Using a new avoidance measure in the clinic

A new measure of avoidance is a pretty good thing. Until now we’ve used self report questionnaires (such as the Tampa Scale for Kinesiophobia, or the Pain Catastrophising Scale), often combined with a measure of disability like the Oswestry Disability Index to determine who might be unnecessarily restricting daily activities out of fear of pain or injury. These are useful instruments, but don’t give us the full picture because many people with back pain don’t see that their avoidance might be because of pain-related fear – after all, it makes sense to not do movements that hurt or could be harmful, right?

Behavioural avoidance tests (BAT) are measures developed to assess observable avoidance behaviour. They’ve been used for many years for things like OCD and phobias for both assessments and treatments. The person is asked to approach a feared stimulus in a standardised environment to generate fear-related behaviours without the biases that arise from self-report (like not wanting to look bad, or being unaware of a fear).

This new measure involves asking a person to carry out 10 repetitions of certain movements designed to provoke avoidance. The link for the full instructions for this test is this: click

Essentially, the person is shown how to carry out the movements (demonstrated by the examiner/clinician), then they are asked to do the same set of movements ten times.  Each set of movements is rated 0 = performs exactly as the clinician does; 1 = movement is performed but the client uses safety behaviours such as holding the breath, taking medication before doing the task, asking for help, or motor behaviours such as keeping the back straight (rotation and bending movements are involved); 2 = the person avoids doing the movement, and if the person performs fewer than 10 repetitions, those that are not completed are also coded 2. The range of scores obtainable are 0 – 60.

How and when would you use this test?

It’s tempting to rush in and use a new test simply because it’s new and groovy, so some caution is required.

My questions are: (1) does it help me (or the person) obtain a deeper understanding of the contributing factors to their problem? (2) Is it more reliable or more valid than other tests? (3) Is it able to be used in a clinical setting? (4) Does it help me generate better hypotheses as to what’s going on for this person? (5) I also ask about cost, time required, scoring and whether special training is required.

This test is very useful for answering question (1). It provides me with a greater opportunity to review the thoughts, beliefs and behaviours of a person in the moment. This means I can very quickly identify even the subtle safety behaviours, and obtain the “what’s going through your mind” of the person. If I record the movements, I can show the person what’s going on. NB This is NOT intended to be a test of biomechanical efficiency, or to identify “flaws” in movement patterns. This is NOT a physical performance test, it’s a test of behaviour and belief. Don’t even try to use it as a traditional performance test, or I will find you and I will kill (oops, wrong story).

It is more valid than other tests – the authors indicate it is more strongly associated with measures of disability than measures of pain-related fear and avoidance behaviour. This is expected, because it’s possible to be afraid of something but actually do it (public speaking anyone?), and measures of disability don’t consider the cause of that disability (it could be wonky knees, or a dicky ticker!).

It’s easy to do in a clinical setting – A crate of water bottles (~8 kg) and a table (heights ~68 cm) are needed to conduct the BAT-Back. The crate weighed  7.8 kg including six one-litre plastic bottles. One could argue that people might find doing this test in a clinic is less threatening than doing it in real life, and this is quite correct. The setting is contained, there’s a health professional around, the load won’t break and there’s no time pressure, so it’s not ecologically valid for many real world settings – but it’s better than doing a ROM assessment, or just asking the person!

Does it help me generate better hypotheses? Yes it certainly does, provided I take my biomechanical hat off and don’t mix up a BAT with a physical performance assessment. We know that biomechanics are important in some instances, but when it comes to low back pain it doesn’t seem to have as much influence as a person’s thoughts and beliefs – and more importantly, their tendency to just not do certain movements. This test allows me to go through the thoughts that flash through a person’s mind as they do the movement, thus helping me and the person more accurately identify what it is about the movement that’s bothering them. Then we can go on to test their belief and establish whether the consequences are, in fact, worse than the effects of avoidance.

Finally, is it cost-effective? Overall I’d say yes – with a caveat. You need to be very good at spotting safety behaviours, and you need to have a very clear understanding about the purpose of this test, and you may need training to develop these skills and the underlying conceptual understanding of behavioural analysis.

