Evan Johnson on Fear-Avoidance Behavior: The Vicious Cycle of Pain That Creates Pain

Apr. 24, 2019

Stick figure holding their back. If your back hurts enough, you might be so tired of the pain that you feel ready to have someone get in there with a scalpel and fix it. But surgery can only help when the pain is caused by a specific, identifiable problem that has a surgical cure. Straightforward examples include a tumor or a severe fracture, along with a host of other physical problems of the spine that have surgical cures. (You can read more about low back pain here.)

But for the great majority of people who suffer from lower back pain, the cause is not an identifiable surgical issue. On one hand, it is fortunate when significant injury or illness is not a factor. But on the other, patients are often left to contend with a condition doctors call “nonspecific” pain—pain with no identifiable, surgically treatable source. (It’s like the old lament about the common cold: “If only I had the flu, I could take something to make it go away.”) Patients with nonspecific pain have to confront the frustration of knowing that even the world’s most skilled neurosurgeons can’t help.

But that doesn’t mean there’s no help at all. Dr. Evan Johnson, PT, DPT, OCS, Director of Physical Therapy at The Och Spine Hospital at the Neurological Institute of New York, works closely with our physicians to develop treatment plans for such patients. Patients are reassured by his message: “Nonspecific” does not mean “untreatable.” Rather, intricate knowledge of anatomy and decades of experience untangling knots in the human body give Dr. Johnson and his team an array of techniques for addressing lower back pain.

Dr. Johnson says that to maximize effectiveness a physical therapist has to recognize certain habits of mind that patients may develop as they attempt to cope with chronic nonspecific pain. Over the last few years, he has been giving talks about this issue around the country, addressing meetings of the North American Spine Society and other groups of health care providers.

Pain is a powerful force that affects thinking, says Dr. Johnson. The brain and the nerves in the rest of the body are interrelated. When it hurts to do something, patients shy away from doing it. That just makes sense. And part of a physical therapist’s job is to gently teach patients how to move in ways that sometimes seem intimidating at first—in order to get better.

But such teaching may be more complicated than it seems. Dr. Johnson says a growing body of research investigates the human tendency to develop anxiety about pain. Researchers term this process catastrophizing pain, and they observe that it’s part of a vicious cycle. Catastrophizing pain over time can cause the brain to read sensation as more intense: Everything literally hurts more.

And of course, when everything hurts more, there is an ever-greater incentive for a patient not to move in ways that threaten to cause pain. That can be bad news for a lower back that needs gentle strengthening and movement in order to heal.

There’s a name for what happens when chronic pain teaches the brain this sort of hypersensitivity and leads a patient to steer clear even of activities designed to help. Scientists call this “fear-avoidance behavior”—avoidance, rooted in fear of pain.

Fear-avoidance behavior appears frequently in patients who suffer from chronic, nonspecific lower back pain, says Dr. Johnson. Controlling this cycle is a crucial part of effective therapy. Sometimes, simply educating patients on the phenomenon is enough.

Other times, a doctor may refer a patient to a professional who can help address the mental aspects of chronic pain through cognitive-behavioral therapy or other methods.

Because the fact is, patients cannot comply with therapists’ recommendations for exercise when fear avoidance interferes. Pain and avoidance behavior can persist and reinforce each other, which can prevent a patient from feeling better. That’s why Dr. Johnson is on the alert for fear-avoidance behavior, and why he believes it’s important to share this information with other physical therapists.

In dealing with fear-avoidance behavior, compassionate care is the most effective care, says Dr. Johnson. As in all he does at The Spine Hospital at the Neurological Institute of New York, he strives to embody the words of turn-of-the-century physician Francis Peabody: “The secret of the care of the patient is in caring for the patient.”

Learn more about Dr. Johnson at his bio page here.

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