Superdoc (8) - Back pain and the 'fear avoidance model'
Ch-ch-changes. Everything’s changing.
Something that hasn’t changed? I’m still talking about fear and back pain, though this time with a focus on ‘the fear avoidance model’.
The fear avoidance model was developed in the 1980s, to try to understand why some people had significantly worse outcomes from their long term or chronic pain. The model says that we are all somewhere on a spectrum.
At one end is the person who doesn’t worry too much about their pain; the often quoted example is the farmer. His back hurts from hauling bales of hay, but he has an attitude of, “It’s only pain” – he just gets on with the job.
At the other end of the spectrum is the person who’s frightened of the pain. They worry about what it means and self-monitor their level of pain. If something hurts they worry that it might be doing harm and try to avoid any fresh experiences of pain. They are called ‘pain avoiders’. Extreme pain or fear avoiders are often low in self-efficacy or belief that they’ll cope. Doctors know this type of patient and know that often the extreme pain avoider is very difficult to deal with, and that their consultation will take longer.
It is said that the outcome of the person’s problem will be more dependent on the person’s fear of the pain, that is, their beliefs about the pain, than the actual level of pain itself. People at the pain avoidance end of the spectrum often use distressing terms when talking about their pain, such as ‘it’s terrible’, or ‘excruciating’, ‘my life is horrible’, or ‘it’s devastating’.
Some things can send patients more towards the fear end of the spectrum; for example, if a doctor tells a patient they might end up in a wheelchair, that person will naturally be frightened. Fortunately that advice is rarely given these days, but less dramatic examples persist.
If a person is told they mustn’t lift, is told to be active or be a bit careful, or they are given worrying advice about the results of investigations, they will logically avoid activity.
They want to get better and they feel that protecting their back is the way to do it.
However, there is good medical evidence to suggest that protecting the back is counterproductive. People tend to avoid activity, and through not moving their back as much, the back becomes stiffer. Often these people become depressed because they can’t do what they previously did.
A patient being told they have three degenerate discs will be sent towards the fear and pain avoidance end of the spectrum, thinking, ‘Goodness there must be something terribly wrong if you have degenerate discs.”
Not everyone is told that it’s normal to have wear and tear. It's just the same as we develop wrinkles around our eyes, we develop age-related changes in our spine. Something we used to call a degenerative disc disease is as ridiculous as calling wrinkles a disease.
The best researchers in the world can’t tell us what the exact structure is that causes back pain. Some researchers suggest that episodes of back pain are healthy, that they help the spine realign the internal mechanism, which is part of the aging process. But quite frankly we don’t know at this time, so hypothesising is just that.
In the absence of evidence all opinions are equal.
At the end of the day the important issue is the patient. Patients need evidence-based advice that fosters return to activity. The best back guidelines are to be found in the most recent major publication on back pain, the European Guidelines, based on a massive exercise undertaken across many countries. The advice of the Guidelines is that the best way to prevent back pain is activity and exercise.
Questions that can be asked of the patient with back pain to determine what their place on the spectrum of fear of pain is, include:
- On a scale on one to ten, how worried are you about your back problem?
- Do you think that activity hurts your back?
- Do you think activity causes your back harm or slows the healing process?
Answers to these questions will give a pretty clear indication of the person’s beliefs and worries about their back problem, and what needs to be done to address them.
An acute episode of back pain can be agony. If back muscles go into spasm it’s like a cramp in the calf, pain is severe and the person has difficulty moving. While we know to stretch out a calf cramp, when there’s a cramp or muscle spasm in the back we tend to hold ourselves stiff, the pain is so severe it feels like the back is going to break.
The fear of back pain is a 20th and 21st century phenomenon of the developed world. Unfortunately we can’t vaccinate against it, but there is much that can be done with simple, straightforward discussions.
Ways of sending people towards the coping end of the spectrum involve helping them understand about the nature of back problems, what they can do to deal with symptoms, and how it is important that they keep active. They can be helped by telling them the reason for treatment, ie that treatment is to help them feel better, and that treatment’s not going to alter the long-term outcome of their back problem.
The person with back pain can be helped by understanding that they are the person in control of the situation and that, while it’s hard and people around them are there to help, fundamentally they are the person most likely to influence the major outcome.
If only misconceptions about pain could ch-ch-change too… Perhaps I’ll add that to my list of new year’s resolutions (yep, we have them too); help to correct as many health misconceptions as possible. Seems like only a mission for – da-da-da-daaa – Superdoc!