When would I use it? Any time I suspect a person is profoundly disabled as a result of their back pain, but does not present with depression, other tissue changes (limb fracture, wonky knees or ankles etc) that would influence the level of disability. If a person has elevated scores on the TSK or PCS. If they have elevated scores on measures of disability. If I think they may respond to a behavioural approach.

Oh, the authors say very clearly that one of the confounds of this test is when a person has biological factors such as bony changes to the vertebrae, shortened muscles, arthritic knees and so on. So you can put your biomechanical hat on – but remember the overall purpose of this test is to understand what’s going on in the person’s mind when they perform these movements.

Scoring and normative data has not yet been compiled. Perhaps that’s a Masters research project for someone?

Holzapfel, S., Riecke, J., Rief, W., Schneider, J., & Glombiewski, J. A. (in press). Development and validation of the behavioral avoidance test – back pain (bat-back) for patients with chronic low back pain. Clinical Journal of Pain.

 

 

Fear of pain, not always fear of harm

I know it’s actually Friday Funnies day, but before I go there I want to explore something I’ve been observing for a while.  Over the past four or five years, the TSK (Tampa Scale for Kinesiophobia) has been a really popular instrument for identifying and monitoring pain-related anxiety and avoidance.  It has been found to have a two-factor structure, ‘harm’ and ‘activity avoidance’, and has been used as both a predictive measure and an outcome measure that is strongly associated with disability.

What I’ve seen though, is that many patients have a fairly low score overall on the TSK, particularly characterised by a low score on the ‘harm’ scale.  At the same time, these patients have been among the most fearful of the patients I see of experiencing pain and most avoidant of specific movements.  Something is missing here.  I should add that the TSK is not administered alone, it’s included in a battery of questionnaires, and that along with the questionnaire responses, interview, observation and functional assessments are also carried out.

What I seem to see is that this group of people don’t *think* they’re fearful of harm – in fact, they almost all say they’ve been told, and accept that they’re not doing any damage to their body, but at the same time they’re strongly avoidant of movements that provoke their pain.  When I ask them what might happen if they do the movement they’re avoiding, often they’ll say something like ‘I don’t want to increase my pain, it hurts too much, and I’ll never sleep’.  Yeah, catastrophising.

Some of the other measures do correlate with their avoidance – disability measures, of course; low mood quite often; low pain self efficacy; and very often high catastrophising on a couple of the other measures we use.

What I think I’m seeing is that in a group of patients who often have had prior pain management input, there is a ‘head knowledge’ (ie they’ve had ‘information’ or ‘education’ about hurt vs harm), but they haven’t developed at least two things:

1. Self efficacy for coping with activities despite pain
2. Experience of successfully and consistently carrying out activities despite fluctuations in pain, and especially doing activities that provoke pain

And importantly, their underlying level of catastrophising doesn’t seem to have been addressed.  Or at least that’s one hypothesis.

A measure I used to use a lot, but seems to have fallen out of favour is the Pain Anxiety Symptoms Scale (especially with ACC in New Zealand publishing a ‘Compendium of Pain Measures’ that seems to have ranked questionnaires on somewhat arbitrary factors).  The PASS is a scale originally developed by McCracken and colleagues, and has four factors: cognitive anxiety, fearful appraisal, activity avoidance and physiological arousal.  There is a shorter version recently used by Carleton & Asmundson (2009).

This was a useful measure to me because it helped to identify the way in which anxiety about experiencing pain might be affecting the individual, and suggested some ways to address this.  For example, if the person scored very high on cognitive anxiety, it might be difficult for them to think of coping strategies during pain flare-ups.  If the person indicated high physiological arousal, helping them develop effective relaxation strategies often gave them tools to manage the situation with feeling ill.

It might be helpful to use the PASS with these patients who don’t believe they’re fearful of pain, but do avoid.  But I’m still not sure that this taps into exactly what underlies the avoidance behaviour.

Why am I worried about this? Well, if I’m trying to identify who to select for specific exposure therapy, the TSK has been suggested as a useful screening tool – and one that can demonstrate change over time.  But if the person doesn’t reach a certain ‘cut-off’ point, this approach might be overlooked.  If I use the PASS, I might identify the ‘what happens’ aspect, but I might not identify the avoidance component.  If I only look at catastrophising, I might reduce catastrophising, but fail to help the patient successfully engage in *real* activity despite pain.

