Clinical Rheumatology

, Volume 32, Issue 8, pp 1121–1129 | Cite as

Fear of movement and avoidance behaviour toward physical activity in chronic-fatigue syndrome and fibromyalgia: state of the art and implications for clinical practice

  • Jo Nijs
  • Nathalie Roussel
  • Jessica Van Oosterwijck
  • Margot De Kooning
  • Kelly Ickmans
  • Filip Struyf
  • Mira Meeus
  • Mari Lundberg
Review Article


Severe exacerbation of symptoms following physical activity is characteristic for chronic-fatigue syndrome (CFS) and fibromyalgia (FM). These exacerbations make it understandable for people with CFS and FM to develop fear of performing body movement or physical activity and consequently avoidance behaviour toward physical activity. The aims of this article were to review what measures are available for measuring fear of movement and avoidance behaviour, the prevalence fear of movement and avoidance behaviour toward physical activity and the therapeutic options with fear of movement and avoidance behaviour toward physical activity in patients with CFS and FM. The review revealed that fear of movement and avoidance behaviour toward physical activity is highly prevalent in both the CFS and FM population, and it is related to various clinical characteristics of CFS and FM, including symptom severity and self-reported quality of life and disability. It appears to be crucial for treatment (success) to identify CFS and FM patients displaying fear of movement and avoidance behaviour toward physical activity. Individually tailored cognitive behavioural therapy plus exercise training, depending on the patient’s classification as avoiding or persisting, appears to be the most promising strategy for treating fear of movement and avoidance behaviour toward physical activity in patients with CFS and FM.


Chronic-fatigue syndrome Chronic pain Fear avoidance Fear of movement Fibromyalgia Kinesiophobia 





Chronic-fatigue syndrome


Tampa scale of kinesiophobia



Mira Meeus is an awardee of the 2012 early research career grant of the International Association for the Study of Pain (IASP).




