Making sense of low back pain and pain-related fear 1

Samantha Bunzlia, Anne Smithb, Robert Schützec, Ivan Lind, Peter O’Sullivanb

a The University of Melbourne, Department of Surgery, St Vincent’s Hospital

b School of Physiotherapy and Exercise Science, Curtin University c School of Psychology and Speech Pathology, Curtin University d Western Australian Centre for Rural Health, University of Western Australia

Samantha Bunzli PT, PhD. Email: sbunzli@unimelb.edu.au

Anne Smith PT, PhD. Email: Anne.Smith@exchange.curtin.edu.au

Rob Schütze MPsych(Clinical). Email: r.schutze@curtin.edu.au

Ivan Lin PT, PhD. Email: ivan.lin@uwa.edu.au

Peter O’Sullivan PT, PhD. Email: P.OSullivan@curtin.edu.au

The doctoral study which informed this manuscript was approved by Curtin University Human Research Ethics Committee and local hospital ethics committees in Perth, Western Australia.

Corresponding author:

Corresponding Author: Samantha Bunzli, The University of Melbourne, Department of Surgery, St. Vincent's Hospital, Melbourne. Level 2, Clinical Sciences Building, 29 Regent street, Fitzroy 3065, Victoria, Australia. Email: sbunzli@unimelb.edu.au

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Making sense of low back pain and pain-related fear 1

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I affirm that I have no financial affiliation (including research funding) or involvement with 5

any commercial organization that has a direct financial interest in any matter included in 6

this manuscript. No other conflicts of interest exist. 7

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Abstract 1

Pain-related fear is implicated in the transition from acute to chronic low back pain and 2

the persistence of disabling low back pain, making it a key target for physiotherapy 3

intervention. The current understanding of pain-related fear is that it is a 4

psychopathological problem where people who catastrophise about the meaning of 5

pain become trapped in a vicious cycle of avoidance behaviour, pain and disability, as 6

recognised in the Fear Avoidance Model. However there is evidence that pain-related 7

fear can also be seen as a common sense response to deal with low back pain, for 8

example, when one is told that their back is vulnerable, degenerating or damaged. In 9

this instance avoidance is a common sense response to protect a ‘damaged’ back. 10

While the Fear Avoidance Model proposes that when someone first develops low back 11

pain, the confrontation of normal activity in the absence of catastrophising leads to 12

recovery, the pathway to recovery for individuals trapped in the fear avoidance cycle 13

is less clear. Understanding pain-related fear from a common sense perspective 14

enables physiotherapists to offer individuals with low back pain and high fear a 15

pathway to recovery by altering how they make sense of their pain. Drawing on a body 16

of published work exploring the lived experience of pain-related fear in people with low 17

back pain, this Clinical Commentary illustrates how Leventhal’s Common Sense 18

Model may assist Physiotherapists to understand the broader sense-making 19

processes involved in the fear avoidance cycle and how they can be altered to facilitate 20

fear reduction by applying strategies established in the behavioural medicine 21

literature. 22

Key words: Fear Avoidance Model; Common Sense Model; Qualitative research; Low 23

back pain 24

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Introduction 1

L ow back pain (L B P ) is a common condition44. While the majority of care-seekers s top 2

seeking care within three months , around 10 per cent will experience chronic, disabling 3

L B P (C L B P )10, 11. As one of the key providers of L B P care, P hys iotherapis ts are tasked 4

with preventing the trans ition to pers is tent pain and disability, and facilitating a 5

pathway to functional restoration for those who are disabled. 6

Pain-related fear (in addition to psychological distress and self-efficacy) mediates the 7

relationship between pain and disability18. With over 50 per cent of primary care 8

patients with LBP presenting with elevated fear31, 35, pain-related fear is an important 9

target for Physiotherapy intervention. While many models have attempted to provide 10

an explanation of why disabling LBP develops and persists, the Fear Avoidance Model 11

