Making Sense of Low Back Pain and Pain-Related Fear

SYNOPSIS: Pain-related fear is implicated in the transition from acute to chronic low back pain and the persistence of disabling low back pain, making it a key target for physical therapy intervention. The current understanding of pain related fear is that it is a psychopathological problem, whereby people who catastrophize about the meaning of pain become trapped in a vicious cycle of avoidance behavior, pain, and disability, as recognized in the fear-avoidance model. However, there is evidence that pain-related fear can also be seen as a common-sense response to deal with low back pain, for example, when one is told that one's back is vulnerable, degenerating, or damaged. In this instance, avoidance is a common-sense response to protect a "damaged" back. While the fear-avoidance model proposes that when someone first develops low back pain, the confrontation of normal activity in the absence of catastrophizing leads to recovery, the pathway to recovery for individuals trapped in the fear avoidance cycle is less clear. Understanding pain related fear from a common-sense perspective enables physical therapists to offer individuals with low back pain and high fear a pathway to recovery by altering how they make sense of their pain. Drawing on a body of published work exploring the lived experience-of pain-related fear in people with low back pain, this clinical commentary illustrates how Leventhal's common-sense model may assist physical therapists to understand the broader sense-making processes involved in the fear-avoidance cycle, and how they can be altered to facilitate fear reduction by applying strategies established in the behavioral medicine literature.