Ep 281: Tackling pain-related fear with exercise therapy, with Drs Courtney Mears and Matthew Heindel

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[00:01:13] Our biggest tool as a clinician is how we communicate with people. I don't think it's the latest joint mobilization technique or exercise that we find online. I really think it's how you approach a conversation with a patient. I think it's really understanding, you know, why are you worried about this? And what does pain mean to you?

[00:01:42] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research to quality practice. I'm Claire Ardern, the Editor-in-Chief of the Journal of Orthopaedic and Sports Physical Therapy. It's great to have you listening today.

[00:02:01] Musculoskeletal rehabilitation clinicians are not psychologists, you know that. And of course, you also know that when working with people with chronic musculoskeletal conditions, psychological factors like a person's thoughts, their beliefs, and their emotions can also exert a strong influence on outcomes. When someone has pain, they might feel scared to move or convinced that moving in a certain way will damage their body.

[00:02:25] Today, we discuss how a person's thoughts about shoulder pain can change over a relatively short exercise-based rehabilitation program and what this means for how you approach discussions about fear and moving with the patients you work with. Joining me are Drs. Courtney Mears and Matt Heindel, who have been leading important work in this field. Dr. Mears is a physical therapist at the University of Southern California and a researcher in the Clinical Biomechanics Orthopaedic and Sports Outcome Research Lab.

[00:02:54] Her research focuses on understanding the relationships between psychological factors, shoulder pain, and functional outcomes. Dr. Heindel is also a physical therapist and a postdoctoral associate at Duke University's School of Medicine, where he studies the neuroimmune mechanisms of chronic musculoskeletal pain.

[00:03:11] Dr. Heindel completed his PhD on the mechanics of pain and muscle dysfunction in rotator cuff tendinopathy in 2025 at the Clinical Biomechanics Orthopaedic and Sports Outcome Research Lab at the University of Southern California. Dr. Courtney Mears, Dr. Matt Heindel, welcome to JOSPT Insights. Thanks, Claire. Thanks for having us. Yeah, thanks so much for having us, Claire. It's an honor to be here. Today, we're focusing on shoulder function and the relationship to fear.

[00:03:37] Our listeners will know there's a relationship between musculoskeletal pain and fear. Today, we're going to talk specifically about some research you've been both intricately involved in looking at pain-related fear for people with rotator cuff tendinopathy. Matt, I'm going to start with you. In this research project, and people will find the link to the article in the show notes, you've been studying how pain-related fear and catastrophizing change during an exercise-based shoulder rehabilitation program.

[00:04:06] Let's start by talking a little bit about what it was you were measuring and how you did those measurements. Thanks for asking. So we have these 64 individuals who had the unilateral rotator cuff tendinopathy or unilateral shoulder pain who came to the clinic over this eight-week span in which they received a resistance exercise program. And they came in at baseline two weeks, four weeks, and eight weeks. And we gave them questionnaires involving their pain and function.

[00:04:35] And then the OSPRO, which is also the long name, is the optimal screening for prediction of referral and yellow flag assessment tool. And it's a really neat tool because it asks just 17 questions. It actually estimates the score of 11 scales in three different domains. And so it does this rather exhaustive understanding of their psychosocial involvement of their pain. And it does it in a really concise, succinct manner. We tracked those things over the eight weeks.

[00:05:03] What we saw was there were three things. So kinesiophobia, fear avoidance, pain catastrophizing were the three things we were most interested in because they comprise the pain-related fear construct. And they change over time, even with a resistance exercise protocol that's not geared towards changing these psychosocial factors. And not only do they change over time, but they are related to the change in pain and function that these individuals are experiencing.

[00:05:29] And then when we look at these individuals differently and we subgroup them based upon people who said, you know, if left alone today with no change in symptoms for the next six months, I am satisfied or I'm not satisfied with my level of pain and disability in my shoulder. People who said they were satisfied had a significant reduction in their pain-related fear, whereas those who said they were not satisfied, they still had quite high pain-related fear.

[00:05:55] And we were extremely careful not to necessarily provide education or even counseling regarding their condition or even what we were trying to target. So even without a psychological intervention, it was clear that exercise helped facilitate this change. It's really interesting. And I think that leads us perfectly to you, Courtney. Putting your clinician hat on, what does this mean in clinical practice? And how do you take this information and use it in day-to-day clinical practice?

[00:06:24] You know, in the clinic, I always use this information to really remind myself that someone's recovery isn't just solely based on improving their strength or improving their range of motion. I think we have to consider that a patient's belief about their pain and their movement can also influence how they're doing functionally and just like their engagement with rehab in general. You know, I use these questionnaires because like Matt said, they're really easy to administer. Ours is 17 questions.