(FAM)41 has been widely adopted and validated in the Pain and Physiotherapy 12

literature15, 47-49. It describes how the experience of LBP symptoms in some cases can 13

initiate a set of negative cognitive, emotional and behavioural responses. In line with 14

the theory that cognitive factors precede emotional reactions17 the FAM proposes that 15

individuals who ‘catastrophise’ about the meaning of their pain may become fearful 16

and subsequently avoidant of physical activity that threatens their wellbeing. A vicious 17

cycle ensues in which avoidance behavior leads to physical disability and depression 18

that in turn, heightens the pain experience. The FAM also proposes that when 19

someone first develops LBP, the confrontation of normal activity in the absence of 20

catastrophising leads to recovery. 21

(Insert Figure 1) 22

Currently, some Physiotherapists stigmatise individuals presenting with high pain-23

related fear. Some refer to them as ‘phobics’ with extravagant pain behaviours, while 24

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others feel under-equipped to treat individuals with high pain-related fear37. This 1

clinical commentary stems from a body of work seeking to advance the clinical utility 2

of the FAM for Physiotherapists treating people with pain-related fear. It draws on a 3

prospective qualitative investigation of 36 individuals with chronic, non-specific LBP 4

(pain lasting >6 months not attributed to any underlying pathology or structural 5

abnormality) and high pain-related fear (>40 Tampa Scale of Kinesiophobia25); 6

recruited from a range of primary and tertiary care settings. Personal explanations and 7

narratives related to the beliefs underlying pain-related fear, the factors associated 8

with these beliefs and changes in fear over time were explored through in-depth 9

interviews at baseline and 4-month follow-up (see publications6-8 for more detail on 10

the study design). Key findings from this body of work include: 1. That radiological 11

reports, negative explicit and implicit advice from clinicians, and cultural beliefs about 12

the structural vulnerability of the spine reinforced pain-related fear and avoidance 13

behaviours; 2. Some individuals with high pain-related fear believed pain is a sign of 14

damage, while others reported fear of pain and associated suffering, and some 15

reported both. These beliefs associated with limited pain control coping strategies led 16

to avoidance of pain-provoking movements and activities; 3. A common narrative was 17

an attempt to make sense of a threatening pain experience that they perceived as 18

uncontrollable. Repeated failed attempts to control pain and the impact of pain 19

reinforced fear by trapping individuals in a cycle of worry; 4. Individuals attributed 20

reductions in pain-related fear to gaining control over the pain experience through a 21

‘new’ ability to make sense of pain linked to enhanced control over pain and/or the 22

effects pain has on life. 23

This body of work highlights that broader sense-making processes (attempts to make 24

sense of pain) beyond just catastrophising, play a role in the narratives of individuals 25

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who experience episodes of high fear. These are not fully captured by the current FAM 1

which describes one type of sense-making (catastrophising) and only identifies two 2

factors that influence it (negative affect and threatening illness information). To capture 3

these broader sense-making processes, we reviewed other health behaviour models 4

in the literature. The Common Sense Model (CSM)19 not only accounts for broader 5

sense-making processes, but also includes the key constructs believed to influence 6

behaviour in musculoskeletal conditions (i.e. outcome expectancies, self-efficacy, 7

goals, socio-structural factors, emotional or stress constructs and symptom related 8

control)16. Drawing on our qualitative data, this clinical commentary illustrates the utility 9

of the CSM as a framework to assist Physiotherapists to understand the broader 10

sense-making processes involved in the fear avoidance cycle and how they can be 11

altered to facilitate fear reduction. 12

The Common Sense Model 13

The CSM emerged from early research in the 1960’s investigating the influence of fear 14

on health-promoting actions such as smoking cessation22. Since then, the CSM has 15

been widely used to explore how sense-making processes influence coping and 16

outcomes in a variety of chronic conditions including diabetes, heart disease and 17

osteoarthritis5, 28, 29. Interventions based on the CSM have improved self-management 18

behaviour and disease-related distress in individuals with non-musculoskeletal chronic 19

diseases13. 20

According to the CSM, when we experience a symptom such as LBP, we attempt to 21

make sense of it by forming a cognitive ‘representation’ based on our existing beliefs 22

about LBP. We ask ourselves: What is this pain (‘identity’ beliefs)? What caused this 23

pain (‘cause’ beliefs)? What consequences does this pain have (‘consequences’ 24

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beliefs)? How well can I control this pain (‘control’ beliefs) and how long will it last 1

