Fear-avoidance behaviors related to chronic back pain

Q: I discovered the hard way that I am what they call a "catastrophizer" and I have a problem called fear-avoidance behaviors (FABs). This all relates to my chronic back pain. Yesterday I heard a report that they now have figured out there are different kinds of fear-avoidance behaviors. What kinds are there?

A: As you have discovered for yourself, fear-avoidance behaviors (FABs) refer to ways people with chronic pain change their behavior, actions, movements, and activities. These changes are based on the fear that their pain will increase or that their actions will cause reinjury. Thoughts and emotions rule their behaviors because of concerns, worries, and fears that further harm will come to their spine.

For the most part, these fears are unfounded and become an obstacle to recovery. Patients put much more importance on back pain and assume the pain means the spine is weak and vulnerable. This just isn't true. But without proper education, the patient becomes anxious, depressed, and inactive. They may start using more and more medications and become more like a "sick" person than someone who is going to recover.

It sounds like you have been working through all of this. And you are correct that new theories are being put forth and tested. One of those is that there are subgroups or categories of specific types of FABs. The three identified subgroups include: 1) misinformed avoiders, 2) learned pain avoiders, and 3) affective avoiders. As you can see by the names, these groups are based on the emotions and beliefs held by patients and used to explain why they are avoiding certain movements and activities.

The misinformed avoider avoids activities that might provoke pain based on common sense that another injury would cause more pain. Therefore they avoid anything that might lead to another back injury. This group of patients can be swayed in their views with new information based on reasoning and logic.

The second group (the learned avoiders) developed fear-avoidance behaviors based on actual experience. When they moved in a certain way, their pain increased. So they stop any activities that are painful but they never go back to re-try those movements. If they did, they might discover there is no longer any pain associated with the activities they have been avoiding.

And finally, the affective avoiders are patients who are very distressed about their pain. They have an irrational fear of physical movement and refuse to see reason or try any new activities. This group tends to exaggerate any advice or precautions given to them by their physician or physiotherapist. All their thoughts are focused on their back pain. They are said to be "hypervigilant."

Treatment can be focused for each of these groups. For example, the misinformed avoiders must be given new information and guided through stretching and easy movements. This will help them see it is possible to move and engage in physical activities without hurting themselves. They must be convinced that physical activity won't cause further spine degeneration. Educational brochures, booklets, and videos may be helpful with this subgroup but they must come from spine experts or they aren't effective. At least that's what studies so far have shown.

What about learned pain avoiders? What's best for them? This group is a little more difficult to reach with effective treatment. First of all, when they move, it does hurt. So they aren't misinformed at all. The panel suggested that research is needed to find better ways to help these patients. Some studies have shown that back pain can be reduced for these patients by repeating the same motion or movement over and over. Why this works to stop the pain signals remains unknown.

The last group (affective avoiders) have fears so strong the fears become phobias. They are deeply entrenched in their beliefs. One program that has worked for this group is to re-introduce activities slowly starting with the least worrisome (and easiest) movements.

Slowly, with repeated actions and exposure, more and more activities are introduced. The patient is guided through the activities slowly and carefully by the physiotherapist. Over time, they become more confident and more willing to engage in physical activities once again.

One other approach that seems to have merit for the affective avoiders is called functional restoration. The patient is given a certain number of exercises and activities to do each day. This is a quota-based approach. As the patient completes each task successfully, he or she becomes more confident that "hey, my spine can handle that just fine!"

At the same time, this group of patients is given counseling aimed at reducing and eliminating negative beliefs that result in disability. Studies show that this approach helps people get back to work. For those individuals who are still working, functional restoration helps them reduce the number of sick days.

If you recognize yourself in any of these groups, it may be helpful to adopt some of the techniques described here. See a physiotherapist if you need help with specific suggestions. Don't give up! There's plenty of evidence to suggest you can be successful in reducing fears and improving function.

Reference: James Rainville, MD, et al. Fear-Avoidance Beliefs and Pain Avoidance in Low Back Pain -- Translating Research Into Clinical Practice. In The Spine Journal. September 2011. Vol. 11. No. 9. Pp. 895-903.

North Hill Physiotherapy provides services for physiotherapy in Calgary.