[00:06:52] They have a 10 question one too. So it's really easy to monitor fear, avoidance, any of these psychological factors. But it also encourages me to really continue my conversations and observations around my patients and really look for, you know, is my patient avoiding a certain movement? Or are they repeatedly expressing a concern about maybe tissue damage that they may or may not be, you know, having damage during our rehab?

[00:07:21] And or are they just really lacking confidence, just progressing something? And I think for me, it really helps me kind of take a step back. And, you know, these people are coming to us because they're in pain and everyone's pain experience is different. And it helps me approach them with a curiosity about what they're feeling and experiencing. And it really helps me feel like I can collaborate with them given what I know about pain and movement, what they feel about pain and movement.

[00:07:50] And it helps me understand that just because someone comes in and says this day one doesn't mean that it doesn't change on day seven. And it also doesn't mean that it doesn't change again on day 58. Right. So it's really just kind of helped me broaden my just like outlook on people. And it's helped me really just open up the door for conversations that can be heard.

[00:08:15] I like that broad approach, keeping your mind open as opposed to going in with a closed mindset of what you're expecting to see. And then that's going to, if I see X, Y, Z, I'm going to do A, B, C, keeping that open mind that things can change and change quickly. Absolutely. We're going to use a few different terms here to speak of, we're going to speak of different constructs. So I think maybe now is a really good time to define some of these constructs because people see them in the research a lot.

[00:08:43] Matt, let's have you define what we're talking about here. We're talking about pain-related fear, catastrophizing, fear avoidance beliefs. So let's set the scene a little bit. Yeah. So we think of the construct of pain-related fear is mostly involving these three separate subdomains. So we have the fear avoidance, which we capture with both the physical activity and the work subscale.

[00:09:07] And so that's going to be this fear that's attached to avoidance, usually of behavior, in this case, movement. And we have pain catastrophizing, which is essentially a sensationalizing of the pain experience that they're experiencing. And then lastly, we have kinesiophobia, which is this fear of movement. Kinesiophobia captures the fear component. The fear avoidance captures the fear attached to behavior.

[00:09:32] And then the catastrophizing is the sensationalization of their experience of pain. So it's usually like this heightened pain state. So it's really capturing a cognitive component and a behavioral component to fear, if I'm hearing you correctly, Matt. Well said. Yeah. And Courtney, what does that look like in practice? For me as a clinician, this is my patient who might come into the clinic and they have shoulder pain and they completely avoid emotion.

[00:10:01] Or they talk about completely avoiding emotion. Or maybe they're repeatedly expressing concern about tissue damage or that a movement may make things worse. On the catastrophizing part, I think the language a patient uses matters. You know, not just saying, oh, I feel pain, but it might be something, like Matt said, more sensationalized. Like, my arm is going to fall off. Or I can't use it at all.

[00:10:29] And there's just like a language around catastrophizing. But this can also look like a patient who maybe just lacks confidence in an exercise progression. So I think there's a very wide range about what this looks like. It's very individual to the person too. And then what are your tools in those situations? How do you approach working with patients to overcome or to address some of these behaviors and cognitions around fear?

[00:10:59] Yeah, I think our biggest tool as a clinician is how we communicate with people. You know, I don't think it's the latest, you know, joint mobilization technique or exercise that we find online. I really think it's how you approach a conversation with a patient. And I think it's really understanding, you know, why are you worried about this? And what does pain mean to you? And it's really about validating to them that their pain is real.

[00:11:29] And also explaining that while the pain is real, it's, you know, that pain during rehab might not always indicate that something's going wrong. And so the tool I pull most from is really my listening tool. So it's how I listen with people. It's how we collaborate together. Because even though I might think this exercise or this motion is going to help them, that doesn't mean that they're confident in using it.

[00:11:55] And I think being okay with saying, we don't have to do this today. Let's find another version. But also not avoiding it completely. Like, I think if as a clinician you go, okay, we'll just skip it all together. I think you feed into the avoidance for patients. And so you have to be very mindful. Again, and you find this out because you've communicated with them and figured out what range they feel comfortable in. And again, you use your teamwork tool.

[00:12:23] So you're collaborating with them and figuring that out too. So in that sense, it's, you know, maybe if the overhead reaching is feared, maybe we start at a lower range. So it's the same kind of version, just at a different modification. And over time, we're patient and we gradually increase it. The goal is that your patient also develops the confidence to do it. And we want to create a successful movement experience for them. I like that sense of a movement experience.

