Kronik Ağrılarda Egzersizin Rolü: Korku-Kaçınma Döngüsünün Kırılması
Özet
Kronik ağrı, üç aydan uzun süre devam eden ya da altta yatan doku hasarını aşan, biyopsikososyal boyutları olan bağımsız bir klinik durum olarak tanımlanmaktadır. Bu çalışma, konuyla ilgili literatürün taranması sonucunda oluşturulmuş olup korku-kaçınma modeli çerçevesinde egzersizin rolünü derlemektedir. Modele göre bireyler ağrı sonrası ya yüzleşme ya da kaçınma yolunu seçmekte; kaçınma davranışı kısa vadede rahatlatıcı görünse de zamanla fiziksel dekondisyon, santral sensitizasyon ve işlevsel kaybı derinleştirerek kısır döngüyü pekiştirmektedir. Ağrı felaketi beklentisi, kinezyofobi ve hipervigilans döngünün temel bileşenleri olarak öne çıkmaktadır. Egzersizin bu döngüyü kırmada endojen opioid sistemini aktive ederek, beyin plastisitesini destekleyerek ve öz-yeterliliği güçlendirerek etkili olduğu vurgulanmaktadır. Kademeli egzersiz, kademeli maruz bırakma, psikolojik bilgi-temelli fizik tedavi ve ağrı nörobilimi eğitimi gibi kanıta dayalı stratejilerin, bireysel korku hiyerarşisine göre uyarlandığında kinezyofobi ve engelliliği anlamlı ölçüde azalttığı gösterilmektedir. Sonuç olarak egzersiz, yalnızca fiziksel bir müdahale değil, ağrı-tehdit ilişkisini kortikal düzeyde yeniden yapılandıran çok katmanlı bir terapötik yaklaşım olarak değerlendirilmektedir.
Chronic pain is defined as pain persisting beyond three months or exceeding the expected tissue-healing period, representing an independent clinical condition with biopsychosocial dimensions. This study was developed through a review of relevant literature, examining the role of exercise within the framework of the fear-avoidance model. According to the model, individuals respond to pain either through confrontation or avoidance; while avoidance appears protective in the short term, it ultimately reinforces a vicious cycle through physical deconditioning, central sensitization, and functional decline. Pain catastrophizing, kinesiophobia, and hypervigilance emerge as core components of this cycle. Exercise is shown to break this pattern by activating endogenous opioid systems, promoting brain plasticity, and strengthening self-efficacy. Evidence-based strategies such as graded exercise, graded exposure, psychologically informed physical therapy, and pain neuroscience education demonstrate significant reductions in kinesiophobia and disability when tailored to an individual's fear hierarchy. Overall, exercise is presented not merely as a physical intervention but as a multilayered therapeutic approach capable of recoding the pain-threat relationship at the cortical level.
Referanslar
Crombez, G., Eccleston, C., Van Damme, S., Vlaeyen, J. W. S., ve Karoly, P. (2012). Fear-avoidance model of chronic pain: the next generation. Clinical Journal of Pain, 28(6), 475–483. https://doi.org/10.1097/AJP.0b013e3182385392
DeBaets, L., Matheve, T., Meeus, M., Struyf, F., ve Claes, A. (2023). Understanding discrepancies in a person's fear of movement and avoidance behaviour: a guide for musculoskeletal rehabilitation clinicians who support people with chronic musculoskeletal pain. Journal of Orthopaedic & Sports Physical Therapy. https://doi.org/10.2519/jospt.2023.11420.
Engel, G. L. (1977). The need for a new medical model: a challenge for biomedicine. Science, 196(4286), 129–136. https://doi.org/10.1126/science.847460.
Eynur, A., Onat, U. K., & Eynur, B. R. (2026). Efficacy of Kangoo Jump Exercises for Primary Dysmenorrhea in Young Women: Results from a Pre-Post Study. Research in Sport Education and Sciences, 28(1), 37-47.
George, S. Z., Fritz, J. M. and Childs, J. D. (2008). Investigation of elevated fear-avoidance beliefs for patients with low back pain: a secondary analysis involving patients enrolled in physical therapy clinical trials. Journal of Orthopaedic & Sports Physical Therapy, 38(2), 50–58. https://doi.org/10.2519/jospt.2008.2647.
Tatikola, S. P., Natarajan, V., Amaravadi, S. K., Desai, V. K., Asirvatham, A. R., & Nagaraja, R. (2025). Effect of pain neuroscience education+ (PNE+) in people with different mechanisms of chronic pain: A systematic review and meta-analysis. Journal of bodywork and movement therapies, 41, 215-237.
Jadhakhan, F., Sainsbury, J., and Foster, N. E. (2023). Effects of exercise/physical activity on fear of movement in people with spine-related pain: a systematic review. Frontiers in Psychology, 14, 1213199. https://doi.org/10.3389/fpsyg.2023.1213199.
SH, Kori (1990). Kinesiophobia: a new view of chronic pain behavior. Pain Manage, 3, 35-43.
Kang, J. W., Zhang, Y. H., Yuk, Y. S., & Lim, H. W. (2025). The effects of psychologically informed physical therapy on kinesiophobia, pain, disability, depression, and anxiety in patients with chronic low back pain: an intervention study focusing on graded exposure. Journal of Physical Therapy Science, 37(11), 556-560.
LA de Oliveira, L. A., Gross, A. R., Carlesso, L., Hanna, S., Bakaa, N., Silva, D., ... & Macedo, L. G. (2025). Graded activity for chronic low back pain. The Cochrane database of systematic reviews, 2025(2), CD015507.