  1. 1.
    Bradley LA, McKendree-Smith AGS (2000) Pain complaints in patients with fibromyalgia versus chronic fatigue syndrome. Curr Rev Pain 4:148–157CrossRefPubMedGoogle Scholar
  2. 2.
    Clauw DJ, Chrousos GP (1997) Chronic pain and fatigue syndromes: overlapping clinical and neuroendocrine features and potential pathogenic mechanisms. Neuroimmunomodulation 4:134–153PubMedGoogle Scholar
  3. 3.
    Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL et al (1990) The American college of Rheumatology 1990 criteria for the classification of fibromyalgia. Report of the multicenter criteria committee. Arthritis Rheum 33:160–172CrossRefPubMedGoogle Scholar
  4. 4.
    Fukuda K, Straus SE, Hickie I, Sharpe MC, Dobbins JG, Komaroff A (1994) The Chronic Fatigue Syndrome, a comprehensive approach to its definition and study. Ann Intern Med 121:953–959CrossRefPubMedGoogle Scholar
  5. 5.
    Van Houdenhove B, Egle U (2004) Fibromyalgia: a stress disorder? Piecing the biopsychosocial puzzle together. Psychother Psychosom 73:267–275CrossRefPubMedGoogle Scholar
  6. 6.
    Häuser W, Thieme K, Turk DC (2010) Guidelines on the management of fibromyalgia syndrome. A systematic review. Eur J Pain 14:5–10CrossRefPubMedGoogle Scholar
  7. 7.
    Nielsen LA, Henriksson KG (2007) Pathophysiological mechanisms in chronic musculoskeletal pain (fibromyalgia): the role of central and peripheral sensitization and pain desinhibition. Best Pract Res Clin Rheumatol 21:465–480CrossRefPubMedGoogle Scholar
  8. 8.
    Vierck CJ (2006) Mechanisms underlying development of spatial distributed chronic pain (fibromyalgia). Pain 124:242–263CrossRefPubMedGoogle Scholar
  9. 9.
    Nijs J, Meeus M, Van Oosterwijck J, Ickmans K, Moorkens G, Hans G, De Clerck LS (2012) In the mind or in the brain? Scientific evidence for central sensitization in chronic fatigue syndrome. Eur J Clin Invest 42(2):203–212CrossRefPubMedGoogle Scholar
  10. 10.
    Price JR, Mitchell E, Tidy E, Hunot V (2008) Cognitive behaviour therapy for chronic fatigue syndrome in adults. Cochrane Database Syst Rev 16(3):CD001027Google Scholar
  11. 11.
    White PD, Goldsmith KA, Johnson AL, Potts L, Walwyn R, DeCesare JC, Baber HL, Burgess M, Clark LV, Cox DL, Bavinton J, Angus BJ, Murphy G, Murphy M, O'Dowd H, Wilks D, McCrone P, Chalder T, Sharpe M (2011) PACE trial management group. Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial. Lancet 377(9768):823–836CrossRefPubMedGoogle Scholar
  12. 12.
    Busch AJ, Barber KA, Overend TJ, Peloso PM, Schachter CL (2007) Exercise for treating fibromyalgia syndrome. Cochrane Database Syst Rev 4:CD003786PubMedGoogle Scholar
  13. 13.
    Sarzi-Puttini P, Buskila D, Carrabba M, Doria A, Atzeni F (2008) Treatment strategy in fibromyalgia syndrome: where are we now ? Semin Arthritis Rheum 37:353–365CrossRefPubMedGoogle Scholar
  14. 14.
    Jason LA, Richman JA, Rademaker AW, Jordan KM, Plioplys AV, Taylor RR, McCready W, Huang CF, Plioplys S (1999) A community-based study of chronic fatigue syndrome. Arch Intern Med 159:2129–2137CrossRefPubMedGoogle Scholar
  15. 15.
    Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Katz RS, Mease P, Russell AS, Russell IJ, Winfield JB, Yunus MB (2010) The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res 62(5):600–610CrossRefGoogle Scholar
  16. 16.
    Jammes Y, Steinberg JG, Mambrini O, Brégeon F, Delliaux S (2005) Chronic fatigue syndrome: assessment of increased oxidative stress and altered muscle excitability in response to incremental exercise. J Intern Med 257:299–310CrossRefPubMedGoogle Scholar
  17. 17.
    Lapp CW (1997) Exercise limits in chronic fatigue syndrome. Am J Med 103:83–84CrossRefPubMedGoogle Scholar
  18. 18.
    Bazelmans E, Blijenberg G, Voeten MJM, van der Meer JWM, Folgering H (2005) Impact of a maximal exercise test on symptoms and activity in chronic fatigue syndrome. J Psychosom Res 59:201–208CrossRefPubMedGoogle Scholar
  19. 19.
    Black CD, O’Connor PJ, McCully KK (2005) Increased daily physical activity and fatigue symptoms in chronic fatigue syndrome. Dyn Med 4:3. doi: 10.1186/1476-5918-4-3 CrossRefPubMedGoogle Scholar
  20. 20.
    Lambin DI, Thibault P, Simmonds M, Lariviere C, Sullivan MJ (2011) Repetition-induced activity-related summation of pain in patients with fibromyalgia. Pain 152(6):1424–1430CrossRefPubMedGoogle Scholar
  21. 21.
    Sorensen B, Streib JE, Strand M, Make B, Giclas PC, Fleshner M, Jones JF (2003) Complement activation in a model of chronic fatigue syndrome. J Allergy Clin Immunol 12:397–403CrossRefGoogle Scholar
  22. 22.
    Ohashi K, Yamamoto Y, Natelson BH (2002) Activity rhythm degrades after strenuous exercise in chronic fatigue syndrome. Physiol Behav 77:39–44CrossRefPubMedGoogle Scholar
  23. 23.
    Vlaeyen JWS, Kole-Snijders AMJ, Boeren RGB, van Eek H (1995) Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance. Pain 62:363–372CrossRefPubMedGoogle Scholar
  24. 24.
    Lundberg M, Grimby-Ekman LA, Verbunt J, Simmonds MJ (2011) Pain-Related Fear: A Critical Review of the Related Measures. Pain Res Treat. doi: 10.1155/2011/494196 PubMedGoogle Scholar
  25. 25.
    Kori SH, Miller RP, Todd DD (1990) Kinesiophobia: a new view of chronic pain behavior. Pain Manag 3:35–43Google Scholar
  26. 26.
    American Psychiatric Association. (1997) Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). p. 1085Google Scholar
  27. 27.
    Asmundson GL, Taylor S (1996) Role of anxiety sensitivity in pain-related fear and avoidance. J Behav Med 19(6):577–586CrossRefPubMedGoogle Scholar
  28. 28.
    Fischler B, Dendale P, Michiels V, Cluydts R, Kaufman L, Meirleir DK (1997) Physical fatigability and exercise capacity in chronic fatigue syndrome: association with disability somatization and psychopathology. J Psychosom Res 42(4):369–378CrossRefPubMedGoogle Scholar
  29. 29.
    Nijs J, Duquet W, De Meirleir K (2004) Kinesiophobia in chronic fatigue syndrome: assessment and associations with disability. Arch Phys Med Rehabil 85:1586–1592CrossRefPubMedGoogle Scholar
  30. 30.
    Nijs J, Vanherberghen K, Duquet W, De Meirleir K (2004) Chronic fatigue syndrome: lack of association between pain-related fear of movement and exercise capacity and disability. Phys Ther 84:696–705PubMedGoogle Scholar
  31. 31.
