People with low back pain and high fear have been shown to experience more severe, persistent and disabling pain than those with low fear, making fear a key target for intervention.
We ask you to consider the following interview extracts:
John: “I would never bend over to pick something up. I try to brace myself on any move (…) because any time it hurts I think that I’m doing more damage. Like if it hurts it is getting worse and I am killing, I am breaking down, I am killing myself” (John, a 42 year old school teacher who has experienced back pain for 2 years).
Emma: “I don’t think that picking up that pen is going to damage my spine. But I know if I bend over and pick up that pen, that pen is going to irritate me for the next half an hour. Why would I do that? If it is going to irritate me for half an hour when I could have a half hour pain free why would I do that? I can achieve a lot in half an hour if I am not in agony” (Emma, a 48 year old caterer who has experienced back pain for 1 year).
These two accounts illustrate the key finding from our recent qualitative investigation of fear in people with chronic low back pain. Both these individuals score highly on the Tampa Scale of Kinesiophobia, a widely used tool to assess “fear of movement and physical activity that is (wrongfully) assumed to cause (re)injury”. High scores on the Tampa (>37/68) are used to identify candidates for fear reduction interventions aimed at changing underlying beliefs that pain is a sign of damage. However, such interventions have had modest results. Some individuals do well, others do less well and a high percentage (up to 1 in 3) drop out of treatment.
Findings from our study may help to shed some light on these modest effects. In the examples above, John describes fear of painful activity that he believes could cause damage to his spine (damage beliefs) and Emma describes fear of painful activity that she believes will impact on subsequent function (functional loss beliefs). We hypothesize that whilst John may respond well to fear reduction interventions aimed at changing underlying damage beliefs, Emma is more likely to respond to interventions aimed at providing alternative pain control strategies linked to functional goals. The allocation of all people with high fear to interventions aimed at changing underlying damage beliefs, may be resulting in a dilution effect due to the inclusion of people who do not believe that pain is a sign of damage.
Our findings suggest that in order to deliver targeted, individualized interventions, it may be important for clinicians to understand the beliefs underlying fear in patients with low back pain. Whilst the Tampa Scale may be a useful tool to assess high fear, future research is needed to develop a questionnaire that can aid in the identification of beliefs underlying fear. In the meantime, clinicians may consider including simple questions into their assessment of individuals presenting with low back pain and high fear such as:
Do you worry that performing a painful activity will cause damage to your spine?
Do you worry that performing a painful activity will impact on all the other things you need to get done in your day?
Sam Bunzli worked for 10 years in musculoskeletal physiotherapy and is a PhD Candidate at Curtin University conducting her research under the supervision of Professor Peter O’Sullivan and Dr Anne Smith.
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