Are you afraid to push your patients?

We have all heard about fear avoidance, or pain-related anxiety and avoidance in patients (Vlaeyen & Linton, 2000). This model of pain disability has become increasingly prominent over the past 10 years and research has demonstrated its effectiveness in predicting those who will develop long-standing disability, as well as providing amodel for treatment approaches – the graded exposure approach being one (Vlaeyen, 2002; Leeuw, Goossens, van Breukelen, deJong, Heuts, Smeets, Koke, Vlaeyen, 2008)).

Shortly after the model was introduced, researchers posed the question – are we as clinicians fear avoidant? Do we avoid asking our patients to ‘push’ themselves – either into increasing pain, or possible harm? (Linton, Vlaeyen, Ostelo (2002) is a good example).

In this recent editorial, Ostelo and Vlaeyen (2008) ask the question: have things changed? Do we still limit our expectations of people who experience pain because of our own beliefs and attitudes? Do we project our own concerns onto our patients, and in so doing, increase their risk of ongoing disability?

Bishop, Foster, Thomas & Hay (2008) suggest in their study that indeed, our treatment behaviour is correlated with our personal beliefs and attitudes, and that this affects our expectations and recommendations for our patients. Although there are several criticisms of that study (low response rate, yet another questionnaire with relatively little cross-validation of the content, and the use of vignettes rather than observing actual clinical practice), it nevertheless raises questions that haven’t previously been asked about the influences on patients, rather than focusing only on patient beliefs and attitudes.

It’s not an easy area to study, but intriguing, and opens the fear avoidance model up to include more environmental factors than are currently included. So, a question for all of us: how do we feel about asking patients to persist with activities despite pain? What do we do – both intentionally in terms of recommendations, and unintentionally in terms of our verbal and nonverbal behaviour?

Ostelo R.W.J.G & Vlaeyen J.W.S.(2008) Attitudes and beliefs of health care providers: Extending the fear-avoidance model Pain (135:1-2), pp 2-3.