Developing a New Zealand PHODA – Photographs of Daily Activities
One of the goals I set myself for this new year was to complete developing a New Zealand version of the PHODA.  The PHODA was originally developed by Kugler, et al., (1999) and consists of 100 photographs depicting people carrying out various daily activities.  There are two versions of the lower back PHODA, the second is an abbreviated electronic version developed by Leeuw, et al., (2007), that has undergone preliminary validation assessing its psychometric properties.  A third version, this time an upper body one, was developed by Turk, et al., (2008), which measures fear related to neck position and loading and was found to be satisfactory in terms of psychometric properties.

The main problem with the lower back PHODA, both the shortened version and the original, is the context-specific nature of the photographs.  For New Zealand patients, the pictures are identifiably non-New Zealand, and while I can’t be sure that this affects the measurements obtained, patients comment frequently that the photographs look different from their experience.  The one developed by Turk doesn’t even pretend to provide contextual cues and is simply a set of photographs with people against a plain background.

Another concern with this set of photographs is that some of the activities shown don’t relate to the kind of activities that my patients say bother them.  It’s not clear from the listed authors whether any of them are occupational therapists, and I know the original PHODA was developed within a physiotherapy facility, so from my perspective I think some of the activities that people I work with have been omitted. As I’ve indicated above, the one developed by Turk doesn’t consider contextual cues, nor whether the activities are relevant to the individual at all.

Ensuring the activities that are important to people are included in an assessment like this seems to be an element of test design that hasn’t been considered in as much detail as many other aspects of the measure.

Why might it be useful to consider activities that are relevant?  There are two main reasons: the influence of context on the fear itself, and the interference fearing the activity has on life.

I can see the utility of context-free assessments in research – but in the case of fear of movement, I think it’s the context that influences the fears in many cases. For example, it’s quite common to have someone fearful of carrying out a straight leg raise in a clinical examination – but at the same time be able to bend down to take shoes off.  Walking on a flat surface poses much less demand and concern than walking over rough ground or a slippery floor at a busy shopping mall.

If an activity isn’t important or valued by me personally, then I might be able to avoid it and never have to learn to manage it. For example, I might not value working out at a gym, so learning that I’m safe to use certain gym equipment probably isn’t useful; I may never ride a bicycle, so working out how fearful I am of cycling probably isn’t relevant.

Similarly, if an activity isn’t encountered often, then the interference level of any fear related to that activity is fairly low. For example, if I never have to drive because I have very helpful friends, I might not think my fear of twisting to reverse the car is a problem; and if I never have to do my own grocery shopping, I might not worry too much about my worries that I’ll be hit by a rogue shopping trolley!

To make our therapy relevant to the people we work with, we need to find out what it is they want to, or need to, be able to do – and one way to assess what our exposure-based therapy should cover is to develop a set of photographs that is contextual and relevant to the real worlds of our client/patients.

So I’m about to embark on developing a new set of photographs specific to the cultural context of the people I work with.  The process I’ve followed is this (and yes, I hope to write this up more formally over time!):

  1. I’ve reviewed the three main papers describing the development of PHODA or the PFActS-C (try saying that fast!) and several others related to using photographs to elicit reports of fear or phobia
  2. I’ve reviewed the most frequently used functional self-report measures used in low back pain research (for example, theRoland-Morris, Sickness Impact Profile)
  3. I’ve collated the activities described as problematic by the patients I’ve seen over the past 12 months (not a random sample, no, but a group of people experiencing chronic low back pain who live in the community)
  4. I’ve considered the major biomechanical loads that are described by patients and in the literature
  5. I’ve considered the community contexts in urban New Zealand
  6. I’ve also thought about the typical ages of people attending the Pain Management Centre to ensure the people depicted in the photographs are reasonably representative
  7. Finally, I’ve included activities from the three major domains of activity – productive activtiy (focusing primarily on domestic productive activity), leisure (including socialising and sports), and self care

I’ll be following the development process described by Kugler in terms of the movement patterns: (lifting, bending, turning, reaching, falling, intermittent load, unexpected movement, and long-lasting load in stance or sit with limited dynamics).  However, I’ll be modifying the ‘falling’ to locomotion over slippery ground, and I’ll be including some contextual elements that people I’ve been working with complain about – namely, being in a crowded area such as a shopping mall, and pushing a trolley around a supermarket to do the groceries.

