Afraid to Move?

Hey everyone, it’s Dr. Fred Bagares. In this episode, I dive into something I see all the time—patients who recover from an injury, like a lumbar disc herniation, but then get stuck… mentally. Physically, they’re doing great. But emotionally, they’re fearful of moving the wrong way and causing another flare-up.

I walk you through a real case of a surfer who did incredibly well with physical therapy but developed a fear of flexion. We talk about where that fear comes from, why it’s so common, and how we as clinicians—and even friends or family—can support people in getting back to full, confident movement.

🕰 Timestamps & Key Topics:

• [00:36] The case of the cautious surfer
  Young, athletic, diagnosed with a disc herniation—responds well to PT but gets stuck avoiding movement.
• [01:50] Recognizing fear-avoidant behavior
  How I noticed the red flag just by watching the patient get up from a chair.
• [04:07] Today’s focus: managing fear after recovery
  How we help patients transition from protection mode back to full function.
• [05:06] Where does the fear come from?
  Pain, trauma, unknown causes, and imagined worst-case scenarios.
• [06:38] When fear shapes your lifestyle
  How patients may re-engineer their lives to avoid bending—and why that’s a problem.
• [07:55] The MRI effect and mental images of damage
  Why seeing their own scans can sometimes increase fear instead of ease it.
• [09:09] Giving patients tools (not just time)
  Why it’s not enough to say “it’ll get better”—they need options and confidence.
• [11:03] Educating, re-educating, and managing expectations
  How I approach conversations around natural healing timelines and treatment tools.
• [12:27] When imaging can be helpful—for peace of mind
  Why I sometimes order a repeat MRI or EMG even when it’s not medically necessary.
• [13:50] Movement tasks and mental wins
  How I help patients reintroduce movement through safe, scalable activities they enjoy.
• [15:05] Matching the patient to the right care team
  It’s not just about sending them to PT—it’s about finding the right fit.
• [15:59] Getting the surgical perspective (even when it’s not surgical)
  How second opinions can reinforce reassurance.
• [16:24] The patient’s next step: getting back in the water
  Why even dipping back into the pool was a huge milestone for this surfer.

If you’ve ever worked with—or been—the person who’s physically healed but mentally hesitant, this episode is for you. Baby steps matter. Movement matters. And our job is to guide people through both the physical and mental parts of recovery.

🎧 Thanks for tuning in to Talking Rehab Podcast! Don’t forget to subscribe, share, and follow me for more content around sports medicine, spine care, and everything in between.