(‘timeline’ beliefs)? These five belief dimensions that comprise the ‘representation’ 2

are grounded in our own unique personal, social and cultural context. They are 3

influenced by our previous experiences of LBP both direct and vicarious, and are 4

constantly updated with new information from sources such as the media, clinicians 5

and by the perception of bodily sensations20. 6

How we ‘represent’ LBP will influence what we do about it (problem-based coping). A 7

self-regulatory process follows in which the outcome of the coping response is 8

appraised and this appraisal feeds-back into the representation of LBP to guide future 9

coping responses. If the outcome of the response is appraised to be in the direction 10

of the target goal (e.g. no flare-up of pain) then the representation is deemed to be 11

useful and the response will be maintained. If the outcome is not in the direction of the 12

target goal, then the representation will be updated and the response adjusted 13

accordingly. 14

How we ‘represent’ LBP will also influence our emotional response to the symptom 15

(emotion-directed coping). We ask ourselves: how do I feel about this pain and what 16

can I do to make myself feel better about it? The literature shows that symptoms 17

perceived as unpredictable and uncontrollable and/or as having intense 18

consequences, are commonly perceived as threatening and elicit a fear response28. 19

In turn, this fear response may elicit more worry and rumination. 20

21

A continuous interaction between cognitive, behavioural and contextual factors means 22

that the representation is constantly updated to influence on-going behaviour22. Thus, 23

while the content of the cognitive representation will differ between individuals and 24

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within individuals over time, the processes involved in making sense of LBP are the 1

same33 (see Figure 2). 2

(Insert Figure 2) 3

The CSM as a framework to understand pain-related fear 4

Fear as a common sense response to a threatening pain experience 5

According to the CSM, pain-related fear may be a ‘common sense’ problem-solving 6

response based on a threatening representation of LBP. The participants in our study 7

described threatening representations of LBP based on their ‘identity’ beliefs about 8

the structure and function of the spine (Quote number 1 (Q1)), their ‘causal’ beliefs 9

(Q2), their beliefs about the ‘consequences’ of LBP (Q3), and their experience of LBP 10

as uncontrollable (‘control’ beliefs) (Q4) and unpredictable (‘timeline’ beliefs) (Q5). 11

“The spine is the core of your body. All the nerves and everything are in your spine. 12

It holds your structure together” Q1 (female (f), 39years of age (yo), 0.5years (yrs) 13

LBP) 14

“I don’t know what causes it, I don’t know what I am doing to exacerbate it and that’s 15

scary” Q2 (f, 61yo, 0,5 yrs LBP) 16

“There is something about the back. It’s that fear of I don’t want to do something to 17

my spine because if I damage it I’m not going to be able to walk, I’m not going to be 18

able to mobilise and what if I’m an invalid and can’t do anything?” Q3 (f, 51yo, 2yrs 19

LBP) 20

“You just don’t want to live with that sort of pain...everything stops, you are just so 21

consumed with that pain level. I am writhing, really distressed and can’t cope. It is 22

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just not good and so I avoid it” Q4 (f, 53yo, 2yrs LBP) 1

“It terrifies me. Because I don’t know physically I am going to be able to cope with in 2

the future. What I am going to be able to do work-wise? How can I secure the future 3

for my son?” Q5 (f, 53yo, 2yrs LBP) 4

5

From a CSM perspective, if a person with LBP believes, or has been told, that 6

performing a painful activity will cause damage to their spine, it is common sense to 7

avoid or modify that activity (Q6, Q7). Similarly, if one experiences stabbing pain in 8

their back with bending, it is common sense to avoid or modify bending movements 9

(Q8). Fear avoidance behaviour may therefore be perceived as a ‘common sense’ 10

problem solving response to avoid noxious threat. 11

“I was constantly told by my parents that I have a family history of back pain and that 12

I should take care to sit straight and not lift anything heavy” Q6 (f, 33yo, 12yrs LBP) 13