Many people have commented on the huge number of photographs that need to be reviewed, and I’m mindful of one of the authors (Johan Vlaeyen, personal communication) saying that it’s important to include so many photographs because of the unique factors that people identify as their specific fear.  Even the abbreviated electronic version has 40 photographs, some depicting activities that many of the people I see don’t regularly do, such as riding a bicycle, or using the ‘back exercise’ machine.

I hope to organise the photographs into groups, representing various activities, so it will be possible to eliminate those that the person has never done, and include those that the person specifically wants to be able to do but is fearful of.  This will, of course, make the assessment less rigorous in terms of psychometrics – but at the same time, much more relevant to the individual.  Because I tend to use the photographs as an individualised measure, I’m less concerned with overall psychometrics than whether it works well for the people I’m using it with!

I will, however, be asking the patients who participate in the development of this assessment to rate how important these activities are in their lives, so that if photographs do need to be excluded to reduce the number, it won’t just be the movements that ensures they remain, but it is also the value that people place on the activities.

Once I’ve completed this study, I’ll post the results on here – so you will need to come back to see what I’ve come up with!

Kugler K, Wijn J, Geilen M, de Jong J, Vlaeyen JWS: The
Photograph series of Daily Activities (PHODA). CD-rom version
1.0. Institute for Rehabilitation Research and School for
Physiotherapy Heerlen, The Netherlands, 1999

Leeuw, M., Goossens, M. E. J. B., Breukelen, G. J. P. v., Boersma, K., & Vlaeyen, J. W. S. (2007). Measuring Perceived Harmfulness of Physical Activities in Patients With Chronic Low Back Pain: The Photograph Series of Daily Activities—Short Electronic Version. The Journal of Pain, 8(11), 840-849.

Turk, D. C., Robinson, J. P., Sherman, J. J., Burwinkle, T., & Swanson, K. (2008). Assessing fear in patients with cervical pain: Development and validation of the Pictorial Fear of Activity Scale-Cervical (PFActS-C). Pain, 139, 55–62.

D TURK, J ROBINSON, J SHERMAN, T BURWINKLE, K SWANSON (2008). Assessing fear in patients with cervical pain: Development and validation of the Pictorial Fear of Activity Scale-Cervical (PFActS-C) Pain, 139 (1), 55-62 DOI: 10.1016/j.pain.2008.03.001



  1. I have just read your comments above and I found it very interesting! We have also developped a “new” PHODA. And what about you? Is your New Zealand PHODA already available ?

    Christophe Demoulin
    Liège University (Belgium)

    1. Hi
      No we haven’t completed it yet, we’ve done an upper limb one that we use for CRPS, but not yet worked through the low back pain one. It takes a while! Are you intending to publish yours? I’d love to know your methodology, perhaps to swap notes.

      Thanks for getting in touch, I’ll email you.

      1. Do you know that there is also a version “lower extremities” and “Cervical spine and shoulder”.
        These versions are available at Zuyd University, Heerlen NL. Contact: Sandra Beurskens.
        Fon van de Riet (Zuyd University)

      2. Fantastic news!
        The NZ Phoda is still in development – the basis is less about movement planes, more about contextual cues, and the activities are based on what we know about people’s occupations (in an occupational science context).

  2. Hi.. I was wondering if you have progressed any further with the development of the NZ PHODA? We are in Sydney, Aus and are interested in photographs that might be threatening to patients with low back pain.

    1. Hi James
      I’ve started working on it, collecting photographs which are currently on Flickr as
      There’s a lot of work to do to develop this, mainly identifying the features of the environment and movements that bother people, then photographing models who are willing to engage with the programme! My aim is to get shots representative of Australasia, and to move beyond simply biomechanical movement variations and into contextual elements. For example, I’ve found that many people avoid supermarkets and shopping malls – too many people, slippery floors, nowhere to easily sit down and so on, and in these environments the “fear factor” is higher than the same movements in a less busy context. Let’s catch up and talk about where to go from here, I’ll email you directly.

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