Threat prioritization and fear of pain dynamics are associated with engagement in postoperative activities after thoracoscopic lung surgery.

Fear of pain (FOP) often leads to activity avoidance, hindering recovery after thoracic surgery. We proposed the concept of “Threat Prioritization”—the cognitive weighing of activity-induced pain against inactivity-induced complications. This study investigated whether prioritizing complication risks over pain is associated with greater engagement in postoperative activities and a subsequent reduction in FOP. In this prospective cohort study, 121 patients undergoing thoracoscopic lung surgery were enrolled. FOP (Fear of Pain Questionnaire-9) and cough strength (Semi-Quantitative Cough Strength Score, SCSS) were assessed on postoperative days (POD) 1 and 3. Therapeutic ambulation episodes (POD1–3) were recorded. On POD3, patients were categorized as “Complication-Focused” or “Pain-Focused” based on their self-reported primary concern during recovery. Multiple linear regression was used to identify predictors of FOP reduction. Complication-Focused patients (n = 45) showed significantly stronger cough on POD3 (Median SCSS: 4.00 vs. 2.50, p < 0.001) and higher distribution of ambulation episodes (Median: 4.00 vs. 4.00, p = 0.003) compared to Pain-Focused patients (n = 76). Postoperative air leak rates were comparable between groups (20.0% vs. 19.7%, p = 1.000). Regression analysis (Adjusted R2 = 0.433) showed that greater FOP reduction was associated with higher ambulation counts (B = -1.25, p < 0.001). Conversely, activity-linked breakthrough pain was associated with attenuated fear reduction (B = 5.31, p < 0.001). Changes in physiological pain intensity were not significantly associated with FOP reduction (p = 0.964). Age, sex, and surgical extent were included in the model a priori but were not significant predictors (all p > 0.05). A mindset prioritizing complication risks over pain is associated with increased engagement in essential recovery activities without increasing observed air leak rates. Postoperative FOP reduction appears to be driven by behavioral engagement rather than physiological pain relief alone. These findings suggest that perioperative interventions targeting threat prioritization may facilitate functional recovery.