Making sense of fear in people with low back pain

Dr. Samantha Bunzli outlines the difficulty dealing with patients’ fear in clinical practice in an edition of the Australian Physiotherapy Association’s magazine InTouch. Dr Samantha Bunzli is a physiotherapist and Postdoctoral Research Fellow at the Centre for Research Excellence in joint replacement surgery: OPtimising oUtcomes, equity, cost effectiveness and patient Selection (OPUS), at The University of Melbourne, Department of Surgery. In her research, Sam uses qualitative methodologies to explore patient experiences of musculoskeletal pain through a cognitive behavioural lens.


Negative beliefs about low back pain (LBP) are common.  Fifty percent of the general population believe pain in the back means that the back is damaged. Around ninety percent believe that ignoring pain can damage the back; and seventy believe there is ongoing weakness in the back following an episode of LBP. It follows then, that the experience of LBP can feel threatening and scary for many people. If the spine is the central structure of the body, protecting the precious spinal cord, what happens when the spine is ‘damaged’, ‘weak’ or ‘worn’? Could it mean ending up in a wheelchair?


Contrary to popular beliefs, the spine is a strong structure and serious underlying structural causes of LBP are rare. The association between common MRI findings such as disc degeneration and disc bulges and LBP disability is weak. In contrast, what people believe and do about their LBP has a strong influence on how long the pain will last and how disabled they will be by it. Among the most predictive of these beliefs, are fear avoidance beliefs associated with pain-related fear.


The fear avoidance model has been proposed to help us understand how interpreting the LBP experience as threatening can lead to pain-related fear and kinesiophobia: “an excessive, irrational and debilitating fear of physical movement activity”.  However, approximately 50 percent of people seeking care for LBP will present with high fear and associated avoidance behaviours. This suggests that rather than being a ‘phobic’ or ‘psycho-pathological’ response, it may be more useful to think of fear avoidance as a normal, culturally endorsed response to a threatening pain experience.


In our recent publication in JOSPT, we propose a ‘common sense’ perspective of fear avoidance. We draw on Leventhal’s Common Sense Model, explaining how when we experience a symptom of pain in the back, we attempt to make sense of it by forming a cognitive ‘representation’ of the pain. We ask ourselves:


  1. What is this pain? (Identity beliefs)
  2. What caused this pain? (Causal beliefs)
  3. What might be the consequences of this pain? (Consequence beliefs)
  4. How can I control this pain? (Control beliefs)
  5. How long will this pain last? (Timeline beliefs)


These five belief dimensions that form the representation are based on our personal, social and cultural contexts. They are constantly updated by information from the media, friends, clinicians and our perception of how the pain feels at any given point in time. This ‘representation’ will then influence what we do about the pain.


Typically a patient presenting to physiotherapy might have a representation of their LBP that looks something like this: They believe, or have been told, that they have damage to a disc in their spine (Identity belief) caused by lifting (Causal belief). They believe they are at risk of damaging the ‘nerves’ of the spine and ending up in a wheelchair (Consequence belief), and experience sharp ‘pangs’ of pain in the back that are unpredictable and uncontrollable (Control belief), with poor expectations of recovery (Timeline belief).


From a Common Sense Model perspective, if a person with LBP believes or has been told that, bending or lifting will damage their spine, it is a common sense response to avoid or modify that activity. Equally, if a person experiences stabbing pain in their back when they bend or lift, it is common sense to avoid or modify that activity.  Fear avoidance behaviour can therefore be considered a common-sense problem solving response to avoid a pain experience. As long as the outcome of avoidance is expected (i.e. no increase in pain) then the representation is perceived to be useful and avoidance behaviour will be maintained.


However, while avoidance makes sense in the short-term, if it is maintained long-term it can interfere with social and occupational roles. Eventually this may drive people to seek help from a healthcare professional with expectations of a linear pathway from diagnosis of an underlying pathology or structural abnormality – to treatment, removal or reversal of the abnormality – to a cure and return to ‘normal’. However, this expectation is rarely fulfilled, leaving patients with a LBP experience that doesn’t make sense to them. From a common sense perspective, the inability to make sense of a threatening pain experience can generate or perpetuate pain-related fear.


For us as health professionals, the implications of a common sense perspective is that we may reduce fear and avoidance by helping patients to make sense of their pain. In our JOSPT article we propose a common sense approach to sense-making. The approach involves:


  • Encouraging patients to share their beliefs about their LBP along the five belief dimensions comprising the representation
  • Guiding patients to adjust their LBP representation through the provision of new information. This may involve for example, an explanation that they have ‘sensitisation’ of the spinal structures (Identity belief) that are linked to factors such as poor sleep, stress, protective guarding and movement avoidance (Cause belief) that in turn cause more pain and sensitisation (Consequence belief), and that strategies to address these factors such as relaxation and engaging in movement (Control belief) will facilitate a return to valued activities within a specific time frame (Timeline belief).
  • Behavioural experimentation is considered essential so patients can disconfirm beliefs about the negative consequences of performing movements associated with threat or pain. Behavioural experimentation is also important in order for patients to experience that the behaviours arising from this new representation are effective in controlling pain and/or the impact of pain in their lives.


Once patients have an explanation that helps them make sense of their LBP, combined with strategies to effectively control pain and enable a return to valued activities, the threat of LBP is reduced, facilitating fear reduction.


As well as providing a clinically useful framework to assess and treat fear avoidance, we suggest that thinking of fear as a ‘common sense’ response rather than as a ‘phobic’ response is potentially less stigmatizing for patients. Let’s put ourselves in the shoes of our fearful patients who are struggling with a threatening pain experience they can’t make sense of.

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