THE PAIN/FEAR AVOIDANCE MODEL

LIVING HEALTHY – ANDY BAXTERSo the patient says to the doctor, “Doc, it hurts when I do this.” Then the doctor replies “don’t do that.” You’ve heard that one before?  Well, funny or not, there is a flaw in that medical advice that is counter-intuitive to most.  Pain avoidance is not always the right path to follow.

The pain/fear avoidance model walks through my door just about every day in one form or another.  Let me explain it to you and then provide a few examples. You just may find yourself or someone you know in there.

In the pain/fear avoidance model we have to paths in response to pain.  On one path, when we experience pain we respond like so: 1) We fear the pain, 2) We avoid the activity that causes the pain, and 3) We experience disuse, disability and depression. This can then spiral out of control, resulting in atrophy, loss of function, and an overall decline in quality of life, and that’s no joke.

The other path is much simpler: 1) We do not fear the pain, 2) We confront the pain, 3) We recover. Done.

Case #1 Betty is 71 and normally very active.  A few years ago she developed what she self-diagnosed  as severe hip pain.  It hurt when she did stuff, so she stopped doing stuff.  Then she tried other stuff but that hurt too so she stopped doing that stuff.  Then she just stopped, doing.  anything. Fast forward, no, slow, painful forward three years.

Betty is in constant pain and forty pounds overweight when she comes to see me.  Betty has succumbed to the pain/fear avoidance model and for all of the wrong reasons.  First and foremost her hip pain is not actually hip pain at all.  Hip pain typically presents itself in one of three ways; in the butt and low back (posterior), on the side (lateral), or in the front (anterior).  Anterior hip pain is referred to as “true” hip pain.  Betty’s pain is presenting on the side, her foot is turned out (rotated externally) and her knee is caved in toward her midline (valgus collapse).  Betty has a wicked, and common, case of IT Band Friction Syndrome.  The iliotibial band is a particularly stubborn strip of fascia that runs from the ilium down the side of the leg to the tibia on the outside of the knee.  When it is overly tight or aggravated in any way it pulls structures out of alignment, inhibits muscle function, and HURTS A LOT.

I explain this all to Betty. While seated on medically specialized exercise machines, I cue her to rotate her foot in to a vertical, north-south orientation.  This makes her knee cave in more, so we identify that.  She makes the conscious decision to pull her knee out, lining it up directly over her foot.  As she goes through her various activities, she is vigilant to maintain this new orientation, to retrain and reinforce this “new” pattern.  After two sessions Betty calls me, slightly frantic.  “I just got out of a chair without pain for the first time in three years!  Is that even possible?”  Yep, that’s why I make the big bucks, Betty.  Not really, you owe me a sandwhich…

Case #2 Ann, 84, calls and asks to have an appointment for an orientation.  When she comes in I recognize her. She had come in two years prior and had one session, then never came back.  She explains that the recumbent bicycle made her knees hurt, so she stopped. Doing anything.

Ann had lost weight, specifically muscle weight from disuse and atrophy.  She had lost function and what little muscular support she had for her arthritic knees had diminished so of course her pain had increased. Vicious cycle.

I explained this to her and we talked at length about the pain/fear avoidance model.  She processed and accepted this information; she “got it”.  Ann is doing just fine now.  Better than fine, her strength and function is vastly improved and her pain is gone.  She chose the right path.  She confronted her pain.  And she recovered, beautifully.

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