Table 1

How to reconceptualise pain-related fear through exercise—practical solutions

Treatment goalExample
Understand what the patient understandsWhy do you think you have pain?
Challenge unhelpful beliefsIs it safe for you to exercise? Why? Discuss with the patient. Prescribe exercises or movements that were previously avoided/or painful. New inhibitory associations may be made with painful exercises.
Enhance self-efficacyAre you confident of completing this exercise? What do you think will happen? Discuss with the patient. The hierarchy construction of painful exercises, from easier to more difficult may improve self-efficacy.
Provide safety-cuesYour knee is painful because it has become deconditioned and not used to movement. Pain is not a sign of tissue damage. We need to exercise your knee, so it will become strong and conditioned to enable you to do what you need to do.
Provide advice on suitable levels of painIf you’re coping with the level of pain, then continue with the exercise. If the pain is more than you find acceptable or flares up longer than 24 hours after the exercise, then decrease the amount of exercise until you’re coping with it again.
Provide advice on exercise modificationIt is important to adjust the exercises dependent on your symptoms.  This may mean increasing the number of repetitions that you do or the amount of resistance that you use as it becomes easier; or decreasing if it gets too painful.  Try not to avoid doing the exercises altogether as complete rest is unlikely to solve the problem.  Instead reduce the exercises to a level that is acceptable.