“The physios told me not to sit and not to bend forward and I took that very literally 14

because I was desperate not to make my back worse. I kept that going for a couple 15

of years” Q7 (f, 45yo, 12yrs LBP) 16

“Every time I bend it is intense, sharp pain that is almost like I am paralysed for the 17

moment it is happening. So I avoid it” Q8 (f, 25yo, 0.5yrs LBP) 18

19

According to the CSM, as long as the outcome of the avoidance behaviour is expected 20

(e.g. no pain flare-up), the representation is deemed to be useful or coherent, and 21

avoidance will be maintained. Particularly in the early stages of LBP, avoidance can 22

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be considered a common sense solution to avoiding (re)injury and permitting tissue 1

healing to occur. 2

However, while it makes sense to avoid bending to avoid short-term noxious threat, 3

long-term avoidance of bending may interfere with social, domestic, work-related or 4

caring duties (Q9). 5

“I thought maybe if I stop doing everything, it might get better. Because you’re scared 6

of moving its like common sense, well don’t do anything. But then I got weaker and 7

weaker until I was at the point when I couldn’t do the dishes, I couldn’t bend, I couldn’t 8

lift... And I was thinking my god, I can’t do anything without pain” Q9 (f, 51yo, 2yrs 9

LBP) 10

Eventually a lack of control over pain and the interference of pain in life may drive 11

people to seek care, with expectations of a linear pathway involving diagnosis-12

treatment-cure. However, this expectation is based on the biomedical assumption that 13

there is a direct correlation between the extent of underlying pathology and perceived 14

pain severity, which is not the case for the large majority people who have non-specific 15

LBP12. 16

The participants in our research were drawn from a population of individuals at various 17

stages in their care seeking journey. Describing their journey into fear, all participants 18

reported how their previous history of care-seeking had resulted in one of four 19

outcomes: 1. They did not receive a diagnosis for their pain and thus could not enter 20

into the diagnosis-treatment-cure pathway. In the absence of a biomedical explanation 21

for their pain, the participants feared that the legitimacy of their pain was in question 22

(Q10). 2. They received a diagnosis of an underlying pathology that could explain their 23

pain, but were told that the underlying pathology could not be fixed (Q11). 3. They 24

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received a diagnosis of an underlying pathology that could explain their pain and 1

entered the diagnosis-treatment-cure pathway, but their expectations of a cure were 2

not fulfilled (Q12). 4. They received a diagnosis grounded in biopsychosocial 3

principals, but were not provided with effective strategies to gain control over pain 4

(Q13). In each case the repeated experience of a discrepancy between the expected 5

and actual outcome of care-seeking behaviour, resulted in a LBP experience that did 6

not make sense to them. 7

“You feel like you are losing face when all the tests come back negative and the 8

doctor is thinking it is all in your mind …But I guess when they say there is nothing to 9

show, how can you treat it? Q10 (f, 61yo, 0.5yrs LBP) 10

“To me it seemed like a clear path – clear diagnosis, clear treatment option with a 11

high success rate and resolution of the problem. Why can a knee ligament be fixed, 12

but a back ligament can’t? What makes this joint different?” Q11 (f, 41yo, 7yrs LBP) 13

“When the pain flares-up they say ‘your muscle imbalance is out again’. But I have 14

been doing cross fit for 7 weeks and I have been doing Pilates for 10-11 weeks, 15

surely it can’t be that weak… this doesn’t make sense” Q12 (f, 33yo, 0.5yrs LBP) 16

