STOPS Back Pain - Graded Activity and Exposure
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STOPS Back Pain - Graded Activity and Exposure

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

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

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STOPS Back Pain - Graded Activity and Exposure STOPS Back Pain - Graded Activity and Exposure Document Transcript

  • 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   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  
  • 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  
  • 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  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  
  • 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  
  • 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  
  • 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  
  • 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  
  • 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  
  • 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  
  • 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  
  • 29/08/12  Contact  E:    stopsbackpain@gmail.com  W:      www.facebook.com/STOPSbackpain  T:    @stopsbackpain   14