I’ve pondered whether there is another way of approaching the assessment of fear and avoidance of pain – some combination of the activity avoidance subscale of the TSK or the PASS, with a measure of fear of pain.  Maybe something like Fear of Pain Questionnaire (Short Form), but I’m not sure.

In terms of what to do for treatment: I wonder whether the increasing emphasis on cognitive strategies, or ‘education’ about chronic pain has reduced the opportunity for behavioural approaches to be included in pain management.  For some psychologists, behavioural approaches like reducing pain behaviour and exposure therapy appear to have become a little passe.  This can leave physiotherapists and occupational therapists (who may not always have had the background knowledge about how to conduct exposure therapy) in the position of trying to help a rather reluctant patient start to do the very things they’ve been avoiding.  And while ‘just doing it’ is a behavioural strategy, good knowledge and skills about the cognitions the patient has and how to work with them is vital, or the response may be to reinforce the patient’s beliefs that they were indeed right to avoid those activities!

Exposure therapy is not the same as ‘graduated reactivation’. It’s also not the same as the approach used to reduce sensitivity in a CRPS limb – which should probably more appropriately be called ‘graded desensitisation’.

Anyway, back to my musings: my concern is that ACC in New Zealand is starting to specify the questionnaires that ‘should’ or ‘must’ be used in treatments.  And the risk is that on the basis of cut-off scores for the TSK, these highly disabled patients might not receive the sort of cognitive and behavioural input they need.  As well, there are few ways to measure progress over time, apart from the level of engagement in tasks.

As we all know well, there are many different reasons for people to fail to reduce their disability despite having had effective pain management – but for an eager case manager (and some ill-informed clinicians), failure to reduce disability can be attributed to ‘lack of motivation’, or ‘failure to comply with treatment’, or something equally unhelpful.  Without a good clinical model, effective measurement instrument, well-conducted treatment and adequate support, I worry that we risk focusing too much on the measurement properties of the TSK in our clinical practice, and that the pain-related anxiety and avoidance (Fear-avoidance) model doesn’t always explain the situation for our patients.

As usual, more research required – someone’s PhD I hope! In the meantime, I’m hoping to carry on pondering, and wandering through the research papers to find out if anyone else has come up with a model and/or measurement tool that might be useful.  If you’ve got one – drop me a line, I’d love to know!

McCracken LM, Zayfert C, Gross RT: The Pain Anxiety
Symptoms Scale: Development and validation of a scale to
measure fear of pain. Pain 50:67-73, 1992

CARLETON, R., & ASMUNDSON, G. (2009). The Multidimensionality of Fear of Pain: Construct Independence for the Fear of Pain Questionnaire-Short Form and the Pain Anxiety Symptoms Scale-20 The Journal of Pain, 10 (1), 29-37 DOI: 10.1016/j.jpain.2008.06.007

Ostelo RW, Swinkels-Meewisse IJ, Knol DL, Vlaeyen JW, & de Vet HC (2007). Assessing pain and pain-related fear in acute low back pain: what is the smallest detectable change? International journal of behavioral medicine, 14 (4), 242-8 PMID: 18001240

Recovering from a wrist or ankle fracture: pain-related fear, catastrophising and pain influences outcome

I have no idea how many wrist and ankle fractures occur every year, but I can bet it’s not a small number by any imagination. For most of us, I’m guessing we’d expect to have a fracture, wield a wonderfully-autographed cast, get it removed and go on our merry way – but after reading this article, and having seen some very sad people over the years, perhaps my expectations of speedy return to normal might be over-inflated!

This paper by Linton and colleagues from Orebro, Sweden, is a novel one in that most of our knowledge about chronic pain comes from observing people recovering from low back pain. After all, low back pain is one of the most common pains, it’s the one that produces the most long-term work disability, and treatments for it eat up health budgets like little else. BUT, in a fracture, we have a nice clear-cut incident that begins the process of recovery, a well-known pathophysiology, and a well-understood recovery process from a biophysical perspective, so it provides us with a great opportunity to see what the risk factors are for longterm pain and disability.

