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Fear and the Role of Physical Therapy
By Rachel Feinberg, D.P.T.

Fear of re-injury and increased pain can lead to avoidance of activity. A physical therapist can work closely with the client to provide the necessary education and guidance.

Fear of re-injury, fear of movement (kinesiophobia) and avoidance due to increased pain levels are common barriers to returning to normal life, work or recreational activities after an injury. Research suggests that an individual's pain-related fear and avoidance are important factors in determining activity level 6-12 months after an injury.

With prolonged pain, the client and often the provider, do not understand the heightened pain response. The continued pain increases underlying fear and worry of continued damage or further injury that has not been identified. Driven by fear of further pain or the threat of further damage, many people with prolonged pain increasingly restrict activities and begin to exhibit a maladaptive avoidance response. For clients that have serious pathology, it can be confusing as to how to differentiate pain that could be damaging and pain that is likely not damaging. Unfortunately, this fear can be further propagated by healthcare providers as they instruct the client to avoid painful movements or attempt to explain a client’s diagnosis. Messages like “slipped disc,” “the spine is out of alignment” and “the back of an 80 year old” can lead to higher levels of fear and disability.

When working to overcome fear, the different aspects of fear and avoidance must first be determined. Many times fear of re-injury, fear of increased pain level and avoidance due to other factors are grouped together, when in fact they are quite different. Time should be spent to understand the thoughts or concerns surrounding the fear so that education and understanding can be directed towards addressing the aspect of fear that is limiting rehabilitation and recovery.

Treatment for overcoming fear of re-injury includes the client's understanding their diagnosis, the anatomy involved with this diagnosis, the physiology of why movement is not damaging and understanding the difference between pain and damage. Education on topics such as the role of hypersensitivity and changes in the spinal cord and brain with persistent pain may be helpful. For those who are interested in reading more on the topics of pain versus damage and tissue sensitivity, the book Explain Pain by David Butler and Lorimer Moseley, is recommended.

A fear of increased pain levels with movement can be another barrier to recovery. In this case, the client may understand that the pain is not damaging, but does not want to suffer through high levels of pain and is fearful of being unable to control the increased pain level. Treatment focuses on education on the detrimental effects of avoidance or guarding and the importance of movement. Further treatment includes education and instruction on flare management skills such as relaxation breathing, pacing and meditation skills. Identifying short and long term goals can be helpful in helping the client stay focused on why they are pushing through expected increases in pain.

Physical therapy can play a significant role in assisting a client in overcoming fear. It is the role of the physical therapist to combine their knowledge of the diagnosis, anatomy, physiology and body mechanics and determine which exercises and movements are safe for each individual client. When done correctly, movement and exercise can improve strength, flexibility, function and activity tolerance. Short-term increases in pain can make a client doubt the benefit and safety of these recommended exercises or movements. The physical therapist can help alleviate these concerns. Using flare management skills as mentioned above, can help the client feel more in control of increased levels of pain, allowing for a higher level of confidence and faster progression. With any activity that has been avoided due to fear, the client begins at a level that is just above their comfort level and is encouraged to slowly but consistently push that level further. The physical therapist provides education on pacing techniques including safe activity progression and how frequently to take breaks in order to best manage expected increases in pain.

Another aspect of treating fear and avoidance is recognizing that maladaptive thinking styles can lead to higher levels of disability. Many people with chronic pain deal with anxiety, a lack of feeling in control, catastrophizing, disappointment from only being able to perform at a low physical level, and many other emotions and thinking styles. A doctor or physical therapist should recognize if this could be contributing to a lack of progress and determine if a referral to a pain psychologist may be necessary.

Overall, with any type of fear, treatment includes education, repeated exposure to activities that have been avoided, instruction on active pain management techniques and taking an active role in recovery. Increases in pain are normal and should be expected. A physical therapist can play a large role in this treatment plan and should work closely with the client to provide the necessary education and guidance.

Feel free to contact Rachel by email or call her at 650-223-6400 for more information.

Rachel Feinberg, D.P.T.
Feinberg Medical Group
825 El Camino Real Palo Alto, CA 94301
Tel 650-223-6400
Fax 650-223-6408
Feinberg Medical Group

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