“What the clinical psychologist said does make sense. There are situations when I’m 17

just thinking about doing an activity then suddenly my back will be hurting. I haven’t 18

done anything but the pain is there. I understand that my nervous system may be 19

wound up, but how can I control it?” Q13 (male (m), 33yo, 8yrs LBP) 20

21

Fear as a common sense response to a pain experience that doesn’t make sense 22

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The CSM also describes how pain-related fear may be generated or perpetuated by a 1

lack of a coherent representation to make sense of a threatening LBP experience. In 2

the absence of a useful cognitive representation to make sense of pain in order to 3

guide effective problem-solving behaviour, behaviour will be driven by the emotional 4

response to pain. Fear is a common emotional response to a ‘threatening’ 5

representation in which the symptom is perceived to have severe consequences, to 6

be unpredictable and/or uncontrollable1, 14, 28. While fear avoidance behaviour 7

restores emotional equilibrium by reducing fear in the short term41, it prevents 8

opportunities for positive exposure and may reinforce incoherency regarding the 9

identity, causes, consequences, time-line and/or the curability/control of the 10

symptoms. Thus a vicious cycle ensues in which fear avoidance behaviour reinforces 11

an incoherent LBP representation that in turn reinforces pain-related fear. This 12

commonly results in heightened disability, as valued life activities are avoided, 13

escalating depression and distress, and placing lives ‘on-hold’, in a state of 14

‘suspension’9. 15

The CSM as a framework to understand fear reduction 16

The participants in our prospective study who experienced a reduction in fear over the 17

study period attributed fear reduction to ‘making sense’ of their LBP linked to improved 18

perceived control over pain and/or their response to pain. Pain control appeared to 19

occur through learning alternative movement strategies and also by shifting attention 20

away from pain towards valued goals. The participants who could not achieve pain 21

control were more likely to report poorer outcomes at follow-up. The two pathways to 22

fear reduction described by the participants in our study are described below. 23

Reducing fear by decreasing the threat of pain: 24

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The first pathway to fear reduction described by the participants involved the creation 1

of a non-threatening, coherent LBP representation that could guide effective problem-2

solving behaviour. According to the CSM, the basis of a non-threatening, coherent 3

LBP representation is the combination of diagnostic certainty (identity dimension) that 4

can explain one’s symptoms (cause dimension), which replaces erroneous beliefs in 5

the damaging effects of pain (consequences dimension) and prescribes procedures 6

for controlling or resolving the symptoms (timeline, control dimension). 7

Table 1 illustrates the transition from a threatening, incoherent LBP representation to 8

a non-threatening, coherent representation drawing on the experiences of a 9

participant in our prospective study who experienced a reduction in fear. 10

(Insert Table 1) 11

The CSM describes a causal relationship between belief change and behaviour 12

change that is dynamic, reflexive and bidirectional, consistent with the principles 13

underlying exposure techniques42. By experiencing control over pain during 14

behavioural experimentation not only are expectations of damage associated with 15

performing threatening movement addressed through positive disconfirmatory 16

experiences, but also expectations of suffering/functional loss associated with painful 17

movements (Q14, Q15). From our analysis of interview data, the study participants 18

who learnt to control pain by modifying the way they moved, associated this with an 19

ability to self-manage flare-ups in pain while achieving valued life goals, thus building 20

pain self-efficacy (Q16, Q17). 21

“There was a notable improvement in the first week, so it wins you over” Q14 (m, 22

42yo, 2yrs LBP) 23

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“In my head I thought I would break in half if I bent over. But the Physio said your 1

structure is fine, you need to learn how to move again. And I thought who do I trust? 2

The people who told me my structure was broken beyond repair, or the person 3

saying your structure is fine, it’s ok to bend and I feel better after one session?” Q15 4

(f, 41yo, 7yrs LBP) 5

“When I had a bad flare-up that day, I went to my stretches and that fixed it. You 6

build up confidence in your body when the worst happens and you get through it” 7

Q16 (m, 42yo, 2yrs LBP) 8

“You have to be able to have the success of doing it without pain to go actually I can 9

do it. The proof is in the pudding” Q17 (f, 41yo, 7yrs LBP) 10

The CSM describes how, when the outcome of behaviour is consistently appraised as 11

being in the direction of the target goal, the new representation is deemed useful in 12

guiding effective problem solving behaviour and the LBP experience will ‘make sense’. 13

