Chronic Pain Management: Fear, Avoidance, and Disability

pain fear avoidance and disability

Pain often causes people to feel afraid – and, the greater the pain, the greater the fear. This is a natural response and pretty helpful for acute pain. In acute pain, fear causes us to stop what we are doing, try to figure out the immediate cause of the pain, and make sure we avoid that cause, whether it is a hot dish, a hammer hitting our finger, or an angry person striking out.

Fear is generally not helpful for chronic pain management. Researchers have explored the“Fear Avoidance Model” as it relates to chronic pain management and coping with pain. Simply put, the Fear Avoidance model suggests that a person with chronic pain may feel so afraid of making pain worse or of being re-injured that he or she may avoid situations or types of movement that they fear could potentially worsen pain and increase disability. Often, the person “over corrects”, being too cautious and avoiding too much. Over time, a little-used body will start to weaken – deconditioning may actually make pain worse and lead to greater disability. So, in a misguided way the p

erson's fear of becoming disabled by pain can actually increase disability.

Here are some examples of  common activities that may be associated with fear and avoidance:

  • walking
  • exercise
  • taking a shower or bath
  • other grooming such as shaving or applying make-up
  • household chores
  • sexual activity
  • recreation
  • working
  • socializing
  • playing with kids
  • moving the area of the body that hurts

Your fears could be holding you back and, through deconditioning,  increasing the likelihood of disability. Use the Goalistics' Pain, Fear, and Avoidance Checklist to examine your fears. Ask yourself and your doctor whether you are being realistic. When your doctor gives you the go ahead, you may wish to create a pacing plan to gradually and safely increase activities that you have been avoiding.

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8 Comments

  1. Alvaro Escorcia says:

    Having developed a condition of chronic pain in my shoulder and in some cases in my neck, I was initially lost by having to visit several doctors and various Imaging tests. I visited first my internal medicine – gastroenterology doctor (#1), taking the opportunity of my routine colon screening which was due. He referred me to a General Practitioner (#2); she prescribed basic pain medicine and asked me to come back in two weeks. I could not wait the two weeks and looked for an orthopedic doctor (#3). He gave me a shot (steroid) in the upper-arm / shoulder and ordered X-rays of the shoulder and upper extremity saying the pain would go away quickly, and to come back in 2 weeks. Again, I could not wait the 2 weeks. Then he prescribed shoulder MRI; found indications of tendinitis and prescribes different pain killers, one of them opioid (which I did not take). In the next visit I suggested the Doctor that perhaps he should consider that my arm pain increased a lot when I moved my neck to look upwards, and to the upwards-left. He then prescribed another MRI, this time of my cervical spine, and refereed me to another Doctor, this time a spine orthopedic surgeon (#4). He studies the second MRI and took additional X-Rays after which he told me the options, suggesting spine surgery through the front part of my neck, but that excercising would help in the case my pain was still tolerable. Because I did not want to go for surgery right away, I was advised to visit another doctor ($5), this time a pain doctor with a lot of experience in chronic conditions in the spine.
    Well… that was 4 months ago. The excercises seem to have worked-out and I am now almost pain free and live a normal life.

    The cumulative cost of this condition to my health plan (mostly paid by my employer and some co-paid by me) exceeded 25K USD out of which at least 80% was wasted in my opinion. The cost estimate of the surgery, which I am still not sure is needed, ranges between 85K and 185K depending if we do with network providers or not.

    I think there are some things fundamentally wrong in our system that took me the way I went: For example (1) Lack or orientation at the beginning; Doctor#2 should have managed my case and got me into excercises in a few days. (2) No accountability by doctors. too much of passing the ball from one to another. (3) Lack of an integrated plan to deal with the pain. (4) No visibility of the progress and results of managing the pain.

    I think we have wonderful education programs for Doctors, and we have perhaps the best doctors and science in the word, yet I think the overall system is ineffective and inefficient.

    • Hello,
      Thanks for sharing a bit about yourself. I agree that for many patients, the road to pain management is tedious with too many ineffective side trips. I am glad that the exercises have helped and that you are living normally again :-)

  2. Jack Cain says:

    Striking a balance between rest and activity is certainly one of the most difficult aspects of chronic pain to learn and to manage. Too much bed rest certainly makes my pain worse just as surely as too much (or the wrong) activity.

    I have learned to identify what the root cause of my pain really is most of the time. While the pain is always the abnormal reaction my body has developed to a specific signal, the real cause generating the signal is what is important. A strained muscle or spasm pulling on the vertebrae where my pain originates needs different therapy than pain coming from pressure on those vertebrae from some other reason. It is very important to note that there is a huge difference between the actual pain of a muscle spasm or strain compared to the pain from my spine itself. Muscles get ice, heat, stretching – whatever is appropriate for muscles. Treating the muscle will get it to stop pulling on my spine. Otherwise if I “pop” my back, the pain will just return because the muscle will pull it out again. The pain from the muscle itself – or if I strain a muscle in a different part of my body – is barely noticeable. Contrary to what is expected, I’ve been on opioid therapy for 6 years without developing any hyperalgesia.

    One of things that can help remove some of the fear is having a cushion available so that if you overextend yourself, you have a way to manage the resulting pain. For me, that is having breakthrough pain medication, a Human Touch 1650 massage chair, a handheld “thumper” for percussion massage, three professional-grade ice packs, one reusable heat pack (those things are amazing!) and plenty of Thermacare heat wraps on hand. All of these things can be employed to deal with the various aspects of my pain.

