1. Knowledge: Understanding what is happening inside the body
One important way to begin to address fear avoidance is with knowledge. Some people with pain spend a lot of time learning about their condition through books, the internet, and other sources. The information they find may or may not be accurate, and this should be considered. Other people in pain may avoid the topic, wanting to spend as little time thinking and focusing on it as possible. Whatever the case, we believe that the person in pain is the “expert” on their own experience. Health care providers can be “experts” in current evidence, theory, and knowledge around pain, and sharing this information with clients can be extremely helpful.
The knowledge that is provided can take many different forms:
The knowledge that is provided can take many different forms:
-What is happening inside the body?
-Which movements are good versus which ones could be harmful?
-Which activities are safe and which are unsafe?
-What does pain mean? Is it causing damage, or not?
-Coping strategies, techniques, and resources that are available.
Using knowledge and education to address fear avoidance sounds obvious, but there are many factors that affect the the outcome of education. For instance, a 2003 study on using education to address fear avoidance suggested that, as expected, people who were avoiding tasks because of fear of pain benefited from fear avoidance based physical therapy. What the authors didn’t expect was that the same education could actually lower clinical outcomes in people who they considered “confronters”, meaning people who tended not to try to avoid pain (George, Fritz, Bialosky & Donald, 2003). We interpret this to mean that it is essential for the clinician to understand the client’s current beliefs about their pain in order to determine what kind of information might be helpful to the client.
Using knowledge and education to address fear avoidance sounds obvious, but there are many factors that affect the the outcome of education. For instance, a 2003 study on using education to address fear avoidance suggested that, as expected, people who were avoiding tasks because of fear of pain benefited from fear avoidance based physical therapy. What the authors didn’t expect was that the same education could actually lower clinical outcomes in people who they considered “confronters”, meaning people who tended not to try to avoid pain (George, Fritz, Bialosky & Donald, 2003). We interpret this to mean that it is essential for the clinician to understand the client’s current beliefs about their pain in order to determine what kind of information might be helpful to the client.
2. Self-Efficacy: Believing that you can do something about the pain
Another essential tool is self-efficacy, a term that came from Bandura, a prominent psychologist in the 1990s. Some people may wonder - why talk about psychology when the problem is physical pain? The answer is that human beings are complex, and our minds and bodies impact each other. To put it succinctly, “chronic pain is inherently both a medical and a psychological condition – what healthcare providers call a biopsychosocial condition” (McCallister, 2013).
So what is self-efficacy? The textbook definition of self-efficacy is: “one’s belief about one’s ability to perform behaviors that should lead to expected outcomes” (Weiten, 2004). Basically, when it comes to pain, self-efficacy is the belief that you can manage the pain and continue living your life. Self-efficacy is essential to overcoming the effects that pain can have on everyday life. When people truly believe that they can do the things that are important to them and enjoy activities despite pain, they are well on their way to reclaiming their lives.
The great news is that health care providers can help people develop self-efficacy. One way is through information, as we described above. As Sandy Hilton explained, “when a person isn't afraid they are going to hurt themselves it allows them to act with more self-efficacy” (Hilton & Blickenstaff, 2015). So health care providers can encourage people to build self-efficacy by providing information about what movements and activities are safe to try. Once the person begins to try things and have success with them, the feeling of “I can do this” is reinforced.
Health care providers can also enhance self-efficacy simply by choosing their language and focus carefully. Sandy Hilton described this as “looking for opportunities instead of dysfunction in the way we describe things with patients.” By keeping our language ability-focused rather than impairment-focused, we emphasize people’s strengths, and reinforce that they can use these strengths to their advantage in managing pain (Hilton & Blickenstaff, 2015).
If you are a person in pain, look for health care providers who encourage and support you to develop your own strengths and abilities in managing your condition. Also, keep an eye out for ways to foster this empowerment in your own life.