[00:12:53] Nice way to put it, Courtney. Courtney described this really well, where you're essentially doing this graded exposure, but with the cognitive reframing. So you're not just having them do the movement, but you're also providing this positive reinforcement. And this is essentially the foundation for a lot of the psychological interventions that we're seeing in musculoskeletal conditions that are becoming preeminent, this cognitive functional therapy and the pain processing therapy. This is the exact same concept as you're providing, you know, they're doing the movement that they're fearful of.

[00:13:21] And then you're providing this cognitive reinforcement and providing a safe environment. If I was to differentiate what's or if I was to really put my finger on what's the difference between what a psychologist is doing and what a physio or a PT is doing, this is a big part of it is that exercise or the movement piece alongside the cognitive reframing or the psychological piece is putting the two together rather than trying to separate them out. Exactly. Exactly. Well said.

[00:13:50] Matt, let's come back to the research for a little bit. You talked at the top of the podcast about patients almost differentiating themselves into different groups. And some of the trajectories that are presented in the article indicate that how some of the patients thought about moving changed over time. What does that mean for clinicians who are looking to apply these research results in practice? I think it means a few things. One, there's good news.

[00:14:19] So even the people who come in with these high psychological factors, that doesn't necessarily mean that they're going to have the psychosocial factors that stay high the entire time. So they definitely can change, even with just exercises, what we saw. But there's a lot of variability. And so we're going to encourage people to measure this, not just once, but measure it often. So in our study, we measured it at two weeks and at four weeks.

[00:14:42] And we started to see kind of a bifurcation around the four-week mark if you look at our data, especially have that being an indicator of if this person's pain-related fear isn't changing on that four-week mark. Maybe it's time to make sure that we're addressing this as something that's particularly important. You know, it really just showed me that some of our patients during the study, even if they had high psychological factors, they did improve in exercise. But even people with low psychological factors also improved.

[00:15:11] So again, I think it just reinforces that even though I think a lot of people tend to label someone as like a yellow flag patient when we evaluate them. Or again, if we only assess at the initial evaluation, these, you know, like the Ospro. But because these things can change, you don't want to assume that a patient's fear is stable. And you don't also want to assume that just because they're participating in exercise, that that means it's automatically going to reduce it.

[00:15:41] Yeah, of course. What are the next research questions that come from here? So you've measured the trajectories in patients who have been completing this structured exercise therapy program. What next? Where do we take this and what sort of research needs to happen next, Courtney? I think for me, it's kind of, it's really identifying like when is the optimal time? Like when is this optimal time to really, you know, maybe deliver a certain protocol to address psychological factors is one question.

[00:16:11] I had second to that. It's what is that protocol? So like, what do we tell people and does that work? And is it just what we deliver? But is it how we deliver it? Because I would argue, you know, something that I say, if someone else said it, the exact same words, I bet we have a very different delivery. So I know, or I think that mattered. Yeah. And it's almost, it's that sense of some patients you connect with really easily and some you don't.

[00:16:37] So it's that human to human contact that creates a bit of an unknown variable in all of this too. So I think you're onto something there. Matt, what would you, what are the research questions you see? Yeah, I think Courtney, you know, hit the nail on the head. I mean, it's, you know, we refer to as like a stepped care trial. So somebody's not particularly succeeding in this initial intervention. So, you know, the clinical practice guideline is, you know, it's clear that we need to be delivering resistance exercise for these individuals.

[00:17:04] But, you know, if they're not successful, which, you know, up to 40% of people over time sometimes won't respond to resistance exercise. Well, then they're one of those 40% that we can kick them to a different intervention, which would, you know, maybe be a psychologically informed care. It links a bit, I think, to this growing momentum behind things like personalized care, personalized medicine. And I think really behind the fancy name, what we're saying there is that people respond in different ways to different interventions.

[00:17:33] And we're trying to get better at identifying who is going to respond to which treatment so that people can get to the right place faster. Yeah, you hit the nail on the head. And that's one of the things that's so interesting about this condition in particular, this study in particular. And that in other studies, we've seen that there are these people with really high psychosocial factors at baseline. And that's what predicts their long-term response. We didn't see that. We saw that it was the change that predicted their response.

[00:18:01] And so, you know, there might be other conditions like hip osteoarthritis or something where there's more high pain-related fear. They can separate these individuals at baseline and provide personalized medicine. But it seems like in rotator cuff tendinopathy, the results of the low psychological factors, psychosocial factors, we need to assess their change over time in order to really tease out, you know, who isn't responding well. Courtney, I want to bring us back to this idea of fear. We started with fear. We've gone into the broader constructs around movement-related fear and fear avoidance beliefs.