Reducing fear by changing emotional responses to pain: 14

The second pathway to fear reduction described by the participants involved changing 15

available responses to manage emotions related to pain. We have stated before that 16

fear is a typical emotional response to a threatening representation in which the 17

symptom is perceived to be unpredictable and/or uncontrollable and to have severe 18

consequences14. Based on findings from our study, we suggest that when individuals 19

are equipped with strategies that enable them to control their worry about the 20

consequences of their actions sufficiently for them to engage in valued life activities, 21

the achievement of desired outcomes means the behavioural strategy is appraised as 22

effective. This appraisal is fed back into the representation, reinforcing coherency. 23

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Some participants in our study described how their acceptance of the uncontrollability 1

and unpredictability associated with pain (Q18) and/or a ‘letting go’ of negative 2

thoughts about the identity, causes and consequences of pain (Q19), enabled them to 3

control their worry and shift their focus from pain towards valued life goals (Q20). 4

“I view everything at the moment as: can I change it – yes? Ok then I change it. Can I 5

change it - no? Then just stop worrying about it” Q18 (f, 38yo, 4yrs LBP) 6

“It makes sense to me now… in the past I would grab hold of negative things and hold 7

on to them, dwell on them. Now I’m more focused on where I need to go and don’t let 8

these things bog me down.” Q19 (m, 33yo, 8yrs LBP) 9

“I have realized that you can’t let the pain dominate your life. You’ve just got to keep 10

going and when it turns up say ‘gidday, how are you’ and continue on” Q20 (m, 39yo, 11

13yrs LBP) 12

The CSM as a framework to treat pain-related fear: 13

In the section that follows we demonstrate how the CSM can provide a clinically useful 14

framework for Physiotherapists to assess and treat pain-related fear, applying 15

strategies well known in the behavioural medicine literature. 16

A CSM approach to assessing and treating pain-related fear involves 5-stages13, 17

underpinned by motivational, reflective and validating communication techniques26: 18

1. Encouraging the individual to describe their condition along the five dimensions of 19

the representation. Clinicians can explore unhelpful beliefs informing an individuals’ 20

LBP representation by exploring the diagnostic labels they associate with their LBP, 21

by exploring their beliefs about the cause of their LBP, how long they believe it will 22

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last, and their beliefs about the consequences of their LBP. In particular, clinicians 1

may explore underlying damage, suffering/functional loss beliefs, how controllable the 2

individual perceives their LBP is and what they believe it will take to better manage 3

their LBP. It is helpful to question individuals about how they respond to pain and their 4

appraisal of the outcomes of this action. The clinician should aim to identify gaps, 5

confusions, discrepancies and misconceptions in the representation, to raise 6

awareness of how these impact on the LBP experience and how the representation 7

may need to be reshaped to assist the individual in making sense of their pain 8

experience. Example questions are presented in Table 2. 9

(Insert Table 2) 10

2. Prompting the individual to think about experiences that led to misconceptions and 11

to evaluate the importance of those experiences. Individuals can be prompted to 12

discuss the results of any imaging investigations they have had. Clinicians can 13

consider how individuals link words to concepts that activate representations21 by 14

investigating how individuals interpret the diagnostic labels they may have received. 15

For example, in our research the diagnostic label ‘degeneration’ appeared to elicit a 16

representation of LBP as incurable with consequences for future function (i.e. 17

wheelchair). Similar problematic interpretations of diagnostic LBP labels have been 18

documented in Australian Indigenous23 and non-patient populations2. Clinicians can 19

encourage individuals to discuss other experiences that may influence misconceptions 20

include observing others with LBP, previous direct experiences of LBP, and healthcare 21

encounters. Encouraging individuals to think and talk about experiences that led to 22

confusions and misconceptions can enable clinicians to understand the strength of the 23

beliefs (how committed the individual is to them). 24

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3. A discussion between the individual and clinician about how the gaps, confusion 1

and misconceptions in the representation impact on their behavior. For some 2

individuals the beliefs informing the representation may be implicit and only become 3

apparent through behavioural experimentation21. Clinicians may assist individuals to 4

develop a ‘body awareness’ of the negative impact of protective movement 5

behaviours, avoidance of valued activities, unhelpful lifestyle behaviours, and 6

unhelpful emotional responses to the pain experience, through the use of mirrors, 7

videos, diaries and feedback40, 45. By reflecting underlying beliefs in real-time, a 8

dialogue can pursue about how the gaps, confusions and misconceptions in the 9

representation are perpetuating the vicious cycle of pain. 10

4. The presentation of new information to fill in gaps, clarify confusion and replace 11

misconceptions. Providing an individual with a diagnosis that can explain their LBP 12

symptoms can give rise to strategies to address them. Rather than providing 13

diagnostic labels, such as ‘disc bulge’ or ‘degenerate disc’, individuals can be provided 14

with a ‘diagnostic explanation’ that addresses all five dimensions of the representation. 15