3. Re-introduce movements and activities: Gradually taking activities back from the thief
Re-introducing movements that have become worrisome is basically hypothesis testing and rewiring the connections in the brain. In a way it is creating that sense of safety for the body to progress. It is saying “You know that big, bad thing you're afraid of? Well maybe it just isn’t so scary as you think. Maybe you can deal with it.” There are different ways to create that sense of safety so there is room to increase activities, but today we are specifically going to look at graded exposure. This part of our post will be geared more toward clinicians, as it will be detailed about the specific therapy approaches. Through graded exposure the hypothesis of “If I do this movement, then I will cause pain or harm” is being tested.
It’s important to note that graded exposure is different from graded activity. Both have a role in pain management, but graded exposure specifically has a role in looking at fear avoidance behaviour. Graded activity is where you choose one specific action, and gradually increase the difficulty level (intensity, duration, speed, etc) to increase your ability (strength, coordination, and skill). Graded exposure is where you look at the activities you’ve avoided because of fear of pain, and work from the “least scary” task to the “most scary”, to increase your confidence.
For example, if you’ve been avoiding carrying groceries in from the car, graded activity would be starting with a box of cereal, then gradually building up to heavier grocery items. The goal would be to build up muscle strength so you can physically carry all the necessary groceries. Graded exposure addresses the emotional and psychological side more than the physical side. For example, if your specific fear is that carrying the groceries will result in injuring yourself further, being in excruciating pain, or not being able to go to work the next day, etc, then graded exposure addresses this fear. In graded exposure, you are not necessarily grading the specific activity, but grading which activities you’ll try, in what order. You would grade the exposure by starting with tasks that cause less anxiety and working up to tasks that have more fear attached to them.
You might ask - what if my fear is a worsening of pain, and the fear comes true? Prior to beginning graded exposure, the clinician would help the client develop strategies for addressing these situations. Then, even if the hypothesis is proven true, the client is able to cope, and confidence still builds. We would also anticipate that often the consequence may not be as severe as the client fears (for example, if the client fears they will “break their back” lifting the groceries, the reality is they may find their pain increases temporarily, but they are extremely unlikely to actually fracture a vertebra).
When we first starting learning about graded exposure, we both wondered “why would anyone ever want to do this? It sounds awful and hard”. We’ve learned that the motivation for this particular method of re-introducing movements and activities often comes when people recognize that fear is affecting what they’re able to do, and they want to take back the control. This approach is also different from “flooding”, which is what some people associate with exposure therapy. In flooding, people do things no normal person would do - like climbing in dumpsters if they are afraid of germs. Instead, this approach focuses on realistic everyday activities.
When deciding what activities to start with and what order to try activities it is critical to choose an activity that is both physically doable and emotionally achievable, and this is where the health care provider’s expertise and encouragement come in. The first consideration is the safety of the task, and whether the person believes it is safe. The second consideration is how realistic the task is - it has to be a task that the client can achieve. By starting with something that is achievable it creates that confidence and momentum to continue forward. Together both of these mean start small. Start with something that is just a tiny bit scary. Don’t give a grade one kid the New York Times and expect them to love reading. Instead you start with books that are at their reading level and gradually build up, and one day they just might grow up to be someone who loves the New York Times.
All these tools work together
To summarize, we will return to the example of the gentleman with back pain from our previous two posts. He was able to find success in regaining activities because of the combination of tools that met his individual needs. His doctor began by establishing trust and a working relationship. Then the doctor provided education on back pain and how “hurt does not always equal harm”, and movement can actually help improve symptoms. Next the doctor focused on building his self-efficacy by empowering him to realize that the tools he needed were within his reach. Then they discussed specific movements and activities that he had become hesitant about, even though they were important in his life. The doctor helped him understand how to start small in approaching these activities, and how to build on each success. The doctor encouraged him when needed and celebrated with him as he regained these activities. These tools together acted as a shield, protecting the man’s daily activities from the impact of pain.