    Deale A, Chalder T, Wessely S (1998) Illness beliefs and treatment outcome in chronic fatigue syndrome. J Psychosom Res 45:77–83CrossRefPubMedGoogle Scholar
  32. 32.
    van Koulil S, Kraaimaat FW, van Lankeveld W, van Helmond T, Vedder A, van Hoorn H, Donders ART, Thieme K, Cats H, van Riel PLCM, Evers AWM (2008) Screening for pain-persistance and pain-avoidance patterns in fibromyalgia. Intern J Behav Med 15(3):211–220CrossRefGoogle Scholar
  33. 33.
    van Koulil S, van Lankveld W, Kraaimaat FW, van Riel PL, Evers AW (2010) Risk factors for longer term psychological distress in well-functioning fibromyalgia patients: a prospective study into prognostic factors. Patient Educ Couns 80(1):126–129CrossRefPubMedGoogle Scholar
  34. 34.
    Turk DC, Robinson JP, Burwinkle T (2004) Prevalence of fear of pain and activity in patients with fibromyalgia syndrome. J Pain 5(9):483–490CrossRefPubMedGoogle Scholar
  35. 35.
    Nijs J, Thielemans A (2008) Kinesiophobia and symptomatology in chronic fatigue syndrome: a psychometric study of two questionnaires. Psychol Psychother 81:273–283CrossRefPubMedGoogle Scholar
  36. 36.
    Silver A, Haeney M, Vijayadurai P, Wilks D, Pattrick M, Main CJ (2002) The role of fear of physical movement and activity in chronic fatigue syndrome. J Psychosom Res 52:485–493CrossRefPubMedGoogle Scholar
  37. 37.
    Heins M, Knoop H, Nijs J, Feskens R, Meeus M, Moorkens G, Bleijenberg G (2013) Influence of symptom expectancies on stair-climbing performance in chronic fatigue syndrome: effect of study context. Intern J Behav Med (in press)Google Scholar
  38. 38.
    Nijs J, Meeus M, Heins M, Knoop H, Moorkens G, Bleijenberg G (2012) Kinesiophobia, catastrophizing and anticipated symptoms before stair climbing in chronic fatigue syndrome: An experimental study. Disabil Rehabil 34(15):1299–1305CrossRefPubMedGoogle Scholar
  39. 39.
    Vlaeyen JWS, Linten SJ (2012) Fear-avoidance model of chronic musculoskeletal pain: 12 years on. Pain 153:1144–1147CrossRefPubMedGoogle Scholar
  40. 40.
    van Koulil S, Kraaimaat FW, van Lankeveld W, van Helmond T, Vedder A, van Hoorn H, Cats H, van Riel PLCM, Evers AWM (2011) Cognitive-behavioral mechanisms in a pain-avoidance and a pain-persistence treatment for high-risk fibromyalgia patients. Arthrit Care Res 63(6):800–807CrossRefGoogle Scholar
  41. 41.
    Nater UM, Wagner D, Solomon L, Jones JF, Unger ER, Papanicolaou DA, Reeves WC, Heim C (2006) Coping styles in people with chronic fatigue sybdrome identified from the general population of Wichita KS. J Psychosom Res 60(6):567–573CrossRefPubMedGoogle Scholar
  42. 42.
    Gallagher AM, Coldrick AR, Hedge B, Weir WRC, White PD (2005) Is the chronic fatigue syndrome an exercise phobia? A case control study. J Psychosom Res 58:367–373CrossRefPubMedGoogle Scholar
  43. 43.
    Van Oosterwijck J, Nijs J, Meeus M, Levefer I, Huybrechts L, Lambrecht L, Paul L (2010) Pain inhibition and post-exertional malaise in myalgic encephalomyelitis/chronic fatigue syndrome: an experimental study. J Intern Med 268(3):265–278CrossRefPubMedGoogle Scholar
  44. 44.
    Wallman KE, Morton AR, Goodman C, Grove R (2004) Physiological responses during a submaximal cycle test in chronic fatigue syndrome. Med Sci Sports Exerc 36(10):1682–1688CrossRefPubMedGoogle Scholar
  45. 45.
    Harvey SB, Wadsworth M, Wessely S, Hotopf M (2008) Etiology of chronic fatigue syndrome: testing popular hypothesis using a national birth cohort study. Psychosom Med 70(4):488–495CrossRefPubMedGoogle Scholar
  46. 46.
    Vercoulen JHMM, Bazelmans E, Swanink CMA, Fennis JFM, Galama JMD, Jongen PJH, Hommes O, Van der Meer JWM, Bleijenberg G (1997) Physical activity in chronic fatigue syndrome: assessment and its role in fatigue. J Psychiatr Res 31:661–673CrossRefPubMedGoogle Scholar
  47. 47.
    Meeus M, Nijs J, Van Oosterwijck J, Van Alsenoy V, Truijen S (2010) Pain physiology education improves pain beliefs in patients with chronic fatigue syndrome compared with pacing and self-management education: a double-blind randomized controlled trail. Arch Phys Med Rehabil 91(8):1153–1159CrossRefPubMedGoogle Scholar
  48. 48.
    Wiborg JF, Knoop H, Prins JB, Bleijenberg G (2011) Does a decrease in avoidance behavior and focusing on fatigue mediate the effect of cognitive behavior therapy for chronic fatigue syndrome? J Psychosom Res 70(4):306–310CrossRefPubMedGoogle Scholar
  49. 49.
    van Wilgen CP, Bloten H, Oeseburg B (2007) Results of a multidisciplinary program for patients with fibromyalgia implemented in the primary care. Disabil Rehabil 29(15):1207–1213CrossRefPubMedGoogle Scholar
  50. 50.
    van Koulil S, van Lankveld W, Kraaimaat FW, van Helmond T, Vedder A, van Hoorn H et al (2010) Tailored cognitive-behavioral therapy and exercise training for high-risk patients with fibromyalgia. Athritis Care Res 62:1377–1385CrossRefGoogle Scholar
  51. 51.
    Nijs J, van Eupen I, Vandecauter J, Augustinus E, Bleyen G, Moorkens G, Meeus M (2009) Can pacing self-management alter physical behaviour and symptom severity in chronic fatigue syndrome? A case series. J Rehabil Res Devel 46(7):985–996CrossRefGoogle Scholar
  52. 52.
    Taylor RR, Jason LA, Shiraishi Y, Schoeny ME, Keller J (2006) Conservation of resources theory, perceived stress, and chronic fatigue syndrome: Outcomes of a consumer-driven rehabilitation program. Rehab Psychol 51:157–165CrossRefGoogle Scholar
  53. 53.
    Jason L, Benton M, Torres-Harding S, Muldowney K (2009) The impact of energy modulation on physical functioning and fatigue severity among patients with ME/CFS. Patient Educ Couns 777(2):237–241CrossRefGoogle Scholar
  54. 54.
    Crombez G, Eccleston C, Van Damme S, Vlaeyen JWS, Karoly P (2012) Fear avoidance model of chronic pain. The next generation. Clin J Pain 28(6):475–483CrossRefPubMedGoogle Scholar
  55. 55.
    van Middendorp H, Lumley MA, Jacobs JW, van Doornen LJ, Bijlsma JW, Geenen R (2008) Emotions and emotional approach and avoidance strategies in fibromyalgia. J Psychosom Res 64(2):159–167CrossRefPubMedGoogle Scholar
  56. 56.
    Vlaeyen JW, de Jong J, Geilen M, Heuts PH, van Breukelen G (2002) The treatment of fear of movement/(re)injury in chronic low back pain: further evidence on the effectiveness of exposure in vivo. Clin J Pain 18:251–261CrossRefPubMedGoogle Scholar