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Transcript

0:00

what is rehab or rehabilitation my name is fred bagaris a board certified sports and spine medicine physician in virginia beach virginia after 10 years of practice i still find musculoskeletal medicine both fascinating and challenging this podcast is about the lingering thoughts and questions i've had after residency and fellowship my hope is to spark discussion challenge dogma and share my experiences in musculoskeletal medicine welcome to the talking rehab podcast i had a patient recently that was very physically active they were actually a surfer very physically active their entire life and they developed a severe low back pain and leg pain and they ultimately were diagnosed with a lumbar disc herniation and fortunately young healthy lumbar disc herniations are quite common they will resolve with conservative treatment time and again most people do really really well in this particular case they responded very well to physical therapy they started with a mackenzie approach where they were going into lumbar extension and they responded really well meaning they had radicular pain down their leg the leg pain improved with lumbar extension and it did start to centralize and eventually they had minimal symptoms if anything maybe by like the three to six month mark they had no pain with sitting standing they had a little bit of numbness still that that can intensify but on the whole they did very very well and i did review the mri which was taken around six weeks and it did show a very large lumbar disc herniation so when i first talked to them i reassured them that this will respond well with time and conservative treatment and it did the pain was very well controlled however at the very last visit i was observing them as they were getting in and out of the chair and they were like super super stiff perfect form almost too perfect form and so i was asking them you know are you still are you still hurting are you sure you know because we just had like this really good conversation about how well they're responding and you know i just noticed that they were just very very stiff and some some people with disc herniations they just can learn to brace before they they initiate a movement it just feels comfortable and um ultimately they said i just want to make sure that i don't go into flexion too much i like to stay at a neutral position if not go into extension and so you know i i i definitely heard their concern previously was that anytime they would sit down for long periods of time is like very classic disc herniation symptoms so they kind of prefer to stand they prefer to brace they prefer to be in a more upright position but i was telling them i was like well you're really kind of out of that acute phase where flexion will make the symptoms worse or sitting so you know now's a good time to start to re-approach and the more i i started talking to them i could really tell that they were really worried about going into flexion again which is a very natural physiologic spinal movement this was kind of a very classic example of someone who got hurt responds well and they have developed a fear avoidant kind of mindset or behavior as a result which is superhuman very very normal and so that's that's really kind of the topic of today's episode is how do you approach someone like this where they respond well they have learned how to control their symptoms but they have developed a fear avoidance or fear avoidant behavior pattern first thing is that i guess we can kind of talk about why do people fall into this pattern the obvious answer is pain a lot lumber discriminations are extremely painful and even if they're not painful they are very disruptive in people's day-to-day life so naturally people don't want to do anything to go back to that place i would say a large majority of people once they start to feel better they start to kind of just fall back into their typical patterns but why do some people have a difficult time trying to move essentially out of extension and start to go into to new movement patterns and aside from the worry or concern of the pain coming back i think there's a significant component of the unknown a lot of times people end up with these disc herniations and they don't remember doing anything in particular in a way that's actually worse compared to someone who lifted a really heavy object they can clearly identify the event where the where they injured their back but the reality is that some people just wake up and it just happens to hurt nothing in particular they did or it's something they've done a million times before picking up a dog bowl tying their shoes and then pop all of a sudden here they have a disc herniation so for some people they the fear of the unknown of that they don't know exactly what happened in terms of the what caused the actual disc herniation some people they also have the added concern about making the situation worse not necessarily just the symptoms coming back what if i the disc herniation comes back 10 times worse and the first time i could manage it conservatively but the second time what if i need surgery and you know what if i go through all of my conservative treatment all over again i invest all this time and it doesn't get better and then i need to get a surgery and then there's what kind of surgery what how much time off so you can see how people can very quickly go down the rabbit hole and that that fear of the unknown and the fear of recurrence can definitely drive people to essentially just not even dip their toe back in the water they just don't want to even try it so some people i have seen people essentially adjust their lives around it you know unfortunately where they just they buy new desks they buy different beds they really try and avoid it and even for the folks that are successful and find ways to not go into flexion it's i still don't think that's a good idea because again our spines were designed to move in all directions part of the reason why it's designed to move in all directions is to evenly displace the forces of um of the spine not just to the um not just to the bones but also to the discs and when we limit our range of motion then we are concentrating the forces in a very in a limited range of motion and that ironically can contribute to recurrence of symptoms recurrence of a disc herniation i think the last thing i should mention of what may drive people to essentially just be super fearful is some people just have this picture in their mind especially after seeing an mri of what the disc herniation looks like in the brain it's almost like a cartoon i say that not necessarily to make light i really think that some people when they hear they have a disc herniation they don't know what a disc herniation looks like they go online they see pictures and it's never really good you know it's never really a very helpful exercise for well i shouldn't say that it's not always a great exercise for some people when they see things it gives them comfort and in the fact that they can see the problem they can visualize it in the head and they they feel better about it but there are definitely some folks that don't respond that way they feel a lot more anxious after knowing more so knowledge unfortunately isn't always reassuring to everybody so i really had to understand these concerns of my patients the fears of the unknown the fears of recurrence the what they pictured in their mind is actually going on in the back because it has really shaped how i manage these patients and how i approach them and one of the