain-of-the-worlds-greatest-solo-climber).

  3. Larsson, C., Hansson, E.E., Sundquist, K., & Jakobsson, U., (2016). Kinesiophobia and its relation to pain characteristics and cognitive affective variables in older adults with chronic pain. BioMed Central Geriatrics, 16, 128. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4936054/

  4. Smith, B.E., Hendrick, P., Bateman, M., Moffatt, F., Rathleff, M.S., Selfe, J., Smith, T.O., & Logan, P., (2019). A loaded self-managed exercise programme for patellofemoral pain: a mixed methods feasibility study. BMC Musculoskeletal Disorders, 20(129). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6438027/

  5. Steimer, T., (2002). The biology of fear- and anxiety-related behaviors. Dialoagues in Clinical Neuroscience, 4(3), 231-249. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181681/

  6. Patriquin, M.A., & Mathew, S.J., (2017). The neurobiological mechanisms of generalized anxiety disorder and chronic stress. Sage Journals, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181681/.

  7. Severino, P., Mariani, M.V., Maraone, A., Piro, A., Ceccacci, A., Tarsitani, L., Maestrini, V., Mancone, M., Lavalle, C., Pasqioni, M., & Fedele, F., (2019). Cariology Research and Practice, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6398072/.

  8. White paper: Anxiety and breathing difficulties. University Hospital Southhamptom, http://www.uhs.nhs.uk/Media/Controlleddocuments/Patientinformation/Stayinginhospital/Anxietyandbreathingdifficulties-patientinformation.pdf

  9. De Cort, K., Hermans, D., Noortman, D., Arends, W., Griez, E.J.L., & Schruers, K.R.J., (2013). The weight of cognitions in panic: the link between misinterpretations and panic attacks. PLoS One, 8(8), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3734098/.