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STOPS Back Pain - Graded Activity and Exposure

STOPS Back Pain
STOPS Back Pain

This document summarizes research on fear avoidance beliefs and chronic low back pain. It discusses the different components of fear avoidance, including catastrophizing, hypervigilance, avoidance, and disuse. While individual components are associated with poor outcomes, the causal relationships between components are unclear. The research to date on fear avoidance is conflicting due to the model being overly simplistic. Treatment should target catastrophizing, fear, avoidance behavior, and disuse, but other factors like motivation and self-efficacy also influence outcomes. Graded activity is based on operant conditioning principles to reinforce healthy behaviors for chronic pain.

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29/08/12 Graded ac.vity and exposure Jon Ford (PhD, Mphysio, BappScPhysio, Cred MDT) Preamble ≒ Principles already introduced ≒ Frequency of use ≒ Review and prac.cal session ≒ Implica.ons for future RCTs Treatment protocol Study physios ≒ Implica.ons for career paths (eg pain management) 1
29/08/12 Todays session ≒ Review of nomenclature and mechanisms ≒ Review of treatment components ≒ Review of SMC process ≒ Prac.cal implementa.on De鍖ni.ons ≒ Anxiety Displeasing feeling of fear and concern Adap.ve -足 helps an individual to deal with a stressor by promp.ng them to cope with it Maladap.ve -足 when overwhelming and dispropor.onate to stressor 2
29/08/12 Types of anxiety ≒ Related to pain and perceived threats associated with pain ≒ Generalised anxiety not related to pain ≒ Post trauma.c stress disorder ≒ Pain-足related fear and anxiety When s.muli that are related to pain are perceived as a main threat Results in psychophysiological (eg heightened muscle reac.vity), behavioral (eg escape and avoidance behavior), as well as cogni.ve (eg catastrophising thoughts) elements 3
29/08/12 Catastrophising ≒ Anxious pa.ents dwell on the most extreme nega.ve consequences conceivable ≒ The cogni.ve element of fear/anxiety ≒ Pain is interpreted as being extremely threatening (Crombez et al., 1998; Rosens.el and Keefe, 1983) Hypervigilance Environmental scanning for poten.al sources of threat, selec.vely aending to threat related rather than neutral s.muli, broadening of the aen.on prior to the detec.on of these s.muli, and narrows the aen.on in the presence of such s.muli (Eysenck, 1992) Both avoidance behavior and hypervigilance reduce anxiety in the short term, but may be counterproduc.ve in the long run. 4
29/08/12 Avoidance ≒ Behavior aimed at postponing or preven.ng an aversive ≒ In chronic pain it is not possible to avoid the pain ≒ Is possible to avoid the perceived threat (eg ac.vi.es that are assumed to increase pain or (re)injury) Leeuw et al 2007 5
29/08/12 Modern de鍖ni.on ≒ Fear/anxiety on the a鍖ec.ve level ≒ Associated with automa.c thoughts (eg catastrophizing) or more generalized appraisals (eg fear-足avoidance beliefs) on the cogni.ve level ≒ Leads to avoidance of pain associated ac.vi.es on the behavioural level and disuse (Hasenbring and Verbunt 2010) Disuse/decondi.oning ≒ Con鍖ic.ng evidence suppor.ng di鍖erent levels of decondi.oning between people with CLBD and matched controls (Smeets al. 2006; Verbunt et al. 2010) ≒ Measurement issues Pa.ents performance may be in鍖uenced by pain inhibi.on (Leeuw, Goossens et al. 2007) 6
