Fear of Pain More Disabling than Actual Pain

Fear of pain can disable a patient in many ways. Previous literature has reported that the fear of pain induces avoidance behavior (which lends to low physical activity), interferes with cognitive functioning, and that long-standing avoidance and disability eventually affects physiological systems. The authors of this study, performed three separate studies to investigate pain related fear. The first assessed if pain-related fear is more disabling than pain itself; the second looked to see if there is an association between fear and poor work performance; and the third compared pain related fear measures and general mental health to assess which was a better predictor of disability and performance.

The first inquiry consisted of 35 chronic low back pain patients. The participants self-reported their disability by replying to questionnaires that evaluated current pain intensity, pan-related fear, disability and general negative affect. The findings revealed that disability significantly correlated to pain-related fear scores, but not to pain intensity or negative affect scores—pain-related fear was a better predictor of disability than the other two.

In investigating the role of pain severity, pain related fear, pain anticipation, and negative affect's role in predicting performance the authors found, surprisingly, that none of the pain-related fear measures correlated to the patients' level of pain expectancy. What emerged as a predictor of decreased performance was the expectation of pain, not the actual pain experienced.

With 31 chronic low back pain patients the authors finally examined pain severity, pain-related fear, and negative affect scores to predict self-reported disability and behavioral performance. The authors found that if patients' pain occurred suddenly the pain related fear was higher; if patients' pain developed gradually the disability scores were higher. Also pain-related fear was more predictive of physical performance than the current pain intensity or increase. And as other studies have implied, the low back pain patients' physical performance was significantly influenced by the presence of pain radiating in at least one leg.

These findings indicate pain-related fear is a solid predictor of a patient's performance and self-perceived disability. Since it plays such a major role, the authors attempt to answer what, exactly, these patients fear. They offer three possibilities:

• Pain-related fear is more related to the long-lasting effects of physical activity rather than to immediate pain increases during the activity.
• Patients avoid physical activity out of fear of additional harm, injury, or re-injury.
• Patients may fear they could not cope with pain increase.

As well, the authors than provide a plan to handle chronic low back pain patients, or any patients with high levels of pain-related fear:

1. Screening: Identifying the patient early in treatment is recommended. The authors suggest using both the TSK [Tampa Scale for Kinesiophobia] and FABQ [Fear-Avoidance Beliefs Questionnaire], which were used in this study, because, "they are relatively short questionnaires that can be easily used in a primary care setting." During the screening process, it is worthwhile to determine what the patient is actually afraid of—abrupt movement? Spinal compressions? Damaged nerves?
2. Education: Directly and clearly explaining to the patient that their pain is a common condition that can be self-managed and not a disease/condition that needs constant care and attention. The authors stipulate the point of the educational portion is not to lecture, but to simply explain to the patient that their condition can be improved by increased activity.
3. Exposure: The most important step—getting the patient involved in a concrete plan that gradually resumes their normal activities. The authors write, "Such an exposure is quite similar to the graded activity programs, in that it gradually increases activity levels despite pain, but is dissimilar in that it pays special attention to the personally-relevant and pain related stimuli."

The authors conclude that since fear of pain gauged in as a powerful psychological challenge for chronic disability additional studies are needed to understand all the mechanisms that lead to chronic pain and disability.

Crombez G, Vlaeyen JWS, Heuts PH, Lysens R. Pain-related fear is more disabling than pain itself: evidence on the role of pain-related fear in chronic back pain disability. Pain 1999;80:329-339.