For example, it may be explained to them that they have ‘sensitisation’ of the spinal 16

structures (identity) linked to pain sensitizing factors such as adopting provocative 17

behaviours, disrupted sleep, fear, stress, vigilance (cause), that sustain pain and 18

disability (consequence), and that strategies to address these mechanisms such as 19

movement control/body relaxation and cognitive reframing (controllability) will 20

enhance their functional capacity with pain control within a specific time frame (time‐21

line). 22

In order to disconfirm beliefs about the negative consequences of performing 23

movements associated with threat and/or pain, the experience of moving without 24

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flaring up pain and causing damage/suffering or functional loss, is likely to facilitate 1

the adoption of the new understanding and build internal locus of control beliefs. This 2

approach to cognitive restructuring has a strong evidence base in cognitive therapy 3

and behavioural experimentation4. 4

For some individuals, having an explanation that helps them make sense of their LBP, 5

combined with strategies that effectively control them facilitating a return to valued 6

activities, may address unhelpful emotional responses such as pain-related fear, pain 7

anxiety and low mood46. These pain control strategies can directly help regulate their 8

emotional responses to the pain experience via mindful awareness, acceptance, 9

relaxation and breathing regulation34, 39. Goal setting around valued life activities is a 10

form of behavioural activation that has a large evidence base for lifting mood24. These 11

strategies are all firmly within the scope of physiotherapy, with good evidence for the 12

effectiveness of physiotherapy-led interventions targeting emotional responses in 13

people with pain3, 32, 40. 14

5. Bringing about behavioural change through an altered representation. Providing 15

individuals with new information to inform their LBP representation needs to give rise 16

to adaptive behaviours. In addition to providing information, equipping individuals with 17

effective strategies to independently control pain and prevent flare-ups in pain intensity 18

and/or control the impact of pain in their lives and emotional responses to pain, allows 19

them to engage in valued life activities. Matching these strategies to the new 20

representation facilitates individuals to problem-solve the best course of action in any 21

given context. When the selected action successfully brings them towards their target 22

goal, this experience increases the coherency of the new LBP representation. When 23

repeated over time, coherency is established, the LBP experience makes sense, 24

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leading to reductions in fear. 1

The CSM in the context of current and future research 2

While the CSM has been widely used to understand patient responses in other chronic 3

conditions, it has only relatively recently been applied in the LBP literature30, 36, 38. This 4

clinical commentary illustrates how the CSM can assist Physiotherapists to explore 5

concepts that are well known in the behavioural medicine literature, but less well 6

known in physiotherapy literature. It provides a framework for Physiotherapists to 7

understand how existing treatment strategies that aim to reconceptualise individuals’ 8

knowledge about their LBP such as “Explain Pain”27 and Exposure in Vivo43, can be 9

combined with strategies to gain control over pain and responses to pain40, to help 10

individuals make sense of their LBP experience. Conceptualising fear as a common-11

sense response to a threatening LBP experience may enhance how Physiotherapists 12

perceive, interact and communicate with individuals with high fear. Future research 13

may explore the effects of applying this framework on outcomes for patients. 14

Conclusion 15

Insights from our research into the lived experience of pain-related fear suggest that 16

pain-related fear may be conceptualised as an emotional response to a LBP 17

experience that doesn’t make sense. We have presented the CSM as a framework for 18