Methodology
I’ll just briefly describe the methodology here – 79 participants were sequentially recruited to the study if they had a distal fracture, were aged between 18 – 70 years, without any other fractures and not experiencing dementia. Nine dropped out and these were older and female. Each participant completed a modified Fear Avoidance Beliefs Questionnaire, completing this in respect of their beliefs about pain before their injury; the Pain Catastrophising Scale, numeric rating scale for pain before the injury, expected recovery at six months, and actual recovery at six months. Mobility and strength were also tested a time one and six months later.

Results
Pain and worry reduced over time, as expected. Pain level started at 4 (ranging between 0 – 8), and dropped at T2 and T3. The number of people reporting no pain or no worry increased from T1 to T3 from 4% to 46% and from 30% to 57%.
69% of patients thought they should be fully recovered within six months when they were first asked. 36% thought this at T2, but the percentage who actually thought they were fully recovered at T3 were only 29%. That means that although most people thought they would be recovered within 6 months, actually less than 1/3 actually were. I certainly didn’t expect that!

Mobility and strength ratings at T3 showed 45% were not fully recovered at six months if they had a wrist fracture, while 33% of people with ankle fractures were not fully recovered. And yes, they do describe the processes used to measure mobility and strength.

Looking at fear-avoidance and catastrophising, there was a bit of work to get the groups divided into high and low levels of fear.
The proportion of patients with low fear at T1 and T2 was 54%, while for catastrophising was 56%. 29% of the participants had a high fear and pain profile at T2. What this lead to, after looking at an odds ratio analysis examining the relationship between fear and catastrophising, was that higher fear-avoidance beliefs increased the risk for pain , but high fear wasn’t significantly related to future self-rated recovery, mobility or strength. For catastrophising, there was a relationship only for strength.

What can we conclude?
OK, apart from the small sample size, and the need to use the strength of the noninjured limb as a substitute for the fractured one at T1, and the authors suggest that taking more frequent repeated measures might have helped; we can conclude a couple of interesting things:

1. People over-estimate how rapidly they will recover from distal fractures, and expect to be fully recovered within six months, when 2/3 of people won’t be
2. Higher-than-average scores, or increasing scores on pain-related fear and catastrophising are linked with future pain and recovery levels.  This is similar to the repeated findings in back pain and other types of pain, so shouldn’t be unexpected.
3. As catastrophising and pain-related fear drop over time, this could mask those who are at risk of failing to recover.

Linton and colleagues suggest that close monitoring of fear-avoidance beliefs and catastrophising over the first few weeks of recovery would help health professionals intervene with psychological input designed to reduce fear and normalise expectations.  In other words, reassure patients that it’s normal for distal fractures to take a lot longer than 6 months to fully settle down.

One problem with this for me is that I don’t know anywhere in New Zealand where fear-avoidance and catastrophising is measured in people who have distal fractures! Most orthopaedic departments are singularly lacking in psychologists, and provided the fracture is uniting, patient’s fears and worries rarely get a look-in!  I can’t speak for GP’s who might have some ongoing input with a person who has a distal fracture, but I’d expect that unless the person attends and asks for help, their worries and fears won’t be identified.  This then means the physiotherapist who might be involved to help improve function (and maybe the occupational therapist) are the ones who may be left trying to address the patient’s fears.

Do we need to introduce another layer of psychological input delivered by psychologists for this group of people?

I think not – I do think maybe occupaitonal therapists and physiotherapists could be mindful of the natural healing process, the time it takes to recover, and be aware of how fear-avoidance and catastrophising interact to produce disability – and start to structure graded activities to increase the  confidence a person can have in their own ability to move.  And perhaps encouraging gradual return to functional activities rather than ‘exercises’ per se could be a better approach.  No gadgets please OT’s!  Learning to use the limb, attending to fear and catastrophising and addressing these quickly are well within the clinical skills of occupational therapists, physiotherapists, nurses and GP’s – so watch, listen and respond, even in these acute and so-called ‘simple’ injuries.

Linton, S., Buer, N., Samuelsson, L., & Harms-Ringdahl, K. (2010). Pain-related fear, catastrophizing and pain in the recovery from a fracture Scandinavian Journal of Pain, 1 (1), 38-42 DOI: 10.1016/j.sjpain.2009.09.004

Safety behaviours – do they maintain kinesiophobia?

Let me start by saying this post is conjecture, but based both on observing patients, and after reading an interesting paper on ‘subtle avoidance and safety behaviours relevant to social anxiety’.