Each person’s story is different, and in real life it may not be as simple as a person approaching their doctor and finding straightforward answers about how to implement these tools. It may be a different kind of health care provider, or a whole team of providers who do this. It may not be a linear process, and these are only a few of the many tools that can be used. The pain fear avoidance model does not address all possible factors that might be involved in a person’s pain experience. We’ve simplified it for the purposes of this post. But even though each person’s journey and tools will be different, we hope you have found this overview helpful in beginning to understand how health care providers can support people in reclaiming their lives.
Acknowledgment:
Another essential tool is self-efficacy, a term that came from Bandura, a prominent psychologist in the 1990s. Some people may wonder - why talk about psychology when the problem is physical pain? The answer is that human beings are complex, and our minds and bodies impact each other. To put it succinctly, “chronic pain is inherently both a medical and a psychological condition – what healthcare providers call a biopsychosocial condition” (McCallister, 2013).
So what is self-efficacy? The textbook definition of self-efficacy is: “one’s belief about one’s ability to perform behaviors that should lead to expected outcomes” (Weiten, 2004). Basically, when it comes to pain, self-efficacy is the belief that you can manage the pain and continue living your life. Self-efficacy is essential to overcoming the effects that pain can have on everyday life. When people truly believe that they can do the things that are important to them and enjoy activities despite pain, they are well on their way to reclaiming their lives.
The great news is that health care providers can help people develop self-efficacy. One way is through information, as we described above. As Sandy Hilton explained, “when a person isn't afraid they are going to hurt themselves it allows them to act with more self-efficacy” (Hilton & Blickenstaff, 2015). So health care providers can encourage people to build self-efficacy by providing information about what movements and activities are safe to try. Once the person begins to try things and have success with them, the feeling of “I can do this” is reinforced.
Health care providers can also enhance self-efficacy simply by choosing their language and focus carefully. Sandy Hilton described this as “looking for opportunities instead of dysfunction in the way we describe things with patients.” By keeping our language ability-focused rather than impairment-focused, we emphasize people’s strengths, and reinforce that they can use these strengths to their advantage in managing pain (Hilton & Blickenstaff, 2015).
If you are a person in pain, look for health care providers who encourage and support you to develop your own strengths and abilities in managing your condition. Also, keep an eye out for ways to foster this empowerment in your own life.
3. Re-introduce movements and activities: Gradually taking activities back from the thief
Re-introducing movements that have become worrisome is basically hypothesis testing and rewiring the connections in the brain. In a way it is creating that sense of safety for the body to progress. It is saying “You know that big, bad thing you're afraid of? Well maybe it just isn’t so scary as you think. Maybe you can deal with it.” There are different ways to create that sense of safety so there is room to increase activities, but today we are specifically going to look at graded exposure. This part of our post will be geared more toward clinicians, as it will be detailed about the specific therapy approaches. Through graded exposure the hypothesis of “If I do this movement, then I will cause pain or harm” is being tested.
It’s important to note that graded exposure is different from graded activity. Both have a role in pain management, but graded exposure specifically has a role in looking at fear avoidance behaviour. Graded activity is where you choose one specific action, and gradually increase the difficulty level (intensity, duration, speed, etc) to increase your ability (strength, coordination, and skill). Graded exposure is where you look at the activities you’ve avoided because of fear of pain, and work from the “least scary” task to the “most scary”, to increase your confidence.
For example, if you’ve been avoiding carrying groceries in from the car, graded activity would be starting with a box of cereal, then gradually building up to heavier grocery items. The goal would be to build up muscle strength so you can physically carry all the necessary groceries. Graded exposure addresses the emotional and psychological side more than the physical side. For example, if your specific fear is that carrying the groceries will result in injuring yourself further, being in excruciating pain, or not being able to go to work the next day, etc, then graded exposure addresses this fear. In graded exposure, you are not necessarily grading the specific activity, but grading which activities you’ll try, in what order. You would grade the exposure by starting with tasks that cause less anxiety and working up to tasks that have more fear attached to them.