29/08/12 Evidence of causa.on ≒ Cross sec.onal studies Associa.on between causal components of the fear avoidance model as well as with other measures of CLBD such as pain and disability (Leeuw et al. 2007; Wideman et al 2009; Pincus et al. 2010) ≒ Con鍖ic.ng evidence on cause/e鍖ect rela.onships (Pincus, Vogel et al. 2006; Pincus, Smeets et al. 2010) ≒ Recent study shows that although catastrophising and FA predict poor RTW independently, catastrophising does not predict development of FA (Wideman et al. 2009) Conclusion The research to date on fear avoidance is con鍖ic.ng likely resul.ng from the model being overly simplis.c Whilst each individual component of the fear avoidance model appears to be important in presenta.on and prognosis, the causal rela.onship between these components is unclear (Pincus, Vogel et al. 2006; Leeuw, Goossens et al. 2007; Hasenbring and Verbunt 2010; Pincus, Smeets et al. 2010; Simmonds, Smeets et al. 2010) 7
29/08/12 Treatment implica.ons ≒ Target catastrophising, fear/anxiety, avoidance behaviour, disuse? Other factors ≒ Other factors worthy of considera.on? Mo.va.on, emo.onal state, level of pain, self-足 e鍖cacy, and physical decondi.oning ≒ Psychosocial factors generally predict less than 30% of the variance in outcome when examined as a predictor Pathology 8
29/08/12 Graded ac.vity ≒ Based on operant condi.oning principles for chronic pain (Fordyce, Fowler et al. 1973) ≒ Posi.ve reinforcement of healthy behaviors/not reinforcing illness behaviours ≒ Iden.fy func.onal goals ≒ Establish baseline ≒ Commence ac.vity below baseline levels ≒ Incremental increase in ac.vi.es in a .me con.ngent manner regardless of pain Macedo et al 2010 Graded exposure ≒ Feared ac.vity iden.鍖ed ≒ A hierarchy of feared ac.vi.es created ≒ Exposure started with the least feared ac.vity ≒ Assist the pa.ent in appraising the exposure to feared ac.vi.es and its consequences ≒ Address irra.onal beliefs and/or counterproduc.ve beliefs Macedo et al 2010 9
29/08/12 Similari.es and di鍖erences? ≒ Both challenge counter-足produc.ve cogni.ons ≒ Graded exposure Generalises to a variety of fears More direct in addressing beliefs Oken performed by psychologists George et al 2004 10
29/08/12 Case study ≒ Pa.ent pro鍖le 40 year old storeman with 5 and 8 year old FABQ 50/60 Oswesty 60% ≒ Walking limited to 500m ≒ Simng limited to 10 min ≒ Can only lik very light weights ≒ How would you establish func.onal goals? ≒ What would your baseline home program be? ≒ What methods of reinforcement would you use? George and Zeppieri 2009 11
29/08/12 Review of PHODA ≒ 40 pictures where pa.ent can rate their level of fear ≒ PC only ≒ hp://www.psychology.unimaas.nl/phoda-足 sev/Phoda-足SeV_UK.htm 12
29/08/12 Case study ≒ 25 year old FT marke.ng student Referred by Metro Spinal DASS moderate depression and anxiety Marked maladap.ve cure focus Unable to return play netball ≒ What interven.on (psych FC) ≒ Role play session 1 explana.on ≒ Swap and role play overcoming an increase in pain Case study ≒ 50 year old home mum with adult children TAC with moderate PTSD Concurrent moderate severity chronic pain problem Socially isolated and cannot drive Psychology has not helped 10 sessions physio before termina.on of all medical and like ≒ What interven.on? ≒ Role play iden.鍖ca.on of hierarchical list fears ≒ Plan an an.cipated progression of ac.vity/ situa.on over 10 sessions 13
29/08/12 Contact E: stopsbackpain@gmail.com W: www.facebook.com/STOPSbackpain T: @stopsbackpain 14

