The best way to start this week’s series of posts is by quoting Simmonds, Moseley & Vlaeyen (2008) who said: ‘Chronic pain and its often associated movement dysfunction are pervasive, intriguing and complex problems … conceptualisation of pain and movement dysfunction has increased our understanding of both…that conceptualisation remains incomplete until it also includes the mind.’
For many years, ‘reactivation’ has been the watchword for chronic pain management ‘functional’ programmes. This was predicated upon the belief that people with chronic pain became ‘deactivated’ or lost physical conditioning due to low levels of activity, and that if they were encouraged to get fitter they would return to normal function. An alternative option was to use the behavioural school of therapy, where positive health behaviour (to normalise activity level) was reinforced, mainly through therapist encouragement and self-monitoring, and by doing this the individual would return to normal function.
Problem was (and still is), a certain proportion of people just don’t engage in this type of programme, often becoming highly distressed, convinced they had been harmed because their pain increased (often with a raft of new symptoms developing also), and without another alternative, these people were either left without any reactivation or referred for ‘talk therapy’.
In the mid-1990’s, research into the model of pain-related anxiety and avoidance (commonly called the ‘fear-avoidance model’) was initiated, and the growing literature into this model since then has confirmed its value in working with people who develop high levels of avoidance.
Essentially, the model describes the two approaches an individual can take when experiencing pain – either avoidance, with subsequent loss of activity and engagement in life roles; or approach, with increasing re-engagement in activities despite short-term fluctuations in pain. Research has confirmed that it is not just the pain that is the problem, it is the fear and avoidance of pain (or to be quite pedantic, it is the anxiety about pain – fear is quite specific (Rachman, 1998), while anxiety is generalised, future-oriented and the ‘source of threat is more elusive without a clear focus’ (Leeuw et al. 2008)).
Further development of the model has identified some of the underlying thinking patterns that may influence the development of avoidance in response to pain – particularly health anxiety and negative affectivity. Health anxiety refers to the tendency to have catastrophic thinking patterns in response to threats of loss of body integrity, while negative affectivity is the tendency to see the glass half empty rather than half full.
For an excellent recent review of the ‘fear-avoidance’ model, Leeuw, Goossens, Linton, Crombez, Boersma & Vlaeyen (2007) have written in the Journal of Behavioural Medicine (30:1), February 2007.
My interest in posting on this model this week is to review the application of one of the treatment options suggested as a result of this model: exposure therapy. I’ve referred to this approach a couple of times before, in CRPS, in a pain management programme , in whether we are afraid to push our patients, and so on.
My interest currently is because I’m working with a young man who presents with extensive deactivation and loss of roles, depression and difficulty coping who identified almost 70 photographs from my set of 99 PHODA photographs as activities he would not do for fear of either increased pain or potential harm.
I was excited to find that the shortened electronic version of PHODA is available for free download, and I reported recently on a cervical spine version of the PHODA that has been published just a short while ago.
I’m also keen to see how I can integrate some of the work that has been carried out on mindfulness as it is applied to anxiety (eg Forsyth & Eifert, 2007) and whether this can be applied when helping people work through a hierarchy of feared activities.
So…an interesting week ahead!
BTW the three favourite (in terms of number of hits at least!) topics on this blog to date are: mindfulness, malingering and the CBT worksheet – so expect more soon!
Leeuw, M., Goossens, M.E., Linton, S.J., Crombez, G., Boersma, K., Vlaeyen, J.W. (2007). The Fear-Avoidance Model of Musculoskeletal Pain: Current State of Scientific Evidence. Journal of Behavioral Medicine, 30(1), 77-94. DOI: 10.1007/s10865-006-9085-0
Rachman, S. (2004). Fear and courage: A psychological perspective. Sociological Research., 71, 149-176.
Simmonds, M. J., Moseley, G., & Vlaeyen, J. W. Pain, Mind, and Movement: An Expanded, Updated, and Integrated Conceptualization. Clinical Journal of Pain May 2008;24(4):279-280.