bars across my window

Deconditioning? Or just not doing things any more?


For years there has been a general wisdom that people with chronic pain who gradually stop doing things “must” be deconditioned. That is, they must lose fitness, cardiovascular and musculoskeletal, and this is often used to explain low activity levels, high disability and the prescription of graded exercise.

While this explanation makes sense (remember what happens to limbs when they’re in plaster for six weeks? all skinny and wasted?) – it doesn’t inevitably hold, in my experience. I vividly recall a person who routinely swam 20 lengths of an Olympic pool in very fast time every day, yet could not, in his estimation, return to any kind of work, and who did not sit – for an entire three week programme. It’s always seemed a bit odd to me that even though people report they can’t do many everyday activities, they can complete a rigorous gym programme.

So, skeptical me was very pleased to see another paper by the wonderful Nicole Andrews, occupational therapist and PhD, and her colleagues Jenny Strong and Pamela Meredith. This one is about approach to activity engagement, certain aspects of physical function and pain duration and was published in Clinical Journal of Pain in January this year (reference at the bottom of the page). It’s an important paper because it challenges some of the assumptions often made about activity levels and “fitness”, as well as the use of an operant conditioning model for pacing – pacing involving working to a set quota, rather than letting pain be the guide. The concept of pacing has been woven into most pain management programmes since the early days of Fordyce, but more recently has been criticised for lacking a clear definition, and for very little in the way of empirical support as a stand-alone treatment.

In this study, Andrews and colleagues examined the relationship between certain activities and a “habitual” approach to activity engagement, and pain duration. This is a different approach to studying activity and over- or under- activity in that it examines specific activities rather than using a global measure of disability – and this is important because the people we work with do specific activities (or occupations as I’d call them) and it will be more important to be able to predict the types of activities people do, or not do, rather than simply using a general guide.

Andrews and colleagues used a tool I particularly like called the Pain and Activity Relations Questionnaire (McCracken & Samuel, 2007) – this is a 21-item measure that looks at how people approach their activities. It has three subscales – avoidance, confronting, and pacing. Confronting measures “over”activity, while the other two are self explanatory.  They also used the Oswestry Disability Index, an old standard in measuring physical functioning.

The analysis was really interesting, and well-described for those who want to dig deeper into how this team found their results. I’ll cut to the chase and simply point out that they used the items rather than the overall score of the ODI, which allows for a more fine-grained analysis of the kinds of activities individuals engaged in, and how they approached those activities. This is the stuff occupational therapists and physiotherapists really want to get their teeth into!

So, what did they find?

Firstly, individuals who reported high levels of avoidance and low over-activity also reported significant restriction in personal care tasks, compared with those people who reported low levels of both avoidance and activity. There was no relationship between this item and pain duration, but there was a relationship between pain intensity and interference.

Lifting tolerance, however, was affected by pain duration and pain intensity rather than avoidance patterns. Walking tolerance wasn’t affected by approach to activity, or pain duration, but age and pain intensity were important factors. Sitting tolerance was not related to approach to activity, and only pain intensity was a contributor rather than pain duration. Finally, standing was also not associated with approach to activity and was only related to pain intensity.

Sleep was influenced by approach to activity engagement – and with pain duration. This means people with pain for one year and who were inclined to be “over” active and not avoidant, and those who were highly avoidant and highly “over”active were more likely to report problems with sleep than those with low avoidance and low “over” activity. (BTW I put the “over” in quotes because it could also be called “confronting” or “pushing” or “doing” – I think it’s weird term not yet well-defined). The group most likely to report poor sleep were those reporting high “over”activity and low avoidance who reported sleep problems 9.23 times more than those reporting low “over”activity and low avoidance. Once again, pain severity was the only other variable influencing reporting.

Sex life was not associated with approach to activity engagement, nor to pain duration. Social life, however, was associated with approach to activity engagement with those reporting high avoidance and “over”activity reporting more restrictions than those with low levels of both, along with similar results for those reporting high avoidance and low “over”activity – again, pain duration wasn’t associated, but pain intensity was.

Finally, travel was more likely to be reported a problem by all those compared with the low avoidance, low “over”activity group, with the high avoidance, low “over” activity group most likely to report problems.

What does all this mean?

Bearing in mind that the population from whom these participants were taken were attending a tertiary pain management centre programme, and that this is self-report, the findings from this study are really very exciting. As the authors point out, when the ODI is mapped on to the ICF (International Classification of Functioning, Disability and Health) the instrument covers sleep (body function), personal care, lifting, walking, sitting and standing (activity limitations), and social life and travel (participation restrictions). Activity limitations can also be divided into two domains – mobility and daily activities (basic and instrumental activities of daily life) – walking, standing and sitting are therefore “mobility”, while personal care and lifting are “daily activities”.