Leeuw, M., Goossens, M. E. J. B., Linton, S. J., Crombez, G., Boersma, K., ve Vlaeyen, J. W. S. (2007). The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. Journal of Behavioral Medicine, 30(1), 77–94. https://doi.org/10.1007/s10865-006-9085-0.
Lepri, B., Romani, D., Storari, L., ve Barbari, V. (2023). Effectiveness of pain neuroscience education in patients with chronic musculoskeletal pain and central sensitization: a systematic review. International Journal of Environmental Research and Public Health, 20(5), 4098. https://doi.org/10.3390/ijerph20054098
Lethem, J., Slade, P. D., Troup, J. D. G., ve Bentley, G. (1983). Outline of a fear-avoidance model of exaggerated pain perception – I. Behaviour Research and Therapy, 21(4), 401–408. https://doi.org/10.1016/0005-7967(83)90009-8.
Louw, A., Sluka, K. A., Nijs, J., Courtney, C. A., ve Zimney, K. (2021). Revisiting the provision of pain neuroscience education: an adjunct intervention for patients but a primary focus of clinician education. Journal of Orthopaedic & Sports Physical Therapy, 51(2), 57–59. https://doi.org/10.2519/jospt.2021.9804.
Moseley, G. L. (2011). A new direction for the fear avoidance model? Pain, 152(11), 2487–2488. (International Association for the Study of Pain commentary).
Nijs, J., Lahousse, A. and Malfliet, A. (2023). A paradigm shift from a tissue- and disease-based approach towards multimodal lifestyle interventions for chronic pain: 5 steps to guide clinical reasoning. Brazilian Journal of Physical Therapy, 27(5), 100556. https://doi.org/10.1016/j.bjpt.2023.100556.
Nijs, J., Van Wilgen, C. P., Van Oosterwijck, J., van Ittersum, M., ve Meeus, M. (2011). How to explain central sensitization to patients with 'unexplained' chronic musculoskeletal pain: practice guidelines. Manual Therapy, 16(5), 413–418. https://doi.org/10.1016/j.math.2011.04.005.
O’Sullivan, P. B., Caneiro, J. P., O’Keeffe, M., Smith, A., Dankaerts, W., Fersum, K., & O’Sullivan, K. (2018). Cognitive functional therapy: an integrated behavioral approach for the targeted management of disabling low back pain. Physical therapy, 98(5), 408-423.
Rogers, A. H. and Farris, S. G. (2022). A meta-analysis of the associations of elements of the fear-avoidance model of chronic pain with negative affect, depression, anxiety, pain-related disability and pain intensity. European Journal of Pain, 26(8), 1611–1635. https://doi.org/10.1002/ejp.1994.
Simons, L. E., Harrison, L. E., Boothroyd, D. B., Parvathinathan, G., Van Orden, A. R., O'Brien, S. F., ... & Wicksell, R. K. (2024). A randomized controlled trial of graded exposure treatment (GET living) for adolescents with chronic pain. Pain, 165(1), 177-191.
Sullivan, M. J. L., Bishop, S. R., ve Pivik, J. (1995). The Pain Catastrophizing Scale: development and validation. Psychological Assessment, 7(4), 524–532. https://doi.org/10.1037/1040-3590.7.4.524
Treede, R. D., Rief, W., Barke, A., Aziz, Q., Bennett, M. I., Benoliel, R., ... & Wang, S. J. (2019). Chronic pain as a symptom or a disease: the IASP Classification of Chronic Pain for the International Classification of Diseases (ICD-11). pain, 160(1), 19-27.
Turk, D. C. and Okifuji, A. (2002). Psychological factors in chronic pain: evolution and revolution. Journal of Consulting and Clinical Psychology, 70(3), 678–690. https://doi.org/10.1037/0022-006X.70.3.678.
Vlaeyen, J. W. S. and Linton, S. J. (2000). Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain, 85(3), 317–332. https://doi.org/10.1016/S0304-3959(99)00242-0.
Vlaeyen, J. W. S. and Linton, S. J. (2012). Fear-avoidance model of chronic musculoskeletal pain: 12 years on. Pain, 153(6), 1144–1147. https://doi.org/10.1016/j.pain.2011.12.009.
Vlaeyen, J. W. S., Crombez, G. and Linton, S. J. (2016). The fear-avoidance model of pain. Pain, 157(8), 1588–1589. https://doi.org/10.1097/j.pain.0000000000000574.
Vlaeyen, J. W. S., de Jong, J., Geilen, M., Heuts, P. H. and 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. Clinical Journal of Pain, 18(4), 251–261. https://doi.org/10.1097/00002508-200207000-00006
Volcheck, M. M., Graham, S. M., Fleming, K. C., Mohabbat, A. B., and Luedtke, C. A. (2023). Central sensitization, chronic pain, and other symptoms: better understanding, better management. Cleveland Clinic Journal of Medicine, 90(4), 245–254. https://doi.org/10.3949/ccjm.90a.22019.
Woolf, C. J. (2011). Central sensitization: implications for the diagnosis and treatment of pain. pain, 152(3), S2-S15.
World Health Organization (WHO). (2022). Musculoskeletal health. WHO Fact Sheet. https://www.who.int/news-room/fact-sheets/detail/musculoskeletal-conditionsHayden, J. A., Ellis, J., Ogilvie, R., Malmivaara, A., & van Tulder, M. W. (2021). Exercise therapy for chronic low back pain. Cochrane Database of Systematic Reviews, (9), CD009790.