[00:18:31] I want to come back to this bigger picture idea of fear because I think it's such a challenging thing for many of us as clinicians. I get the sense that many people don't necessarily want to bring it up in clinic because it's like you're planting a seed that maybe the person hadn't thought that they should be scared and now they're fearful. How do you approach these sorts of conversations with patients, knowing that for many patients, probably fear and fear avoidance beliefs are going to be relevant?

[00:19:02] Yeah, I think, you know, planting the seed, I don't believe that. I think the seed is already there for most people. So to answer your question, it is something we should consider, but I don't think asking about fear inherently creates it or increases it. But like I said, I think patients already have their concerns about their pain, you know, what their tissues are doing, what the future looks like.

[00:19:27] So I think, you know, a thoughtful conversation really just gives them permission and a space to express what those concerns are. And it really helps us as clinicians and the patient. Again, it's a team dynamic. It really helps us address what misunderstandings might be there. And if we don't ask about it, they're always going to be hidden. And so I really think it's important that we ask.

[00:19:53] For me, it's really avoiding language that labels a patient, though. So I never want a patient to come out of a conversation feeling like I've labeled them as fearful or catastrophizing or psychologically impaired in some way, shape or form. I like using very neutral, open-ended questions. And it really just gives me an idea of what they're thinking. But I also explain why I'm asking.

[00:20:20] Because I think if you just ask the question and someone doesn't understand the why, you're going to lose them and they're not going to buy into this part of therapy, right? Because I think concerns about pain and movement are really common. I think, you know, I would argue that everyone in their life experiences some sort of painful experience, right? So this really helps us design a program for them that feels safe and achievable.

[00:20:47] You know, a lot of patients going through the healthcare system feel dismissed. And we really have to make sure that we're spending our time listening and really getting a good grasp on what they're thinking or what they've been told, on what's realistic, on what may be unrealistic. And again, just to build an understanding. And that way we can offer clearer individualized education to get everyone where they want to be.

[00:21:16] None of us like to feel as if we're being stigmatized or labeled, as you say. And that sense of, oh, she thinks it's just all in my head when I know that my shoulder's a problem is a pretty awful place for someone to find themselves in. You mentioned you like to use neutral language. Courtney, can you give us an example or two of the way you would frame these sorts of questions? Quite simply in general, it's what goes through your mind.

[00:21:44] When you feel pain during this movement. So just very broad, or I might not even use the word pain. I might just use the word symptom. Just to kind of take us away from there a little bit. Or again, like maybe what are some movements that your concern might worsen your shoulder? Or, you know, tell me what you know about your symptoms. And really just getting an idea of what they think and trying to find a connection so that we, again, can reach a goal.

[00:22:12] I don't think there needs to be an overt worry about asking the patients. I think that the bigger worry for us is that you don't address something that is there. So if you don't ask, there's a much larger risk. A few research examples. You know, there's this whole literature looking at ecological momentary assessment. Which, you know, if you have a phone and you're participating in a big research trial, they'll send you a buzz and say, can you rate your symptoms at this moment? They have this for anxiety and PTSD and depression and chronic pain.

[00:22:41] And we've seen across all of these domains that it doesn't change the trajectory even when they're queried. So I feel fairly confident this is the case. And we have a whole body of literature even looking at suicidal ideation that's shown that this isn't the case. It doesn't increase suicide rate. In fact, it decreases it. So I think that I'm fairly convinced at this point that it's so important to ask. And it's going to do more damage if you don't ask than if you do. You don't ask because you think you're going to harm your patient if you do ask them.

[00:23:11] When in fact, by not asking, you're probably harming them more. So I think that's a really important message to underscore Matt. Thank you. And I suppose the other thing that I take from your study, Courtney and Matt, is to say that it's not enough to ask once. You need to have these conversations and you need to measure multiple times. We talk about that measuring strength and measuring range of motion and measuring other symptoms. But it's also measuring these sorts of cognitions and behaviors and beliefs around pain too.

[00:23:41] They're outcomes just like strength and range of motion. I think that's a great place for us to wrap up. I want to say thanks to both of you for leading this important work, for bringing this important work to us today. And thanks, Dr. Courtney Mears, Dr. Matt Heindel for joining me on JOSPT Insights. And thank you for having us. Yeah, thanks for having us, Claire. It was a blast. Thanks for listening to this episode of JOSPT Insights.

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[00:24:41] Talk with you next time.