These findings show that mobility activities were not associated with an individual’s approach to activity engagement – they differ from the other items in that they’re performance skills, that is, they make up other activities can’t be reduced to a smaller component. The authors suggest that the responses to these items in this study may reflect the individual’s perceived capability to engage in daily activities, as opposed to their actual physical performance to engage in these tasks.

I think this means it’s important to ask about what people do in daily life, rather than rely simply on reported levels of walking or sitting. Tie self report into activities – for example, sitting tolerance might be best described in terms of whether a person can sit to watch a whole TV programme, or whether they need to get up during the ad breaks.  It’s important to note the relationship between approach to activity and poor sleep – sleep being one of those aspects of living with pain that people most want addressed. Perhaps by moderating the approach to activity we might be able to help people develop more effective sleep patterns. It also seems to me that we need to tie outcomes from pain management to real life activities in which an individual wants to participate – rather than a more “objective” measure such as the six minute walk test – which might satisfy our urge to measure things in a nice orderly way, but might not be relevant to an individual’s life.

Finally, this study shows that overactivity and avoidance patterns are not inevitably associated with reduced capacity over time. I think this is a “received wisdom” that needs to be unpackaged

 

 

Andrews, N. E., Strong, J., & Meredith, P. J. (2016). The relationship between approach to activity engagement, specific aspects of physical function, and pain duration in chronic pain. Clinical Journal of Pain, 32(1), 20-31

McCracken LM, Samuel VM. The role of avoidance, pacing, and other activity patterns in chronic pain. Pain. 2007;130:119–125.

8 comments

  1. As always, Bronnie, you get me thinking along new lines. And as always, my lines are more tangential than directly related, I guess that’s how my mind works!

    This whole idea of how to measure activity l, and the relevance of that activity, is an important one on so many levels. And it’s not neat, as you indicated, it’s complicated on top of all the other complications of being a human in pain.

    The post made me think of a number of things that may be playing into activity selection and avoidance and being in the work comp system (here in the US) and likely other health systems as well where th ere are things on the line like work restrictions or compensation and the like. My work comp restrictons were very explicit: no running, no climbinh, no sitting for long periods of time, no lifting more than 20 pounds (eventually bumped up to 40). So I avoided those activities outside of PT not because I felt incapable or didn’t want to do them but because I felt obligated to to maintain my benefits and medical care. Through continual avoidance I began to fear doing those things, which persisted even after I was out of the Work Comp system because they had become ingrained DON’Ts.

    So back then if I was asked about activities I engaged in and didn’t engage in I might’ve fallen into some neat little boxes but there would be no context if the doc or therapist didn’t probe into why or into what activities I wanted to do but felt I couldn’t for whatever reason.

    Another thing I came across when I was becoming more active was that if I could do such and such, why couldn’t I go back to work? They didn’t understand that being able to hike, sometimes jog, and do yoga did not equate to the physical demands of being a firefighter. They saw me as active and healthy, and I constantly had to defend myself that though active, I still had pain every day and sometimes the severity was too high for me to think about what to make for dinner let alone respond to 911 calls. And though I was active, my functional ranges of motion and my strength were not what they were when I was a firefighter, I couldn’t step onto the tailboard of an engine laden with gear any more. And my confidence was shot, I no longer believed I could get a fellow firefighter out of a burning building, who may weigh 100 more pounds than me.

    There are many other examples but the point is, just because a person can do a, b, and c doesn’t mean they can do x, y, and z. It’s more complicated than that.

    I see it in the athletes with disabilities I work with, too. Because they ski, it’s assumed by some people that they should be able to do anything. That’s ridiculous! Sport and nature are both incredibly therapeutic, it holds much different meaning for an individual and thus changes the experience. I see people able to ski that have no legs or are paralyzed or have neurological disorders. So skiing might be easy, a pretty difficult task, but some daily activities might be quite difficuly, including walking.

    When I first started snowboarding again I was asked how come I couldn’t return to work. But to prep for snowboarding when I first started back, I did 30 minutes of warm up and up to 2 hours of movement therapy afterward. Because it was worth it! But I still couldn’t sit for longer than 15 minutes without wanting to jump out of my skin because the pain was intolerable. I still couldn’t drive without pain.

    But it helped me to get to where I am now. I was recently asked if I wanted to go back to firefighting because of how well I’m doing. And though I’m active and have successfully changed my pain, it is through very controlled circumstances on my part, through being able to recognize signs of a flare and actively mitigating it, and through not doing high intensity or high impact movements involving my surgical hip.