Physiotherapists to understand the sense-making processes involved in the fear 19

avoidance cycle and as a clinically useful framework to treat pain-related fear. The 20

next generation of fear avoidance interventions may consider including strategies that 21

assist individuals to make sense of their LBP experience, gain control over pain and 22

their response to pain, to optimise treatment outcomes. 23

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1

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45

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TABLE 1. Example of a patient transition from a threatening, incoherent LBP representation (baseline), to a non-threatening 1 coherent LBP representation associated with a reduction in fear (follow-up). The patient is a 42 year old male with 2 year history of 2 LBP 3

CSM constructs

Baseline Follow-up

Identity “I have damage to two of the discs” “The pain is tension in my body and my back not moving properly”

Time-line “I am beginning to think - am I really going to be doing this for the rest of my life… I think I am mentally preparing myself for having a really sedentary kind of existence”

“I think that it is possible that I can get to the point where there won’t be pain”

Cause “It’s caused by degeneration, so my spine is deteriorating”

“Sometimes I will think if I do that that will hurt and it will happen. But then I can have a really bad day and I don’t know why, it’s the unpredictability of it”

“What I have learnt about chronic pain is that it is a result of your behaviour as much as it is a result of something going on inside you. It is not necessarily the fact that something is busted it is that you are continually hurting yourself without moving properly”

“I think pain causes tension and tension causes pain”

Consequences “When it hurts I think I am doing more damage to my back. I think it is getting worse, crumbling, breaking down”

“If something hurts it is for a reason it is your body saying don’t do it”

“ I think what changed in me from seeing the physio was going from being terrified of hurting myself more anytime I moved to realising that moving was the very thing I needed to do, that is the main reason why I changed”

Control/

Curability

“There is damage to the discs ... but it seems it is impossible to fix damage.”

“[Lying on the couch] is the only way to make the pain go away, and prevent it from coming”

“The first session he said well we can fix this. He said there are people with back scans far worse than yours who have no issues, no pain issues. You need to learn how to move again”

“I have the tools in my tool-box to control a flare-up in the future”

Taking action “I would never bend over to pick something up. I try and “So if I go get up and it hurts I will try to apply what he suggested

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brace myself on any move…I will avoid doing things that I would normally do that I would think would aggravate it”

which is if I had of been more relaxed doing it, it probably wouldn’t have hurt so much. So I have started trying to be very aware of just how relaxed I am or am not”

Appraising action

“I have found ways to not be in pain just by finding positions that just kind of work but even moving from any position to any other position is just murder”

“All the physios, all the injections…it feels like I guess temporary relief”

“When he got me to touch my toes on the first day - it wasn’t just that I had done it. I could have done it and it hurt like buggery. But my back wasn’t hurting. And I had done it on my own, without him. He was just standing there”

“There are times when I have been moving around and I would just realise man you are tense and I have just tried to release and think myself into not being tense and it does make a difference”

Coherency “I find all of this a very confusing experience” “A few things he said to me that really made sense were that your back is made to be moving. Perhaps the single most important thing he said to me was don’t be frightened of pain - you are not doing more damage. And when I experienced it for myself... it changed my mind set instantly”

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TABLE 2. The subjective assessment of pain-related fear using a CSM framework: Example questions 1

CSM construct Example questions

Identity Do you have a diagnosis for your pain? Can you explain to me what this means?

Have you had any scans on your back? Can you explain in your own words what these showed?

Cause Do you know what cases your back pain?

How predictable is your pain?

Consequences What do you think will happen if you perform a movement/activity you are afraid of?

Do you worry that doing a painful activity will damage your spine?

Do you worry that it will impact on all the other things you need to get done?

Control/Curability How much control do you feel you have over your pain?

Can you prevent your pain from flaring up?

Can you control your pain once it has flared up?

How much control do you feel you have over your response to pain?

Time-line How long do you expect your pain will last?

How hopeful are you for the future?

Action What do you do when you are faced with a threatening movement or activity?

What do you think it will it take to make your pain better?

Coherency How much does your pain make sense to you?

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1

FIGURE 1. Fear Avoidance Model (based on Vlaeyen and Linton 2000) 2

3

Negative affectivityThreatening illness information

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FIGURE 2. Common Sense Model (based on Leventhal 1980) 3

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