First some definitions: I hope you’re all familiar with the term ‘kinesiophobia’, or ‘fear of movement’ – it’s the fear and avoidance of movements that an individual believes will hurt or harm them.

Safety behaviours: are strategies that may be used to reduce the anxiety of carrying out a behaviour – and are usually ‘logically’ linked to the underlying belief about the movement.  For example, using ‘safe lifting techniques’ can be a safety behaviour in someone who is fearful of bending; taking a deep breath in and breathing out prior to doing a movement may also be a safety behaviour, as can moving very slowly while carrying out the movement.

The reason safety behaviours are important in the treatment of phobia is that they are ‘subtle forms of avoidance that are employed during feared movements’, and as such the prevent the ‘unambiguous disconfirmation of unrealistic beliefs about danger’  (note that I’ve inserted the words ‘movements’ and ‘danger’ in these quotes that I’ve drawn from the paper by Cuming, Rapee, Kemp, Abbott, Peters and Gaston, 2009).

Let’s unpack that sentence: in a phobia, a person holds an unconfirmed and (usually) unrealistic belief that some sort of disaster will occur if they encounter the feared stimulus.  In kinesiophobia, this belief can be complicated by the degree of meaning that people hold about experiencing pain – not only are individuals probably correct in their belief that if they move they may experience pain, but from childhood we have been trained to avoid experiencing pain because it is equal to harm or damage.  The problem for people with chronic pain who also have kinesiophobia is that the movements may exacerbate pain but the pain they experience no longer represents harm or damage.  But it doesn’t feel like this!

As a result, people with high levels of fear and avoidance will avoid movements that they believe will cause pain in the belief that some sort of harm will befall them – the harm may be their belief that some sort of damage will occur in their bodies (their backs will ‘fall apart’ or ‘go out’), or it may be much more subtle, perhaps a belief that ‘I can’t cope if the pain increases’, or ‘I will have an awful day and I won’t sleep if my pain goes up’.

As in social phobia, safety behaviours in kinesiophobia prevent the person from experiencing or verifying that the feared outcome will not occur.  The person may instead believe that the awful thing hasn’t occurred because they have used a protective safety behaviour – so they still believe that the movement will cause harm (think of ‘safe lifting’ techniques supposedly reducing the risk of back ‘injury’); or safety behaviours may actually increase the likelihood of experiencing the negative outcome – by tensing and moving very carefully, the person may increase muscle tension and inefficient movement patterns, thereby increasing pain after the movement is complete.  By carrying out safety behaviours, the person never confronts his or her fear that something horrible will inevitably occur – either increased pain that they ‘can’t cope with’, or ‘damage’.

The paper I read that triggered my pondering today suggests that subtle avoidance and safety behaviours are prevalent in individuals with social anxiety.  The subtle behaviours allow the person to remain in a feared social situation – but only if they carry out these ‘special’ behaviours, for example speaking very slowly or quietly, mentally rehearsing what to say, holding onto a utensil very tightly causing it to shake and so on.  The problem is, these behaviours may make the negative outcome more likely (people will get frustrated listening to someone who speaks very slowly or hesitantly!), and they therefore maintain the fear that ‘people will ignore me and I’ll make a fool of myself’.

Can you see the similarities between these behaviours and maybe what we ask patients to do while getting people to carry out movements?

Maybe we ask people to review their footing and posture before they do a manual handling task – suggesting, in effect, that if they do the task ‘this way’ they will be ‘safe’.

Maybe we encourage patients to breathe in a special way, or pre-plan their movements or ‘wait until you’re warmed up’ before doing movements.

Maybe we get them to do special stretches or breathing exercises at certain times of the day, maybe even ask them to rate their pain and if they report any increase in pain, we reduce the demands on them, or try to identify ‘what has caused the pain’ so we can modify the way they do the activity.

Some patients use medication as a way to avoid experiencing fluctuations in pain – experiencing relief almost immediately after swallowing a tablet and way before it can have had a pharmacologic action.  Some patients use splints or hotties or rubs.

What are we reinforcing in our patients when we encourage them to notice their pain, report on their pain, medicate their pain – maybe we’re actually reinforcing their fear that something awful will happen if they experience a fluctuation in their pain?  Or maybe we are fearful of seeing someone experiencing pain?

