Fear Avoidance in Chronic Pain

Dr. Sechrest: Hello, I’m Dr. Sechrest, your host for Real Pain Care. I’m back with Dr. Patrick Johnson, a clinical psychologist in Seattle, Washington. Last visit we discussed several things but the major focus of our discussion at the last visit was on the psychological evaluation and what role the psychologist plays in the evaluation of chronic pain. Dr. Johnson explained very nicely what the goals of the evaluation were, what’s done during the evaluation, and, in the end, what information is provided back to you as a patient and also back to the medical physician who may have sent you to see a psychologist. Good afternoon, Dr. Johnson.

Dr. Johnson: Good afternoon, Dr. Sechrest.

Dr. Sechrest: Well, thanks for joining us again. I just summarized our discussion on our last visit, and today what I thought we would do is start to talk a bit about some of the behavior patterns that patients tend to get into when they have chronic pain or perhaps come to chronic pain with as part of their overall way of dealing with the world and how some of those behavior patterns may cause problems when we begin to try and manage chronic pain. I would like to discuss those one at a time and investigate those behavior patterns and begin to look at how patients can become aware as to whether or not they may be falling into some of these patterns and, once they’re aware of these patterns, what they might be able to do to try to get out of those patterns. So the first one I thought we would talk about is one that is very common and, I would say in a lot of cases, a lot of people have made the claim that this behavior pattern may be one of the key contributors to people who go on to develop chronic pain and that behavior pattern is something you and I would call fear avoidance. So, if you’re game, let’s talk about this a bit, and if you would start by describing for the viewer, what is fear avoidance?

Dr. Johnson: This is exactly, in my opinion, the right place to start because the term by itself has the potential, of course, to be very loaded, and it’s the kind of phrase or kind of term that can easily be misconstrued. To begin with, well let’s talk about first of all, just as you say what we mean. When we talk about fear or fear avoidance or simply avoidant behaviors in the context of chronic pain, what we’re talking about is that very very common pattern that involves chronic pain patients significantly limiting movement or activity throughout the course of the day for the very obvious and sort of, on one level, common sense reason which is that it hurts. It hurts to move. It hurts to get up and do things. So what we observe one level is there is no mystery about this – what we observe is that when people are hurting, they do a lot less and, as you and I have talked before, in an acutely painful situation, when somebody is still in the process of recovering from an injury or healing up from an injury, as we’ve discussed before, to limit one’s pattern of activity during the course of healing is exactly the right idea. But there comes a point at which healing has really taken place to the extent that it’s going to, to the extent that it needs to, but that it continues to be painful to try to move and so, in that situation or in response to that ongoing pain, in response to that pain that persists past healing, what we see is that people stay in patterns of significantly reduced movement or activity. When that becomes severe, when people are so limited in their pattern of movement that they really end up falling into a pattern of doing almost nothing through the course of the day. What we know is the quality of life suffers enormously at that point. What we also know, by the way which we’ll talk more about, is the lack of movement is probably making the pain problem even worse. But the label that we give to that overall behavior pattern is fear avoidance. It’s the observation that what had been normal patterns of activity through the day are now being avoided because of fears of re-injury or fears of just hurting worse.

Dr. Sechrest: When that occurs, when the patient begins to avoid different activities, avoid movement, avoid things that they think are going to hurt, how does that tend to either prolong or create the situation where chronic pain begins to get worse and worse and worse? How does that actually drive the process?