    I’m nowhere near as strong or fit as I was 6 years ago when I got hurt, and I’m ok with that because I’m a different person now (we all are!). My activities are way different, whereas before I lifted heavy or at high intensities 3-4 days a week and ran high mileage, in addition to training at work for my job, today I walk, hike, snowshoe, and snowboard with some gentle movement regularly and light weights on occasion.

    Anyway, I went on much too long and I’m not sure I got anything clear across. My point is merely that this is complicated and I wanted to use my experience to illustrate that fact. So many judgments are made about people with limited information, using checklists and insurance mandates that confuse or hinder care rather than promote it.

    Thanks for listening!

    1. Jo, once again you describe exactly some of the reasons I so dislike “physical capacity testing” – what you can do in one setting may be completely different in another! And the guilt over doing things yet not being able to return to work is something I SO understand (my own experience with RTW with postconcussion!). Occupational therapists have been interested in the personal meaning of “doing” precisely because the values each person places on certain activities (occupations) means there can be different abilities to sustain those activities in various contexts.

      The problem with compensation systems is that they need to look like they’re being value-free and even-handed to fit within the societal expectations (based on a “moral compass” notion) of who should and shouldn’t be compensated. The model they’ve relied upon is an impairment/body systems one, not the participation or activities limitations or connected human one that we know as biopsychosocial. This view is historic, and set in concrete by the courts and maintained because it provides certainty for the insurer even though the premises on which the model is based is unfair. The thing is, humans DO value doing things based on individual values – a compensation model can’t afford to do this because it’s based on valuing paid employment over anything else in order to be socially justified. EVEN WHEN doing this sustain inequality.

      While I can understand WHY compensation systems do this, and I don’t have answers as to what else they can do, at the moment I think compensation systems maintain the silence and stigma because it maintains the financial viability of the system. It’s only when society has open discussions about the unique motivations for doing things, and can value other aspects of being human apart from their economic productivity that this kind of debate will flourish.
      And as I say, I don’t have solutions – I can just point out that the basis upon which so-called “objective” measures of capabilities is fundamentally flawed because it is not, in fact, objective and value-free.

      When people are considered in purely economic terms, we as a society lose out because human life is intrinsically valuable – pushing people to return to work at the cost of relationships, leisure, and other contributions people make to our world seems unjust to me, and we are poorer as a result.

    1. I can’t really comment on that trial given that I haven’t looked at it recently. The definitions of pacing used in that study did, I think, have some problems. Also, while people may increase their level of activity this may not be related to physical capacity but rather to confidence, self-efficacy, and similar factors.

  2. As Jo said, Bronnie, you do get us thinking!

    In our Yoga for Pain Care program we help people recognise when they are working at “just the right pace”. This isn’t only the physical “right pace” but the emotional/psychological, which ties in with their perception of the situation. As you’ve said, someone can feel completely unable to do, say, housework, but will spend two hours gardening, or weightlifting.

    For some, they manage these surprising activities because they’ve pushed through. Others, though, have found a way of doing something meaningful to them, well.

    The measurement tool you’ve referenced could be helpful initially by giving a language to someone’s perception about their challenges. (I’m wondering if we might integrate it into early stages of the course.)

    But once we’ve got past that point, I think things get more interesting. So much research focuses on “Why can’t they?”.

    A more interesting question might be “How do they?”

    1. Rachel, you speak my language! And it’s a really complex question to ask from a research perspective – I’m seriously interested in the whole decision making process people go through when deciding on a strategy. How do we decide to pace, or to push, or to relax or distract? It’s hard because the research must be carried out in vivo, and in real time, and often people can’t articulate WHY they do these things, though there are undoubtedly variables that influence choice.
      The Canadian Occupational Performance Measure, or the Patient Specific Functional Scale are both useful instruments in this kind of outcomes measure – both allow the individual to select the meaningful outcomes for them and that means it’s relevant to their life. BUT it’s not so easy to use these to compare outcomes across groups (as in an RCT), so you have to take these things into account when choosing them.
      Thanks for dropping by!

      1. Thanks for introducing me to the COPM. It looks like a useful tool. It still has (from what I can glean) a focus on solving a problem rather than setting conditions for a good life, but sometimes we have to start with fixing a problem to show that things can change.

        Keep up the great blogging. I hosted a forum yesterday about Health for Health Practitioners with the theme “How do we help health professionals do their best work?” When I asked at the end “Who is already doing this really well?” an OT here in Perth said “Bronnie Thompson”🙂

  3. Rachael, you’ve made my day! That’s fabulous to hear and a real boost (I’ll put this comment in my “when I need to cheer myself up” folder!). If there’s anything I can do to help – or a way we can get me over to Perth (LOVE Perth – especially the shopping!) I would be over like a flash. XXX

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s