You might ask - what if my fear is a worsening of pain, and the fear comes true? Prior to beginning graded exposure, the clinician would help the client develop strategies for addressing these situations. Then, even if the hypothesis is proven true, the client is able to cope, and confidence still builds. We would also anticipate that often the consequence may not be as severe as the client fears (for example, if the client fears they will “break their back” lifting the groceries, the reality is they may find their pain increases temporarily, but they are extremely unlikely to actually fracture a vertebra).
When we first starting learning about graded exposure, we both wondered “why would anyone ever want to do this? It sounds awful and hard”. We’ve learned that the motivation for this particular method of re-introducing movements and activities often comes when people recognize that fear is affecting what they’re able to do, and they want to take back the control. This approach is also different from “flooding”, which is what some people associate with exposure therapy. In flooding, people do things no normal person would do - like climbing in dumpsters if they are afraid of germs. Instead, this approach focuses on realistic everyday activities.
When deciding what activities to start with and what order to try activities it is critical to choose an activity that is both physically doable and emotionally achievable, and this is where the health care provider’s expertise and encouragement come in. The first consideration is the safety of the task, and whether the person believes it is safe. The second consideration is how realistic the task is - it has to be a task that the client can achieve. By starting with something that is achievable it creates that confidence and momentum to continue forward. Together both of these mean start small. Start with something that is just a tiny bit scary. Don’t give a grade one kid the New York Times and expect them to love reading. Instead you start with books that are at their reading level and gradually build up, and one day they just might grow up to be someone who loves the New York Times.
All these tools work together
To summarize, we will return to the example of the gentleman with back pain from our previous two posts. He was able to find success in regaining activities because of the combination of tools that met his individual needs. His doctor began by establishing trust and a working relationship. Then the doctor provided education on back pain and how “hurt does not always equal harm”, and movement can actually help improve symptoms. Next the doctor focused on building his self-efficacy by empowering him to realize that the tools he needed were within his reach. Then they discussed specific movements and activities that he had become hesitant about, even though they were important in his life. The doctor helped him understand how to start small in approaching these activities, and how to build on each success. The doctor encouraged him when needed and celebrated with him as he regained these activities. These tools together acted as a shield, protecting the man’s daily activities from the impact of pain.
Each person’s story is different, and in real life it may not be as simple as a person approaching their doctor and finding straightforward answers about how to implement these tools. It may be a different kind of health care provider, or a whole team of providers who do this. It may not be a linear process, and these are only a few of the many tools that can be used. The pain fear avoidance model does not address all possible factors that might be involved in a person’s pain experience. We’ve simplified it for the purposes of this post. But even though each person’s journey and tools will be different, we hope you have found this overview helpful in beginning to understand how health care providers can support people in reclaiming their lives.
Acknowledgment:
Diagram by Ashley and Colleen at Reclaiming Life. Graphics used are from Vector Characters.
References
George, S.Z., Fritz, J.M., Bialosky, J.E., & Donald, D.A. (2003). The effect of a fear-avoidance-based physical therapy intervention for patients with acute low back pain: results of a randomized clinical trial. SPINE, Volume 28 (23), 2551-2560.
Hilton, S., Blickenstaff, C. (Physical Therapists). (2015, June 9). Pain science and sensibility Episode 1: Self-efficacy and fear of movement in chronic back pain. [Audio podcast]. Retrieved from http://ptpodcast.com/pain-science-and-sensibility-episode-1-self-efficacy-and-fear-of-movement-in-chronic-back-pain/
McCallister, M.J. (2013). Institute for Chronic Pain Blog: Fear-Avoidance of Pain. Retrieved from http://www.instituteforchronicpain.org/blog/fear-avoidance-pain/ on August 31, 2015.
Weiten, W. (2004). Psychology themes & variations. California: Thomson Wadsworth.