Dr. Johnson: In several ways that we understand, and each of these is very important in its own right. Perhaps the most obvious one that we could put under that heading that we’re all familiar with is “use it or lose it”. The fact of the matter is that the bodies that we inhabit were designed or have evolved to be used and so we know that regular physical activity, regular exercise is not only a useful thing, it’s really a requirement for good health. It’s a requirement for good quality of life and when it’s the case that we stop using a body part because of an injury, if that lack of use persists past the time that the injury has healed, then a number of bad things happen. One is that, as we know, the tissue becomes weak whether its muscle tissue, or bone, or connective tissue, the tissue becomes weak. It also, though, becomes hypersensitive so that any movement is going to be perceived as causing even more discomfort than had been the case at the time of the initial injury. Body parts that we don’t move become stiff in addition to becoming weak, and then when we try to move them, of course, we have a certain amount of inflammation. It’s really in some sense no different than what happens when we go back to the gym after a long layoff or, for those of us who do something like ski or ride bikes, the first time we get back on our bicycle after a long winter, boy, we can feel it. There are muscles that are sore because we haven’t been using them for several months. So, in a chronic pain kind of situation there are those very similar, very much the same, mechanical considerations that the body parts that we’re no longer using, end up being set up in a way for worse pain once we do try to move, once we do try to stretch and get going again. So that’s the first piece. It’s a very mechanical one, a very straightforward physiological piece. The other part to all of this though, is that when you ask someone about the things that they’re no longer doing because of their chronic pain problem, the things that they’re afraid to do, that they’re reluctant to do, that they’re hesitant to do, because of increased pain or because of fear of re-injury. When you ask folks to name those things it becomes very clear that what they’re naming is a series of losses in their lives. So the top of the list almost always is that “I’m not working anymore; and not only do I miss going to work, not only do I miss just getting out of the house and feeling productive, but my income has been significantly lessened as a result of not working”. So there is really a series of losses related to being unable to work because of pain. But also people will talk about our physical activities that they enjoyed or that they just need to be able to do: to look after their homes, or to take care of themselves, to make sure that they get enough physical activity to just feel good, to have quality of life. So those losses when people are not able to move normally or in the way they had been prior to their injury, those losses begin to pile up and they do take an enormous toll – a huge toll – in terms of the quality of life of the individual and that sets the stage for poorer mood, poorer attitude, and very often, in fact most of the time, actual symptoms of depressions. What we know is that once someone gets to the point that they’re actually feeling depressed, and again in the context of what we’re talking about, this can easily simply be because they’re not able to do things that they’d like to be able to do. When someone gets to that place of feeling depressed, they hurt more, and that’s not, as we talked in one of our recent conversations, that’s not imaginary pain, that’s not emotional pain, or hysterical pain, or psychogenic pain. . . it’s pain. But it’s pain that now is being produced by the physical deactivation, by the change in mood, by the perception of all of those losses, by living in a way that has to do with being afraid to move and be active. It’s pain that is much worse even than what was there simply because of mechanical changes in the body related to pain and related to decreased physical activity. To sort of summarize this part of our talk, what I would say is it’s very clear to us that the cost of becoming physically deactivated, because of being wary of movement or afraid to move, the cost of that is very very high, and can be measured in a number of ways including increased pain.

Dr. Sechrest: It’s interesting because I think that what you just described is this vicious cycle or spiral downward that we see so many times in chronic pain patients where they may start out doing something that is very common and makes good sense. . .they’re resting something or avoiding activity because they think they’re protecting their body. Then, once that cycle starts it just continues to get worse and worse and worse until, all of a sudden, they are no longer protecting anything. The vicious cycle is such that the pain gets worse and the fear avoidance is really creating, like you say, the pain in and of itself; where, if you just step back and, sort of take a 30,000 foot view and say, “you know, I’m better off doing some things, getting out moving around to reconnect, to overcome some of these losses, and in the end my overall situation is probably going to be better”. Like you said, I may not hurt any less necessarily but, in general, my overall health will probably be better.

Dr. Johnson: Quality of life, mood, all of that, and what we know is that when overall health improves or mood or quality of life, people actually do hurt less. You know a very important part of what you were just eluding to is the meaning that is associated with the pain. It’s the way people interpret the pain that they have. There are really a number of stories in the medical literature related to chronic pain of the way it is that pain can be perceived differently depending on what it means, and in casual language we talk about “good pains versus bad pain”. We talk about the pain related to a physical workout as maybe being a good pain as long as don’t overdo it and actually injure ourselves. But a very important part in this discussion about fear avoidance is exactly this piece because it’s the way that the pain signal or the experience of pain is being interpreted. If I’m absolutely convinced that any movement is going to produce an increase in pain and that that increase in pain now means that I’ve reinjured myself, I’ve harmed myself, then, of course, I’m going to be understandably very reluctant to move. If, on the other hand, I can work with my providers to get a very accurate assessment of what’s going on in my body and we reach a place that they’re able to explain to me that, you know, if I get going again I’m definitely going to hurt more before I hurt less, but it’s not a pain that I have to worry about meaning that it’s not a pain that means that anything has been damaged or harmed. If I can believe that, if I can believe it at least enough to gently begin to put it to the test, I am almost certainly going to find, provided that we’re getting good information to begin with, I’m almost certainly going to find that, sure enough, that I feel better rather than feeling worse, once I’ve gotten over the hump of the pain getting worse before it gets better, once I get over the hump of the pain increasing a little bit when I first begin to move. So to be able to get the kind of information from my providers that will set my mind at ease that hurt is not the same thing as harm makes all the difference in the world. If I can have some assurance that if I get moving and if it hurts more that doesn’t mean I’m tearing anything up, it doesn’t mean that I’m reinjuring myself or even risking re-injury, it just means that to get moving again is going to hurt, no question about that. If I can just get to that place that is a very, very important hurdle to get past as I then get moving in the direction of regaining my strength, regaining my flexibility, regaining something closer to my patterns of normal activity through the day.