Copyright information

© Clinical Rheumatology 2013

Authors and Affiliations

  • Jo Nijs
    • 1
    • 3
  • Nathalie Roussel
    • 1
    • 2
    • 4
  • Jessica Van Oosterwijck
    • 1
    • 2
    • 5
  • Margot De Kooning
    • 1
    • 3
  • Kelly Ickmans
    • 1
    • 3
  • Filip Struyf
    • 1
    • 2
    • 4
  • Mira Meeus
    • 2
    • 5
  • Mari Lundberg
    • 6
  1. 1.Pain in Motion research group, Department of Human Physiology and Rehabilitation Sciences, Faculty of Physical Education and PhysiotherapyVrije Universiteit BrusselBrusselsBelgium
  2. 2.Chronic Pain and Chronic Fatigue Research Group (CHROPIVER), Division of Musculoskeletal Physiotherapy, Department of Health Care SciencesArtesis University College AntwerpAntwerpBelgium
  3. 3.Department of Physical Medicine and PhysiotherapyUniversity Hospital BrusselsBrusselsBelgium
  4. 4.Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health SciencesUniversity of AntwerpAntwerpBelgium
  5. 5.Rehabilitation Sciences and PhysiotherapyGhent UniversityGentBelgium
  6. 6.University of GothenburgGothenburgSweden

Personalised recommendations