Fear, Avoidance, and Beliefs negatively impact patient care on a daily basis, however, they can be helpful in recovery when properly oriented an placed in perspective.Fear
Fear is hard-wired. Fear keeps us out of trouble. Fear, however, is general, not specific, and certainly not always helpful.
Chronic (long term) pain can make anyone more fearful of movement, while in most cases – certainly in the case of spinal pain – a specific movement or movements may be the cure.
From fear grows avoidance. It creeps along over time. At first, short-lived pain instills fear of very specific situations: You threw your back out lifting a heavy box inappropriately, so you avoid lifting heavy things inappropriately. The next time, you throw out your back by bending over to pick up a shoe. The next time it happens after riding a bike, then after a short hike, and soon, you “…have a bad back” that prevents you from even mild activity without fear of debilitating pain.
The real tragedy (and what research has demonstrated over time) is that your progressive, self-imposed, lack of mobility has left you less flexible, weaker, and less conditioned – paradoxically putting you ar higher risk of developing recurrent, chronic pain. Finding the right direction and degree of force is the key to recovery, but you’ve become so fearful of moving “the wrong way” that no solution that involves directly confronting the source of you pain sounds reasonable to you.
Especially in low back pain (non-specific backache, as they call it in other English-speaking countries), studies find over and over that a patient’s recovery is highly influenced by what a patient believes will make him better, independent of anything that the therapist actually does or does not do.
Unfortunately, similar studies show that medical practitioners tend to prescribe what they believe will help a patient, irrespective of any evidence they may or may not be aware of. While a layperson can have any opinion he wishes, your healthcare provider (theoretically) is being paid to be correct.
While I sometimes have to orient myself toward success rather than being right, I also believe that I have an obligation to select the best course of treatment available to each patient – and sometimes that will set me on a collision course with the beliefs held by patients and/or their health care providers.
A Spine Paralyzed by Fear
I recently had a new patient. It was a “Drive-By” meaning that this patient’s physician apparently did not have a preference for therapists in our area. She’s a health care professional who’s had serious back pain in the past, and was unable to work for months because of it. Nothing surgical, nothing “damaged” per se – just disabled by pain. She went through months of therapy, and eventually went through a program of spinal strength training and Pilates, and was more or less told that she should avoid bending over, or performing movements that cause pain. You can imagine what I encountered at evaluation – a person with a stiff spine, who has altered her whole lifestyle to avoid pain. Not to avoid injury or damage, or to emphasize and pursue happiness, but to avoid physical pain.
Since coming in, she’s been responsive to my recommendations, and her spirits were buoyed by my explanation that her fear is only a fear of pain – not damage, paralysis, or any other such thing. She has multiple extended family members who have been disabled by pain, but so far, she seems to have decided that this will not be her course.
Snatching Defeat from the Jaws of Victory
Today I had a conversation with another health care professional essentially emotionally crippled by her pain. She’s also organized her life to avoid it. She believes that she has a serious underlying problem that no one will address. I evaluated her, and she responded well, and consistent with published research and clinical literature, she has a good prognosis. We talked about her fear – for what seemed like hours – and I assured her that despite her long history of pain, she has a good prognosis for recovery with therapy, based on my examination. She was given one simple exercise – which was even “watered down” form there, so as not to set off a fear response. She was given specific instructions in case she had any additional pain. Yet, the conversation today was back to avoidance as her response. She reports awaking at 4am with increased pain that she attributes to the exercise she was given. Her pain lasted for another two days, during which time she “did nothing” until it abated, and has now decided that she was right after all – avoidance of painful movement is her best option.
Explaining the altered thought process that normally accompanies chronic pain, the evaluation technique that allowed me to classify her pain and establish a plan of care with a proven track record of effectiveness, and that her recovery would take time, but less clinical treatment than she expected was not enough for her. She is convinced that she needs more imaging and diagnostic studies before taking any further action, although she is adamant that she will refuse any injections, surgery, or additional medications that are offered to her based on that specialist’s opinion.
Don’t Be the Horse That Didn’t Drink
If you have a healthcare provider that is up on the latest evidence, has plenty of clinical “people” experience, and who recommends a course of treatment different than what you expect, I encourage you to ask questions. Weigh out risk and reward, and decide accordingly. Trust, allow yourself to believe, and know that pain, injury, and “damage” are not synonymous. Although your problem appears quite unusual to you, it’s probably quite boring and “text book” to the person who’s advice you’ve sought. If you’ve consulted someone to lead you to water, then partake without fear.