Learn about methods of addressing fear and anxiety in back pain. Latest update from the literature

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
Today’s
session
• Review
of
nomenclature
and
mechanisms
• Review
of
treatment
components
• Review
of
SMC
process
• Prac.cal
implementa.on
Defini.ons
• Anxiety
– Displeasing
feeling
of
fear
and
concern
– Adap.ve
-­‐
helps
an
individual
to
deal
with
a
stressor
by
promp.ng
them
to
cope
with
it
– Maladap.ve
-­‐
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-­‐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
defini.on
• Fear/anxiety
on
the
affec.ve
level
• Associated
with
automa.c
thoughts
(eg
catastrophizing)
or
more
generalized
appraisals
(eg
fear-­‐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
• Conflic.ng
evidence
suppor.ng
different
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
influenced
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)
• Conflic.ng
evidence
on
cause/effect
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
conflic.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-­‐
efficacy,
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.fied
• 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
differences?
• Both
challenge
counter-­‐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
profile
– 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-­‐
sev/Phoda-­‐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.fica.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
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