Lower back pain treatment - fear avoidance can make your back pain worse

This is one of the most common psychosocial yellow flags that makes back pain more likely to become chronic. It stems from several beliefs:

  1. Pain is a sign of tissue damage and must be avoided to prevent further ‘harm’
  2. A belief that something is seriously wrong with the low back (diagnosed or undiagnosed) and that activity will make it worse.

  3. A strong belief that the pain must be gone before any exercise or return to work is attempted.

  4. Fear that the pain is uncontrollable and that activity will make it spiral out of control.

All these beliefs usually have one outcome – rest and avoidance of normal activities. It may start out as a simple avoidance of things that we think are causing the pain even though there may be little evidence to support this.




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Case study - Max

Max was a fit 20 year old student. He liked to go to the gym and weight train; he cycled to college and used to spend all his holidays working as a snow boarding instructor in France. On one of these trips, 6 months earlier, he had had a snow boarding accident where he had landed awkwardly and had developed lower back pain.

When I met him he had given up the snow boarding, stopped going to the gym and had started driving everywhere. He was really depressed and fed up, along with his sports his social life had disappeared and he was afraid he would never get back on the slopes.

When I asked him if his back hurt more when he did exercise he looked at me in surprise. He hadn’t really thought about it, his back hurt when he did all sorts of things but he had thought that exercise was certain to be bad for him.

questionsWhen we discussed it more and I asked him if stopping the exercise had reduced his back pain, he realised it hadn’t helped at all, if anything he was feeling worse.

I examined him and reassured him that he had simple back pain and that the pain wasn’t signaling serious harm. I encouraged him to get back to some exercise; we agreed he would start on a paced exercise program which started him off gradually.

Almost straight away he realised it didn’t hurt much more when he exercised then when he didn’t. He gradually worked on his fitness and flexibility and within 6 weeks was feeling back in control of his back pain, it had stopped interfering with his life and he was planning to head off snow boarding again.

Max was easy to treat – he hadn’t had back pain very long, he was keen to get back to sports and he trusted me when I told him he had nothing to worry about. When he became fit again his pain eventually went away. Sometimes it’s not that simple.

Case study - Giovanni

When I met Giovanni he was in his 50s. He had developed back pain 15 years earlier following an accident at work. He was advised at the time that he had really serious spinal damage, was lucky not to be paralyzed and should really look after his back carefully as he now had a  ‘weakness’.

He was warned of dire consequences if he injured his back again, certain disability and even ending up in a wheelchair. He is a very sensible man and took this advice very seriously; he was terrified of ending up disabled so he immediately made major lifestyle changes.

He took to wearing a corset to give him support and protection; he gave up his manual job and took up a clerical post where he could sit down. He soon decided to stop work altogether because sitting was painful too.

He stopped doing anything that he thought might put him at risk – this included lifting, carrying and bending movements and all exercise. He kept himself as stiff as possible to keep himself safe from harm and he had frequent times when his back was really sore, other times it wasn’t so bad, on the whole he managed the problem without seeing his doctor much - and on it went.

Eventually he reached the end of his tether – no matter how much he gave up or stopped doing his pain got worse and his quality of life with it. He could do less and less and finally went to his doctor when he could no longer bend forward to put his socks on – his wife was having to dress him. 

His doctor arranged an X-ray which showed normal age changes or degenerative changes in his spine (lumbar spondylosis). He was referred to physiotherapy.

When I first met him I was shocked at how stiff his spine was - he was as stiff as a board! He had virtually no movement in any direction. Along with that his stomach muscles were really weak, he was very unfit and very fed up as well.  The spine is designed for movement and likes to be surrounded by good supportive muscles. I wasn’t surprised he was struggling.

I introduced Giovanni to the idea that it was far better to move a spine than keep it still, that movement lubricated and fed the joints and that he would feel much better for it. I also persuaded him that his spinal problem was not serious and that he had simple low back pain and that the pain of movement was not signaling tissue damage. He was really nervous; after all he had spent 15 years avoiding movement.

We started with exercises to get him bending again – very simple work. After several weeks we added in some stomach muscle work. He struggled to overcome his fright that he would make it all worse but he persisted.

Eventually he agreed to join a group that helps people get fit after back pain when they are fearful, and he gradually started to pace and get his general fitness levels up again. All this took a great deal of time and bravery on his part. He persisted and 6 months after the start of treatment was able to dress without help again – a major triumph.

Importantly he had started doing some office work for his sons building company which got him out of the house and reduced his isolation. Interestingly his pain hadn’t changed greatly, it certainly hadn’t worsened but it hadn’t gone either. He didn’t mind, he had some quality and independence back in his life. fear avoidance and biopsychosocial model

Fear avoidance has been shown to have a negative impact on lower back pain (1). If you feel that this is something you are having problems with please go and discuss it with your doctor, physiotherapist or other health care provider.


Read about other important aspects of the biopsychosocial model of back pain including more yellow flags:

Differing diagnosis and explanations for back pain.

Lower Back Pain Toolkit Home Page


Leeuw,M.; Goossens,M.E.J.; Linton,S.J.; Crombez,G.; Boersma,K.; Vlaeyen,J. The fear-avoidance model of musculoskeletal pain: Current state of scientific evidence, Journal of Behavioral Medicine, 2007