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STOPS Back Pain - Graded Activity and Exposure

  • 1. 29/08/12 Graded ac.vity and exposure Jon Ford (PhD, Mphysio, BappScPhysio, Cred MDT) Preamble ≒ Principles already introduced ≒ Frequency of use ≒ Review and prac.cal session ≒ Implica.ons for future RCTs Treatment protocol Study physios ≒ Implica.ons for career paths (eg pain management) 1
  • 2. 29/08/12 Todays session ≒ Review of nomenclature and mechanisms ≒ Review of treatment components ≒ Review of SMC process ≒ Prac.cal implementa.on De鍖ni.ons ≒ Anxiety Displeasing feeling of fear and concern Adap.ve -足 helps an individual to deal with a stressor by promp.ng them to cope with it Maladap.ve -足 when overwhelming and dispropor.onate to stressor 2
  • 3. 29/08/12 Types of anxiety ≒ Related to pain and perceived threats associated with pain ≒ Generalised anxiety not related to pain ≒ Post trauma.c stress disorder ≒ Pain-足related fear and anxiety When s.muli that are related to pain are perceived as a main threat Results in psychophysiological (eg heightened muscle reac.vity), behavioral (eg escape and avoidance behavior), as well as cogni.ve (eg catastrophising thoughts) elements 3
  • 4. 29/08/12 Catastrophising ≒ Anxious pa.ents dwell on the most extreme nega.ve consequences conceivable ≒ The cogni.ve element of fear/anxiety ≒ Pain is interpreted as being extremely threatening (Crombez et al., 1998; Rosens.el and Keefe, 1983) Hypervigilance Environmental scanning for poten.al sources of threat, selec.vely aending to threat related rather than neutral s.muli, broadening of the aen.on prior to the detec.on of these s.muli, and narrows the aen.on in the presence of such s.muli (Eysenck, 1992) Both avoidance behavior and hypervigilance reduce anxiety in the short term, but may be counterproduc.ve in the long run. 4
  • 5. 29/08/12 Avoidance ≒ Behavior aimed at postponing or preven.ng an aversive ≒ In chronic pain it is not possible to avoid the pain ≒ Is possible to avoid the perceived threat (eg ac.vi.es that are assumed to increase pain or (re)injury) Leeuw et al 2007 5
  • 6. 29/08/12 Modern de鍖ni.on ≒ Fear/anxiety on the a鍖ec.ve level ≒ Associated with automa.c thoughts (eg catastrophizing) or more generalized appraisals (eg fear-足avoidance beliefs) on the cogni.ve level ≒ Leads to avoidance of pain associated ac.vi.es on the behavioural level and disuse (Hasenbring and Verbunt 2010) Disuse/decondi.oning ≒ Con鍖ic.ng evidence suppor.ng di鍖erent levels of decondi.oning between people with CLBD and matched controls (Smeets al. 2006; Verbunt et al. 2010) ≒ Measurement issues Pa.ents performance may be in鍖uenced by pain inhibi.on (Leeuw, Goossens et al. 2007) 6
  • 7. 29/08/12 Evidence of causa.on ≒ Cross sec.onal studies Associa.on between causal components of the fear avoidance model as well as with other measures of CLBD such as pain and disability (Leeuw et al. 2007; Wideman et al 2009; Pincus et al. 2010) ≒ Con鍖ic.ng evidence on cause/e鍖ect rela.onships (Pincus, Vogel et al. 2006; Pincus, Smeets et al. 2010) ≒ Recent study shows that although catastrophising and FA predict poor RTW independently, catastrophising does not predict development of FA (Wideman et al. 2009) Conclusion The research to date on fear avoidance is con鍖ic.ng likely resul.ng from the model being overly simplis.c Whilst each individual component of the fear avoidance model appears to be important in presenta.on and prognosis, the causal rela.onship between these components is unclear (Pincus, Vogel et al. 2006; Leeuw, Goossens et al. 2007; Hasenbring and Verbunt 2010; Pincus, Smeets et al. 2010; Simmonds, Smeets et al. 2010) 7
  • 8. 29/08/12 Treatment implica.ons ≒ Target catastrophising, fear/anxiety, avoidance behaviour, disuse? Other factors ≒ Other factors worthy of considera.on? Mo.va.on, emo.onal state, level of pain, self-足 e鍖cacy, and physical decondi.oning ≒ Psychosocial factors generally predict less than 30% of the variance in outcome when examined as a predictor Pathology 8
  • 9. 29/08/12 Graded ac.vity ≒ Based on operant condi.oning principles for chronic pain (Fordyce, Fowler et al. 1973) ≒ Posi.ve reinforcement of healthy behaviors/not reinforcing illness behaviours ≒ Iden.fy func.onal goals ≒ Establish baseline ≒ Commence ac.vity below baseline levels ≒ Incremental increase in ac.vi.es in a .me con.ngent manner regardless of pain Macedo et al 2010 Graded exposure ≒ Feared ac.vity iden.鍖ed ≒ A hierarchy of feared ac.vi.es created ≒ Exposure started with the least feared ac.vity ≒ Assist the pa.ent in appraising the exposure to feared ac.vi.es and its consequences ≒ Address irra.onal beliefs and/or counterproduc.ve beliefs Macedo et al 2010 9
  • 10. 29/08/12 Similari.es and di鍖erences? ≒ Both challenge counter-足produc.ve cogni.ons ≒ Graded exposure Generalises to a variety of fears More direct in addressing beliefs Oken performed by psychologists George et al 2004 10
  • 11. 29/08/12 Case study ≒ Pa.ent pro鍖le 40 year old storeman with 5 and 8 year old FABQ 50/60 Oswesty 60% ≒ Walking limited to 500m ≒ Simng limited to 10 min ≒ Can only lik very light weights ≒ How would you establish func.onal goals? ≒ What would your baseline home program be? ≒ What methods of reinforcement would you use? George and Zeppieri 2009 11
  • 12. 29/08/12 Review of PHODA ≒ 40 pictures where pa.ent can rate their level of fear ≒ PC only ≒ hp://www.psychology.unimaas.nl/phoda-足 sev/Phoda-足SeV_UK.htm 12
  • 13. 29/08/12 Case study ≒ 25 year old FT marke.ng student Referred by Metro Spinal DASS moderate depression and anxiety Marked maladap.ve cure focus Unable to return play netball ≒ What interven.on (psych FC) ≒ Role play session 1 explana.on ≒ Swap and role play overcoming an increase in pain Case study ≒ 50 year old home mum with adult children TAC with moderate PTSD Concurrent moderate severity chronic pain problem Socially isolated and cannot drive Psychology has not helped 10 sessions physio before termina.on of all medical and like ≒ What interven.on? ≒ Role play iden.鍖ca.on of hierarchical list fears ≒ Plan an an.cipated progression of ac.vity/ situa.on over 10 sessions 13
  • 14. 29/08/12 Contact E: stopsbackpain@gmail.com W: www.facebook.com/STOPSbackpain T: @stopsbackpain 14