Commitment vs. Fear
Fear is invaluable in life; it shapes us and drives our behaviour. It pushes us to our limits in both positive and negative ways, and without it these limits may not be placed upon ourselves and our lives would look very different. We don’t usually ask for fear or seek it out - it comes from an innate place… nevertheless it is invaluable.
Within healthcare, and the Physio world fear is a double-edged sword, this blog is attempting to explore that.
In the early stages of rehab, I believe the biggest limit to most people’s recovery is their own personal fear. They may fear pain, they may fear the repercussions of their injury (unable to walk, unable to use their left hand to play darts again, losing their job, not able to look after their children etc.) and so it shapes their behaviour. Their fear may be in the simple fact that they believe they will simply not get better.
This in itself is the double-edged sword. Fear can drive people, and personally I feel it drives me. It pushes you on beyond your limits and away from (psychologically speaking) a place you don’t want to be and never want to go back to. On occasions I think to myself I never want to be older and unable to do things so I’ll work hard now to keep fit and in shape to prevent this.
The other side of the coin is the way fear scares you into not pushing those limits, controlling you to stop you from advancing yourself – when the hill is a little too steep, when the downhill speed becomes a bit too fast and we don’t feel in control. This creates the doubt in our mind – something will go wrong. This something that will go wrong then leads us to believe we will damage ourselves further.
Clinically speaking, I see this day to day with my patients. If I ask them to do a task (hop on your operated leg) and they are unsure if they can do it, they will often look at me and check:
‘You mean my bad leg?’.
‘’Not your bad leg, your right leg’’ is often my reply.
To stop the fear from taking over, and give that reassurance that no, I’m not totally mad - and furthermore, that now is the time to challenge this fear. By doing so I’m trying to start these patients onto a pathway where we can take a few calculated risks and reassure them that they are in a safe, controlled environment and they trust the process of progressing rehabilitation with more and more difficult tasks. It’s also important to use simple tasks when first selecting exercises for rehabilitation. It may sound obvious but there is evidence that patients who report a high degree of fear of movement/(re)injury show more fear and escape / avoidance when exposed to a simple movement (Vlaeyen et al. 1995).
When this fall into place well, then people don’t worry about it as much, they learn to trust you because you are guiding them to a safe pace. The art of coaxing people into taking these first steps into a fearful place is something that I have worked at for the last 8 years or so, and sometimes with the greatest will in the world I still cannot persuade them! But once you begin to break this barrier down, you build people back up to have the belief, and most importantly the internal belief that they can do it.
There is a mountain of research into fear and psychology impacting on our behaviours, but less so when looking at the topic of musculoskeletal physiotherapy and rehabilitation. There are some obvious links as pointed out earlier. However, within healthcare there is no ‘’one-fits-all’’ and as much as we’d like to we cannot Pidgeon-hole people and automatically say they are not progressing with their shoulder rehabilitation because they are scared they will hurt themselves again. Fear is multifaceted and interestingly enough impacts upon all of us differently depending on our own personalities, previous experience, thoughts feelings and beliefs systems.
There is now a number of scores and questionnaires used to help quantify our pain related fears. These include the Fear-Avoidance Beliefs Questionnaire (FABQ), the Tampa Scale for Kinesiophobia (TSK), and the Pain Anxiety Symptoms Scale (PASS). These are most commonly used when clinicians are investigating the association between pain-related fear and poor behavioural performance (like we see in clinic when patients are failing). These types of questionnaire usually score highly for people with persistent low back pain and give us the evidence to say that pain related fear can be worse than the pain itself (Crombeza et al.1999).
So, what do we do to break free of the fear controlling cycle?
Many people have commented and written about this, and the simplest way I think about it goes back to that reassurance in clinic, in a safe controlled environment that you just need to try and trust that the professional believes you can do it, and you can do it. Once people do try whatever task I’m asking them to do, and they complete it without as much pain as they expected, or to a higher ability than they expected – this starts rebuilding their confidence in their ability once more.
Susan Jeffers, author of ‘Feel the Fear and do it anyway.’ Explains in her book that it’s not so much about eliminating all the risks in life but rather, facing your fear and training your thoughts to work for you rather than against. This is because just the right amount of fear actually helps you get the task done to the very best of your ability.
This blog is not meant to inspire you to take all the risks in life and have a ‘Zero Fear’’ attitude, but just to appreciate that it is a big part of my job and something I can appreciate in its many forms day to day. As long as you take a deep breath and try, then you can start controlling the fear - not let it control you.
1. Pain-related fear is more disabling than pain itself: evidence on the role of pain-related fear in chronic back pain disability. Crombeza et al. Pain Volume 80, Issues 1–2, 1 March 1999, Pages 329-339
2. Fear of movement/(re)injury in chronic low back pain and its relation to behavioural performance. Vlaeyen et al. Pain. Volume 62, Issue 3, September 1995, Pages 363-372
3. Feel the fear and do it anyway. Susan Jeffers.