Dr. Sechrest: Well, that brings up, I think, an important point and I think you may have eluded to it in this discussion that you went through; and that is, how do I as a patient begin to become aware that perhaps this is occurring to me; perhaps I am slipping into this behavioral pattern of fear avoidance. Is there something I can do as a patient? Is this something that I need to rely on the psychologist or my physician to clue me into so that I can begin to move past it? Are there any clues that I, as a patient, can begin to say, “well, maybe this is my problem and perhaps I need to move past this”. How do I do that?

Dr. Johnson: That’s a great question. I would say the very first thing at the top of the list is so obvious that almost everyone, patients and providers alike, overlook it, and that is, first and foremost, pay attention to, clue into your own unhappiness, your own dissatisfaction. When someone asks you, “Gosh, what’s it like to have chronic low back pain that is so debilitating? What are the things that you’re not able to do anymore because you hurt so much?” Pay attention to how it makes you feel, emotionally, to run through that list, to say to someone, “Oh, sure. I can tell you right now. How much time do you have? I can tell you right now. There’s this long list of things that I’m not able to do anymore and it makes me miserable that I can’t. I’m very unhappy that I can’t.” The reason I suggest that it’s so important to clue into that is because that misery, that discomfort, that dissatisfaction is the motivation, or it provides the motivation that we need to get moving again. So if I can be honest with myself, first of all, and then be honest with my providers about the fact that I am really unhappy not being able to do more of my usual activities that I can do, that unhappiness will hopefully, very naturally, lead us all into a discussion about what will it take to change that. Then at that point, having trust in your providers I would say is a critical piece to be able to work, particularly I would think, with a physician or perhaps a physician’s assistant, or a physical therapist even, to be able to work with those folks to review your x-rays or your MRIs, or your bone scans, or any other information in your medical record that would let us know or let you know at that moment in time, what the actual status of things is; because what the all-important question is movement safe? The all-important question, and this is the question that I always encourage chronic pain patients to ask their physicians and their other providers, the question always is: Is movement safe? If I’m gentle, if I’m careful, if I’m thoughtful about how I get going again, do I need to be concerned that I’m going to tear up my back or tear up my shoulder or tear up my knee, whatever the problem happens to be? Or is there a way if I’m careful, if I’m gentle, if I go about it thoughtfully, is there a way that I can get moving again that will be safe in terms of not damaging myself, not harming the tissue at all even if it makes me hurt more at first? So being able to, first of all, ask the question and then trust the response that you get back so that if your provider says back to you, “Sure, we’ve taken a recent MRI and we’ve had a good look at things, and my best guess as your physician, as your surgeon, is that as long as you’re careful and stay within the guidelines that you get from your physical therapist, you don’t have anything to worry about in terms of damaging the goods, in terms of tearing anything up. You’re going to hurt more. You’re almost certainly going to be more uncomfortable at first then you are now, but that will be the discomfort that comes from moving muscles and tendons and ligaments and bones and skin that haven’t been moved in a long time, or haven’t been moved in these ways. What that means is that you’re now getting your strength back, you’re now getting your flexibility back.”

So those two pieces, right from the get-go in my mind, are the most important. The first one is to be able to be honest with yourself about the fact that you’re not happy living the way that you’re living so that you can clue into the motivation that you have to get going again. Then, to work very carefully with your providers first of all on this question of whether or not movement is safe, and if you have enough assurance that it’s at least worth putting to the test, then all kinds of things open up in front of you in terms of opportunities to gradually, gently, get moving again.

Dr. Sechrest: Well, I think based on what you’ve just said it’s obvious that physicians have some role to play in this and it appears that we, as physicians, can actually make the situation worse at times, and at times we can actually make the situation better. Clearly, from what you said, if we as physicians are somewhat concerned, for example, if we begin to do lots of tests looking for something very serious that sends a message to the patient that maybe something is wrong that they may damage if they’re not careful. On the other hand, if we send a message that, yes, we’ve thoroughly evaluated the situation and we feel comfortable that what we’re telling you is accurate and you’re not going to damage anything, then that is more likely to result in some sort of positive behavior on the part of the patient. Am I correct?

Dr. Johnson: Oh, that definitely would be my bias and my observation and, in fact, I would add something which is that there really can be some terrific subtlety between the physician and the patient along these lines. Because, as a patient, my well-being is at stake, and if I’m asking my physician, “Is it safe for me to get going, to get moving, as long as I’m careful about it?” What I’m really looking for from that doctor is a very convincing and resounding “Yes!”, and if I get anything other than that, if I get any hint at all that my doctor, in fact, may be kind of ambivalent about this or may be concerned that, in fact, I am going to harm myself, well that, of course, is not going to give me the assurance that I need. It doesn’t take much, as a patient, if I pick up on even just the smallest hint of wariness or ambivalence on the part of my doctor, that might be enough for me to say, “Um, boy. I don’t know about this.” So what that means to me, and I think this is just what you’re saying, is that the physician and the other providers, of course, need to have done all of the tests necessary to be able to make the determination as best they can that, yes indeed, movement is safe for you. Then once that determination is made to really be pretty emphatic about that, straightforward, but nonetheless very clear in the statement that: “Yes. As far as I can tell for you to get going again is absolutely the right idea. If you don’t do that all indications are that your pain problem is going to get worse and worse and worse. We know how to work with you to get going in a way that will allow you to see gradual, safe improvement. So, yes, absolutely 100%, I’m in favor of you getting going, getting moving as long as you go about it carefully. As long as you go about it the right way.