    Of greater value is having someone available who has worked with you to learn where your pain is and how to detect whether your pain is coming from that special spot that seems to over-react or if it is the result of something else like a sore or stiff muscle that is exerting unusual strain on the place(s) that triggers your pain. For me, that someone is my wife, who I have taught to feel my spine with her thumbs to detect those areas that are causing pain. At this point, she can tell me where my pain is by feeling the places in my spine that are “out” without me having to tell her what to look for. By staying silent and getting confirmation from her, I get the information that I need to deal with the problem. If she presses on my spine at certain points and I do not get an increase in pain, I know that there is a muscle that is pulling my spine at a pain point. If she presses on those places and I get increased pain, I know that the spine itself needs attention. Generally, my wife then sits on my lower back while I use the extra weight and side-to-side resistance to stretch the muscles and “pop” my spine. She gradually moves up my back until she is sitting across my shoulder blades. Not only does this allow me to do some gentle self-manipulation on those areas that I have learned cause my pain, but I can strengthen my back muscles too. Tightening my abs while flexing my back muscles in various arches while lifting her weight helps keep my muscles in tone without the “bad” bending and stretching that causes more pain. Again in my case, taking more narcotic breakthrough medication does little to help spinal pain from a strained muscle exerting abnormal stress. Wasting a strictly limited medication is stupid when you know it won’t do the right job AND cause more side-effects to deal with.

    While this works most of the time, I go through periods where I cannot manipulate my spine by using this method. It takes some risk to put 100-some pounds on my back when I am in pain. I just went through three straight days where my spine would not budge. Those times are the ones where the various mind-body techniques that usually serve me well break down and I take my breakthrough medication.

    On one note for any physicians who may read this. In my case, I used to be able to go to the emergency room at the local hospital where they would give me 20 mg – 30 mg of morphine IM, 50 mg of Phenergan IM and / or 60 mg of Toradol IM. This happened 3 – 4 times a year. It took time to get the staff to have confidence that I only came in when I had to and that in addition to making sure they notified my PCP I informed my PCP too. They also learned that I did not ask for narcotics if I knew that my pain was being generated by a muscle strain pulling on my spine. This confidence allowed me to avoid a great deal of suffering. My PCP, physiatrist and many of the ER doctors trained at Stanford. After moving to the Portland area, where almost every MD I have encountered either trained or practices with Oregon Health and Sciences University, I am not allowed to go to the ER. This isn’t a judgment on training, quality, etc, but a reminder that different schools have different philosophies and that chronic pain patients can find themselves in very different circumstances when going from one geographical region to another. The fact that I am not allowed to go to an ER for acute pain – those times when every other method have failed – has made me much more cautious about what I do because that safety net has been removed. Not admitting that a chronic pain patient can have acute pain is a big factor in creating fear – and this fear is out of your control so it weighs heavier than the things that can be controlled.

    • Thanks for sharing so much about how you have learned to manage your pain and the frequently frustrating health care system. I think it is especially helpful for people to hear how others are coping and to realize that coping with pain generally involves multiple strategies.

  3. Jack Cain says:

    One additional comment about surgery.

    I also showed serious problems in my cervical spine. I immediately ruled out the standard spinal fusion. Placing abnormal strain on different vertebrae at the top and bottom of the fusion didn’t make much sense to me over the long run.

    I waited until the last day – literally – to have surgery that would be covered by insurance. On December 31, 2008, instead of the fusion, I had two artificial disc implants developed in Europe installed at C5 – C6 and C6 – C7. I ate a nice chicken breast for supper that night, went home the next morning with no need for a neck brace and with a full range of motion. On January 5th, I went to work with everyone else coming of the holiday break. One of my colleagues told me that I looked like a new man.

    The layoff 7 days later was not completely unexpected, which is why I got the surgery the very last day I knew I would be covered. I benefitted from those who underwent surgery from this doctor before me. I now have a scar in a crease in my neck exactly 1.5″ long and unnoticeable unless I tell someone about it.

    Surgery should NEVER be done on a whim. I did my research into my options, found the best surgeon in my region, and questioned the poor guy mercilessly until I was satisfied that he knew what he was doing. In my case, it paid off. Not everyone has such great results, so do your own detailed research into what is available for your situation. Ask twice as many questions as you think you need to. If a doctor or surgeon either will not or cannot answer them, don’t go to them! Not everyone can be an expert in every area. A great surgeon in one area can be a novice in another. If possible within privacy laws, ask for references from others who have had the same procedure from the same surgeon at the same surgery center or hospital. (In my case, I volunteered to be a reference although I was never called.)

    An educated patient is the one that will have the least pain in the end. There are many different things that can help – and not all of them help everyone. The more you know about your body and your situation, the better equipped you will be to manage your pain.

    In my case, by the time that I had that surgery, getting Versed before a procedure like an epidural or ablation actually increased my pain as measured by how much Fentanyl was administered during the procedure. Using my brain to manage my pain was so automatic (and so effective) that having anything decrease my ability to concentrate made me *feel* the same pain in a much stronger way. By immersing myself in the procedure (yeah, it hurts, so what, it will go away), I could endure a double-sided three-level facet nerve ablation procedure with 25 micrograms of Fentanyl as compared to 150 micrograms when administered Versed prior to the procedure. No matter who you are or what your situation, your brain is the most powerful tool you have in your struggle with chronic pain.

  4. angela says:

    I have nuerologically complicated migraines and trigeminal neuralgia. Often I find that if I force myself to get up and get on with it, the distraction of attempting to maintian my every day life ends up as something of a distraction from the pain. This is not, of course, in the place of pain management and medication as needed, but it is the additiona of the theory of “walking it off.”

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