CASE STUDY: Low Back Pain and Fear Avoidance

By Andrew Shepherd

The Client

64 year old woman, slender build.

Presenting Issue

3 week history of lower back pain. Client described the issue as “sore and weak” and located at the lumbosacral junction.

She felt a “sharp” pain come on suddenly on rising from bed one morning. The pain was local only with no referred or radicular pain in the buttocks or legs.

The pain was exacerbated by prolonged sitting and felt better with movement.

The client was afraid to move too much for fear of aggravating the problem and causing further damage.

Medical History

The client had an ongoing history of lower back pain and had seen multiple types of practitioners for the complaint over many years.

Her medical history revealed surgery for breast cancer 8 years ago, which was still in remission. She occasionally suffered from depression and anxiety, and was a self-described “worrier”.

Other medical history included ovarian cysts and a colonoscopy which detected no abnormalities.

Her family medical history was unremarkable.


The client’s lifestyle revealed a social woman who was a moderate drinker, was active and ate and slept well.


On physical examination, a moderate scoliosis was found with a convexity to the left in the thoracic spine.

The client demonstrated marked anxiety with moving too far for fear of injury and her range of motion was severely restricted in flexion, left rotation and left lateral flexion. Her left sacro-iliac joint was restricted in flexion.

Palpation over the ligament elicited severe pain.

There was muscular spasm and bracing around the left sacroiliac joint in the left quadratus lumborum, erector spinae and gluteus medius.

The client was wary of too much pressure and mentioned on several occasions that she was worried she had done real damage to herself.


Treatment consisted of very light myofascial release and gentle sacroiliac mobilisation.

The main focus of the treatment, however, was reassurance. This woman had a history of serious pathology with her breast cancer, was an anxious person and had an ongoing history of lower back pain. However, the findings from the history and examination did not present any red flags or signs of a more serious condition.

Her condition was being severely exacerbated by anxiety and fear avoidance, this being the fear of movement in case further damage occurred.

Before and during the treatment, the patient’s issues were explained to her, using anatomical models and pictures, that although the complaint was painful it was not serious. The pain would resolve quickly with minimal treatment and that regular activity, including some stretching and core stability work, would allow the region to settle and return her to her normal activities. It was also explained that these gentle exercises and activities may cause some transient pain until the body had adapted to them but were not in themselves harmful.

The effect of this reassurance and explanation of the patient’s condition rapidly allowed the patient to relax and enjoy a very minimally invasive treatment.

Afterwards, the client could stand with no problem and could comfortably move more than fifty percent further than her pre-treatment range of motion.

Her feedback expressly illustrated that it was the worry of her condition that was affecting her more than anything and as soon as she had been given an explanation of her complaint the pain began to subside before the actual treatment had commenced.


This case demonstrates that observation of the biopsychosocial factors in a client’s assessment and treatment are important, as well as the contextual factors in the way the practitioner engages with their client. Clients can frequently be anxious about a painful condition even if it is not serious, so it is important as practitioners to recognise this and reassure the client. This can have a powerful and immediate placebo effect in reducing pain and generally aid recovery.

About the Author

Andrew Shepherd is a Massage Therapist (25 years) and Chiropractor (10 years) in Mosman, NSW. In his spare time, Andrew founded the clinical note (SOAP) writing app Medichart.

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