Fear Avoidance

Our four year old boy recently broke his right arm in a high speed downhill cycling accident. It has been an interesting few weeks watching him getting use to the change, with the arm in a plaster of Paris, both the wrist and elbow immobilised. It surprises me how quickly he adapted and how independent he still is, being able to do most self-care activities without help. He plays rough, as always, doing playball and his creative works at the day care. He is quite crazy about cycling, and I wondered how that would go down, 4 weeks without cycling. I prepared myself for quite a frustrated little man!

But, as kids are, I suppose, within a week he was back on his bicycle. At first he just watched his 2 year old brother on his bicycle, going round in the house. Next thing he worked out a way to balance the plaster of Paris on the handle bar and before I know it, he was going downhill in the backyard again. No motivation and applause needed to get him going again, all against my expectations. During the third week with the immobilized arm, he started cycling in the street when we would go for a walk.

This made me think of patients with back pain. For some patients it is very hard to return to their previous activity after an episode of pain. Why is it so hard to return to the way the body used to work before this episode of pain? Pain has been seen as a reason for bedrest, to do the least activity possible. This of course is not true for all patients, but in general people see pain as a reason to immediately stop what they are doing. Lately there has been a shift towards safe movement while in pain, rather than rest. Pain is a protective mechanism, but unfortunately in some patients this protective pain can lead to the total avoidance of daily activities. A general guide for movement while in pain is that it is in order to experience some pain as you move, but you should not force through pain. Movement is important for relaxation of muscles and joint lubrication. It also calms the nervous system. When moving in a calm way, the brain receives messages that movement is ok, and the brain start sending less protective messages to the body. If the brain keeps on sending multiple protective messages, it may to muscle spasms, altered movement patterns and sometimes fear of movement. Fear of movement is not a deliberate choice; it is a reaction of your body. It is a complex reaction and is influenced by a number of factors.

One factor for example is your emotional wellbeing when the injury occurred. If you are in the midst of a difficult time, it is possible that the pain you experience in your back (because of the injury), may be more intense and may take longer to resolve. While in pain, one naturally moves in a different manner, but if this is the case for a long period of time, it might lead to fear avoidance. This means that during the period of pain, you avoided certain movements, once the pain subsided and the injury is healed, you should return to full function, but sometimes you still move in the way as if the pain is still there, thus having a fear of that specific movement.

So what are my suggestions when you do experience an acute episode of back pain?

  • Apply heat to the area, or take a bath (not if you live in the Western Cape, water is too scarce!)
  • Deep breathing – lie on your back and inhale deeply to see the lower ribs expand.
  • Do take it easy; avoid lifting or carrying heavy objects.
  • Take painkillers if necessary.
  • Go for an easy walk around the house or garden.
  • Try and do all self-care activities without help (showering, dressing, cooking, etc.)
  • Do some gentle exercises, best if prescribed by your physiotherapist.
  • SEE A PHYSIOTHERAPIST; for spinal joint mobilization and soft tissue relaxation, and of course for the prescription of specific exercises for your condition.

Your First Ever Physiotherapy Appointment; What to Expect

The physiotherapist will spend 45 minutes with you for the evaluation and treatment.

Some administrative stuff:

It is wise to arrive 10 minutes prior to your appointment.  This allows for time to carefully read through our consent form and to provide all the necessary personal details. Consent to treatment is a pre-requisite.  For evaluation, palpation and treatment, the affected body area will be exposed and the physiotherapist will touch you. 

Be sure to bring your identity number and medical aid details with.  Your account can be submitted directly to your medical aid; otherwise it is for your own account.  We do have card facilities available for payment.

Please bring all relevant medical reports, like X-rays and referral notes, as well as the medication you are taking, with you.


The physiotherapist will have a discussion with you about your problem.  Bring it all to the table!  Explain your problem in detail, information is key and every individual’s problem is different.  Take some time before your appointment to think about your problem and the impact it has on your life.  Some questions the physiotherapist may ask

  • How long has this been a problem?
  • Was there any incident, like a fall or car accident?
  • What worsens the symptoms and what gives relieve?
  • Is there a pattern through the day, comparing morning, midday and evening or night symptoms?
  • What is the intensity of the symptoms?
  • Describe the type of symptoms (stiffness, pain, burning, pins and needles)
  • Have you suffered from this before?
  • General health?

The next step in the evaluation is the active part.  The physiotherapist will most probably have a look at your posture and then ask you to do some active movements.  You should report any change in symptoms, pain and stiffness or discomfort.  The physiotherapist will also perform some specific passive tests.  Your diagnosis and the treatment plan will be discussed.  Listen and ask questions!  It is natural to feel worried or emotional, and not understand everything that has been said.  The physiotherapist will understand this.


For the best outcome it is important to comply with the treatment and advice given.  The physiotherapist will diagnose and treat in the rooms, but will also prescribe some exercises and changes for you to apply at home.  This is the other part of therapy, if you comply, your outcomes is likely to be much better.   Any of the following treatment techniques can be used:

  • Manual therapy
  • Soft tissue techniques
  • Dry needling
  • Electrotherapy (interferential, ultrasound, laser)
  • Strapping
  • Exercises
  • Home or office adaptations
  • Nebulisation
  • Respiratory techniques

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"The best classroom in the world is at the feet of an elderly person." - Andy Rooney



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