Avoiding painful movements or positions

Avoiding painful movements or positions (in the short term)

Avoiding pain is a normal response. Meulders (2020)(1) stated the following “Pain urges the individual to take action and restore the integrity of the body.” Leading to defensive response to prevent further potential damage.

Something hurts, we stop doing it. We will try it again later, it still hurts. We avoid this for longer, if it doesn’t hurt, we continue with our lives. However, sometimes when we think something will hurt, we will also avoid it. An example might be that we hurt our lower back picking up the washing, we remember someone said not to lift objects to avoid wear and tear, we now stop it all together as we think we may be doing further damage.

Avoiding painful movements or positions can be beneficial in the short-term following acute injuries as it can prevent further damage (1-3), possibly also during pain flare ups (e.g., rheumatoid arthritis) and in some conditions (e.g., cancer). However, after an injury over time once healing has occurred avoiding these movements or positions can become problematic and even lead to disability (1-4).

Avoiding painful movements or positions (in the long term)

Western society and certain cultures often attribute pain to damage (5). However, research has shown that this is not the case. That pain and damage are often not closely correlated (especially for prolonged pain not attributed to a disease). We also know that injuries heal with time with (and often without) treatment.

Further info and references can be found here: https://www.evolveflg.com/articles/tissue-healing

Of course, healing times can vary from person to person depending on numerous factors, the above are only a rough estimate with the main aim to demonstrate that injuries can heal.

Our normal defensive response for avoiding pain is therefore, often no longer useful although completely understandable. We may start seeing the following: 

This is Sam’s interpretation of the research taking portions from (1-2,9)

Pain related fear and avoidance behavior has been shown to relate to disability in the following conditions:

• Persistent lower back pain (1)

• Persistent abdominal pain (1)

• Fibromyalgia (1)

• CRPS (1)

• Persistent upper extremity pain (1)

• Persistent neck pain (1)

• Headaches (1)

Pain is not always a sign of damage or pathology. 

Imaging has been an amazing advancement in medical technology and has been hugely helpful in the diagnosis of numerous diseases and often prevents guessing games. Another somewhat surprising finding is that it found a poor correlation pain has with tissue damage (6).

Examples of pain with little or no damage/disease

• Brainfreeze

• Gallbladder stones

• Kicking the fridge

• Stepping on Lego

• Muscle soreness after the gym

• Phantom limb pain

• Eating chili’s

• Majority of lower back pain (90%-95%)

Examples of serious disease with little or no pain

• Early stages of cancer

• Serious injuries during war (when threat is still evident)

• Snake bite

• Serious injuries but you are focused/prioritizing survival.
  

From: https://www.aptei.ca/library-article/vomit-victim-of-medical-imaging-technology/

Injuries can still heal even when movement or positions are painful

A paper which reviewed all studies that compared pain free vs allowing pain during exercises helped with this understanding (6). The paper included 9 studies with a total of 441 participants. The main findings were that in the long-term there was no difference in pain or outcomes and in the short- and medium-term painful exercises were actually superior in these areas. 

Are you avoiding painful movements? 

There is a validated tool which can measure fear of movement (kinesiophobia). Which can be found here: https://www.mdapp.co/tampa-scale-for-kinesiophobia-tsk-calculator-465/

How to break the cycle 

Waiting to decrease pain prior to engaging in physical activities may not be productive in persistent pain, especially when numerous attempts have failed. By focusing on gradually re-engaging in activities independent of pain you are more likely to succeed in improving your quality of life.

So how can you overcome this?

Firstly, you will need to know if it is actually safe and appropriate to move and become more physically active. This is where you may need assistance from a healthcare professional. This can be challenging as research has shown that healthcare professionals can also be fear-avoidant themselves (1,7-8). The Adapt Movement team is prepared to assist you through each step and make a plan appropriate, safe and effective for you and your situation.

Some further interesting research findings. 

Pain can be experienced not only from movement or certain postures, but also from different cues such as observing a movement that you have associated with pain, imagining a painful movement, smells associated with pain, etc. (1).

This is similar to you starting to feel hungry or a craving when you smell or see your favorite food. Or you are mouthwatering before you eat a kiwi fruit or pineapple.

References

1. Meulders A. (2020). Fear in the context of pain: Lessons learned from 100 years of fear conditioning research. Behaviour research and therapy, 131, 103635. https://doi.org/10.1016/j.brat.2020.103635

2. Crombez, G., Eccleston, C., Van Damme, S., Vlaeyen, J. W., & Karoly, P. (2012). Fear-avoidance model of chronic pain: the next generation. The Clinical journal of pain, 28(6), 475–483. https://doi.org/10.1097/AJP.0b013e3182385392

3. Zale, E. L., & Ditre, J. W. (2015). Pain-Related Fear, Disability, and the Fear-Avoidance Model of Chronic Pain. Current opinion in psychology, 5, 24–30. https://doi.org/10.1016/j.copsyc.2015.03.014

4. Vandael, K., Vervliet, B., Peters, M., & Meulders, A. (2023). Excessive generalization of pain-related avoidance behavior: mechanisms, targets for intervention, and future directions. Pain, 164(11), 2405–2410. https://doi.org/10.1097/j.pain.0000000000002990

5. Caneiro, J. P., Smith, A., Bunzli, S., Linton, S., Moseley, G. L., & O'Sullivan, P. (2022). From Fear to Safety: A Roadmap to Recovery From Musculoskeletal Pain. Physical therapy, 102(2), pzab271. https://doi.org/10.1093/ptj/pzab271

6. Smith, B. E., Hendrick, P., Smith, T. O., Bateman, M., Moffatt, F., Rathleff, M. S., Selfe, J., & Logan, P. (2017). Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis. British journal of sports medicine, 51(23), 1679–1687. https://doi.org/10.1136/bjsports-2016-097383

7. Coudeyre, E., Rannou, F., Tubach, F., Baron, G., Coriat, F., Brin, S., Revel, M., & Poiraudeau, S. (2006). General practitioners' fear-avoidance beliefs influence their management of patients with low back pain. Pain, 124(3), 330–337. https://doi.org/10.1016/j.pain.2006.05.003

8. Linton, S. J., Vlaeyen, J., & Ostelo, R. (2002). The back pain beliefs of health care providers: are we fear-avoidant?. Journal of occupational rehabilitation, 12(4), 223–232. https://doi.org/10.1023/a:1020218422974

9. De la Corte-Rodriguez, H., Roman-Belmonte, J. M., Resino-Luis, C., Madrid-Gonzalez, J., & Rodriguez-Merchan, E. C. (2024). The Role of Physical Exercise in Chronic Musculoskeletal Pain: Best Medicine-A Narrative Review. Healthcare (Basel, Switzerland), 12(2), 242. https://doi.org/10.3390/healthcare12020242

This blog was written by Samuel Bulten