Dr. Sechrest: Well, I think you made some key points, and one of the key points is it has got to be credible. The physician or whoever is saying, “Look, I’ve looked at the situation. I’ve done the necessary tests, and I can tell you from my experience and from my knowledge base that you can safely move.” That’s different than someone just saying, “Ah, sure. Go ahead and do that.” If the patient has no faith that the information they’re getting from the physician is accurate information and is based on objective evidence and not just some sort of fly-by-night opinion, then I think what you said is: it’s not useful. It has to be credible. It has to be not only delivered with confidence, that confidence actually has to reflect actual, I would say, authentic evaluation on the part of the physician that they’ve actually looked at what they need to and have made a good solid assessment of the situation.

Dr. Johnson: Right. I would add that a very important detail in that particular conversation, and this one, often, is a source of a lot of confusion, is that is no longer makes sense for the physician to say, “Let pain be your guide”. With an acute injury, if I’ve recently broken a bone or twisted my ankle or twisted my knee, and, after a couple of weeks of not using it I get my doctor on the phone or one of her nurses and say, “You know, I’m kind of impatient with this. Can I get going again?” While it’s still healing up if my physician were to say, “Well, sure. Let pain be your guide. You’ll know if you’re overdoing it.” While I’m healing up, while I’m still in the acute phase that’s good advice. Of course, that makes good sense. But with chronic pain when somebody is ready now to get moving again with a very gentle appropriate physical therapy program, it no longer makes sense to let pain be your guide; because what we know is that if you’ve been essentially flat on your back for six months, any movement, anything that you do that is in the direction of getting stronger, getting more flexible is going to hurt. So that’s an example that I think is worth calling out because it comes up a lot where someone is told by their physician, “Sure, we think exercise is a good idea – just let pain be your guide.” Well, in a chronic pain setting, that doesn’t really make any sense at all so that’s another way that the message ends up often feeling somewhat sort of mixed to folks. Now the alternative, again, is to work particularly with a physical therapist who has worked with a lot of pain patients who can help you lay out a program that is very gentle and very gradual in terms of increasing the amount of activity or the length of time that you’re engaged in a particular activity, but something like the number repetitions becomes your guide, or the number of minutes walking on the treadmill becomes your guide. Somewhat irrespective of whether or not it makes your back hurt more, we assume that it’s going to at first, and some pains, of course, are different than others, and most of the time there is no trouble at all being able to say, “Oh, sure. This is just the discomfort that you feel when you’re getting moving again.” So something about being able to be very reassuring, but also somewhat emphatic or enthusiastic in saying to people, “Yes. It’s time to get moving again. We just need to make sure you do it the right way.” Those are the very important pieces, I would say.

Dr. Sechrest: Well, I think we’ve pretty much covered the waterfront in terms of this behavioral pattern that you and I would call fear avoidance. Is there anything else that we haven’t covered? Anything that you feel like patients need to understand in order to become aware of this behavioral pattern and also to confront this behavioral pattern in order to get better when they have chronic pain? Anything we have not covered?

Dr. Johnson: The only piece I would add is that when I think back for the last 25 years, the patients that I’ve seen who have made the most progress to a person, each of those was someone who said, “You know what? I’m only going to get better as a result of my own effort. I’m only going to get better because of my ability to, in some ways, take charge of the situation and start explaining to the providers I’m working with, what it is that I want.” So the emphasis, particularly with regard to something like getting past this fear avoidance, the emphasis really needs to be on activity both in terms of physical movement as we’ve been talking about, but also in terms of assertiveness, being able or willing to take a very active role in your own recovery by being very clear with your providers what it is that you want, what it is that you’re tired of; what the changes are that you want to see, and to work very actively as a partner with each of your providers rather than in a more passive role as just being somebody who passively receives whatever treatments they offer you. I think it’s safe to say that the progress that you make in managing a pain problem is, far and away, going to have more to do with what you yourself do as a patient, then anything, any techniques, or treatments that someone does to you.

Dr. Sechrest: Well, I think that if we can ever get that into appeal, you and I will probably be out of a job. But I don’t think that’s going to fit into appeals any time soon. So, excellent advice, and thanks so much for discussing fear avoidance with us today. Thanks a lot.

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