People suffering from chronic low back pain may be a bit surprised that their fear and similar behaviors can cause their problem. From chiropractic adjustments and massage therapy to pain-killing drugs and therapeutic mattresses, most current treatments address the structure or the symptoms of low back pain rather than the cause. However, more health care professionals recognize the psychological factors that can be the root to some chronic low back pain cases.
A recent systematic review of 21 studies published in May 2014 in The Spine Journal showed that patients with the highest risks for fear-avoidance beliefs are those with subacute low back pain for four weeks to three months. Dr. Maria Wertli, M.D., from the University of Zürich and her colleagues who conducted the review found that among four cohort studies, patients who had fear avoidance beliefs were less likely to return to work. The cohort studies were conducted by disability insurance companies in the U.S., Canada, and Belgium, including 258 patients with nonspecific low back pain. Wertli and colleagues concluded that those who experienced low back pain for less than two weeks or more than three months are not likely caused by fear-avoidance beliefs. Earlier interventions to reduce this fear may help patients recover faster and avoid chronic pain to set in.
Fear-avoidance belief is a hypothesis that has been a debate among scientists and medical professionals for over two decades. This model suggests that people who are extremely fearful have a tendency to avoid movements and activities that may associate with pain. This consistence avoidance leads to “disengagement from meaningful activities, disability, and depression,” physiotherapist Lorimer Moseley, professor of clinical neurosciences and the Inaugural Chair in Physiotherapy at the University of South Australia, Adelaide, blogged in Body and Mind. The fear-avoidance belief starts a vicious cycle, festering in the mind that the fear of pain might have a larger impact on behavior than pain itself.
However, fear-avoidance behavior is somewhat difficult to detect or identify among chronic low back pain patients, which can cause medical practitioners to either ignore psychological factors that could influence pain or mistaken the behavior as a source of pain when tissue damage or pathology is present in the back. Moseley mentioned fear may not be readily seen in patients because “they seldom display cardinal signs of fear” unless they are confronted directly with movement that may be perceived to cause pain. For example, if patients are asked to bend forward to touch their feet, they may exhibit fear to do so because they think the movement would cause pain. The fear-avoidance behavior model is also too simplistic to explain most cases of chronic low back pain, and it is rarely the sole reason patients avoid “painful” movements.
While science has still much to learn about how the mind can cause pain, health professionals should still consider fear-avoidance belief as a factor in patients or clients with chronic low back pain. It can have powerful effects in their cognitive processes, which can increase the fear of pain and consequently lead to avoidance behavior.
By Nick Ng
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