main approaches i take is trying to give them tools to answer the question so i can simply tell people like these are the things that work physical therapy time injections medication surgery so on and so forth but some people are very reluctant to try anything and sometimes when people are not exactly open to trying anything i give the perspective of this will eventually improve however i think it's also important to know what tools work do we know an injection works do we know if a medication works do we know physical therapy works because you have a strategy you have tools to use when and if the unknown occurs i find that it gives people a lot more control versus like if they're just in an acute pain episode and they don't know what to do and they start googling and ultimately they end up at an urgent care they end up in an emergency room and they still don't really have any answers they don't have any tools so i think it's really important to talk people through all the treatment options i think as physicians we have a tendency to say oh this should improve but if it doesn't then you'll probably need surgery and i think that's absolutely the wrong approach i think that just puts more fear into people than it actually helps them in the big picture of things it probably plants a very debilitating seed in their brain i've definitely had patients have a disc herniation 20 years ago and when i see them they tell the story of how they've kind of lived their life just really fearful of their back and it's it's unfortunate again i think understanding what tools work for you even if you're not a pill person even if you feel that injections are a band-aid you know the injections aren't meant to be a solution the medications aren't meant to be a long-term solution they are supposed to help you during an acute period and that's what i think people need to know is like what actually works for them it even though the research says that all these things should work people are different they don't work for everybody i also try to give a lot of reassurance i think explaining to people the natural timeline of disc herniations or back pain can be super helpful it gives them a timeline of how and when to expect things to improve or not improve the reassurance doesn't come simply out of just a seven-minute conversation there's a lot of there's a lot of texts there's a lot of repeat conversations and i'm fine i'm happy to do that sometimes you just have to hear it a second third fourth time whatever whatever my patients need i'm happy to educate them and re-educate them as things pop up we don't typically order repeat mris after disc herniation if the symptoms improve and the argument for that is does the mri going to change any of the management or their prognosis if their symptoms are well controlled and the answer is no it's not however in the patients where they have that picture in their mind of a disc herniation or something that just is massive in their back those are the times that i will go ahead and order a new mri it's not going to necessarily change the treatment options for a lot of people but i think it will help people understand that the disc is stable it hasn't gotten worse and it might have actually gone away from an anatomic standpoint that might actually give some people a little bit of relief same thing goes for emg or nerve conduction studies the idea of of damage not just to the disc but damage to the nerve that can be really very that can definitely weigh on people's minds that i just had back pain but what if i cause any nerve damage so if i can do a simple 20 minute study of one leg i can tell them hey we now have more information that says that even despite the fact that you lived and survived this bad back pain episode there's no evidence of nerve damage i think that again for some people will give them a little bit of reassurance that okay i'm starting in a place where all the parts healed as they were supposed to and there was no residual damage then they can kind of move they can start to move forward but aside from objective evidence of improvement i i also will have people do some sort of movement a movement task i guess is what i'm asking them to do in this particular case the person was a surfer and being in the surfing i'm not a surfer but surfing is very physically demanding it also occurs in the most unpredictable place which is the water so you know for that particular person i can certainly understand why they would be concerned about about trying to get back into surfing so i gave this person the task of just practice popping up on the board in the sand just something to kind of mimic the movement in them in a very controlled environment they can start doing balancing exercises they can start skateboarding things that are not necessarily a hundred percent in the water some people can bounce back but i also have to sometimes help scale their activities because sometimes when you see a physician or or surgeon they might just say well you should be good to go just return back to your activities as tolerated and that's super vague that doesn't always help people so i try to give them a little bit of a little bit more scalable movement task oriented pathway back another strategy i have is having kind of the right team on board when it comes to physical therapists chiropractors things like that we all have experience we all have opinions but sometimes i have to kind of read my patient and try and match them with someone that i think is going to be on message or on brand if you will because it can be very confusing myself i have one one way of looking at the problem i send them to a physical therapist or a chiropractor and they have a completely different view of the problem maybe they have a less than positive spin on their education of the patient and it can confuse people it can contribute to the fear and it certainly can get in the way of people getting moving again the last person i will also get on board even though i know that the problem is non-surgical sometimes i will just have to get a surgical opinion have the patient talk to the surgeon again just to get a little bit of reassurance sometimes what i say doesn't carry as much weight or maybe they need to get consensus i'm on board with that if that ultimately gets the person feeling a lot more comfortable in their movement hey that's what it's really all about now in this particular case i was able to get the person back at least into the water just kind of essentially just swimming and things like that i'm still waiting to see if they're actually going to it's too cold right now to see if they actually get back into the water to to surf but i'm super hopeful they weren't even in the water before now they're at least in the pool so again it's baby steps uh it's i also didn't necessarily focus on flexion specifically sometimes these if i tell them to just pick an activity that they like to do the movement just follows you know what i mean so people will naturally have to move their spines in certain ways to wade in the water to get in and out of the pool the sometimes the actual activity will force the movement unconsciously anyhow i thought it was a pretty interesting conversation i thought it would make a good episode hope you guys enjoyed this one take care thank you for listening to the talking rehab podcast i hope that this podcast stimulates you to question your own practice and how you approach rehabilitation i truly appreciate your time and attention if you enjoyed listening make sure to like and subscribe to the podcast i wish you a movement-filled day take care