Fear avoidance

Pushing yourself to get things done? Suffering badly after? Or perhaps you are doing very little. Understand the over/underactivity cycle and break out to a better way of doing things.

Pacing is one of the most useful skills to learn if you have pain. Many people with pain tell us this. It’s not easy but it works!

Fear-avoidance

This is the term given to an idea which tries to explain why some people recover whilst others develop chronic illness or disability. In the 1970s Philips proposed that pain is not just one dimensional, ie nerve transmission of impulses, but has physiological, subjective and behavioural dimensions.

1. Physiological

   refers to the way the pain is being transmitted in the nervous system and all the things that are affecting it within the wiring

2. Subjective

   refers to the person’s view of what is going on. For example, if a person gets a pain in the chest, they will think very differently if they interpret it as due to an overstrain in sport or as a heart attack. The ‘heart’ pain will be experienced as ‘worse’ and will certainly cause more distress

3. Behavioural

   refers to what the person actually does in response to the pain. If they respond by stopping all activities and resting, then this will have consequences for their pain

The amount of pain any of us feels is a combination of these factors and others, even though any one of them may be more dominant at times.

Looking at the idea more closely

Let’s look at two opposite scenarios for someone who may just have developed back pain recently.

1. This person has severe back pain but is not afraid what it means, he has a low fear level. He interprets it as a sprain or strain and expects to get back to normal as soon as possible.

   Because he is not afraid he is able to continue to do things even though it brings on some of the pain and he does not avoid at lot of activities or take to bed. He puts the pain in its place as an annoying problem and thinks about it objectively.

   He gradually increases his activities, confident he will improve, and steadily moves towards recovery.

2. This person has severe back pain but is strongly fearful of what it means. He feels it could mean a serious problem in his back.

   Because of this worry, he avoids any activities which cause pain, does less and less and rests a lot of the time.

   He gets less fit and physically able, and is less able to view the pain objectively and without emotions such as worry and fear. He progressed steadily towards becoming chronically disabled by the back pain

These two scenarios illustrate the role that fear can take in controlling what someone does after a painful experience.

The development of fear-avoidance

A number of factors are thought to be involved:

1. Life events, such as trauma, bereavement, abuse
2. Personality factors, such as a tendency to ’somatise’, ie to concentrate strongly on physical symptoms and rate them as important
3. Previous pain experience - such as episodes of back or other pain.
4. The normal coping experiences of the person - passive or active.

There is no simple way of predicting why someone may become disabled, but the best indications come from a combination of physical and psychological factors.

What’s the fear due to?

From experience treating people, the fear seems to come from the belief that pain equals damage. If someone has back pain they feel that damage is the cause of the pain. If the pain increases when they do something then increased damage must be occurring.

This leads to the tendency to avoid activities because of the fear of causing further damage. Unfortunately there is no evidence that rest is a successful treatment for back pain. It may be the worst thing we can do when we have pain.

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