The authors of this paper describe the development of a self-report measure of safety behaviours – maybe it’s time we started to develop something similar for people experiencing kinesiophobia.  Of course, in social phobia, and indeed in most phobia, the fear is out of proportion to the threat, the avoidance interferes with daily life, and most phobia are recognised as being ‘unrealistic’ .  I wonder if we can say the same about pain-related fear and avoidance – or do we have mixed feelings about how OK it is for people to experience pain?

I think our job is to help people reduce their level of suffering, to minimise the interference that pain has on their lives, and to encourage full participation in life.  I’m not so sure that we always do this when we encourage people to avoid experiencing pain by medicating or avoiding movements or carrying out movements in special ways.  What do you think?

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Cuming, S., Rapee, R., Kemp, N., Abbott, M., Peters, L., & Gaston, J. (2009). A self-report measure of subtle avoidance and safety behaviors relevant to social anxiety: Development and psychometric properties Journal of Anxiety Disorders DOI: 10.1016/j.janxdis.2009.05.002

Theory and really practical clinical reasoning

I’ve been mulling over my delight and joy in theory, and wondering whether this turns people off reading my blog.  So today I thought I’d draw a link between theory and everyday work in pain management.

Theory and models really matter!  They form the organisational framework for the data we collect (ie the things we look for when we assess people), from the models we use, we develop hypotheses, or potential explanations for the way the person presents.

It’s these hypotheses we test when we actually carry out therapy: to confirm our predictions.  If our predictions don’t hold, we’ve probably got the wrong explanation and need to look for another one, if they do hold, we can probably work with the underlying theory or model to develop other hypotheses or interventions to predict.

It’s important then, that we have knowledge of a good number of theories or options to have as alternatives when we start gathering information/assessing a person’s presentation.  If we only know a couple of theories (eg we only know about biomechanical models, or psychodynamic explanations, or even cognitive behavioural models) we’re going to be really limited in terms of looking for appropriate information to notice – and it will be hard to organise information that doesn’t fit with our pre-existing model.

For a really practical application of theory to pain management, we don’t need to look too much further than Fordyce.  I’m quoting directly from Dunn and Elliott’s paper on ‘The Place and Promise of Theory in Rehabilitation Psychology Research’ (Dunn & Elliott, 2008).

‘Fordyce effectively developed ideas derived from operant conditioning and principles of reinforcement (e.g., Fordyce, 1971) to motivate clients undergoing rehabilitation. Fordyce (1976) specifically focused on how individuals with acquired disabilities understood and responded to their environments, the people within them, and the contingencies and secondary gains associated with them. As Fordyce (1971) wrote:

The development of an effective treatment relationship with a client or patient . . . . can be enhanced considerably by the professional’s awareness of his client’s [verbal or nonverbal feelings]. What is suggested here is that a more expeditious way to help the disabled person is to focus in helping him to change his behavior. It is quite possible that feelings will follow rather than lead these behavior changes. (pp. 77)

This landmark work initiated an appreciation for operant principles in the development and reinforcement of disabling behaviors, and for use of operant approaches to facilitate and reward healthier, adaptive behavior (Patterson, 2005)’

We have much to thank Fordyce for in our modern pain management approach – applying theory from operant conditioning to a real-life clinical situation offers us as clinicians new opportunities to help people live well.

Similarly, The idea that people are more than their disabilities comes directly from social psychology, where the relationship between the individual and the society or community is the focus. The concept of disability as a communal problem rather than an individual problem, and that disability can motivate people to develop awareness of previously under-used aspects of their abilities has lead to the strengths-based approach in rehabilitation. Tamara Dembo (1969) is cited in Dunn and Elliott’s paper as identifying the view that ‘outsiders assume a disability is all-encompassing so that insiders must always be preoccupied with their physical or mental states; the idea of living a normal and fulfilling life is rejected by these observers. Preferring to focus on their abilities, however, insiders affirm that disability is independent of identity.’ This view comes directly from social psychology.

Many research questions within rehabilitation are identified in response to a gap in knowledge, often clinically related knowledge. This knowledge gap is ‘the psychological distance between what is known and what knowledge is needed’. Typically in rehabilitation we’re trying to solve a problem. When existing information doesn’t ‘solve the problem’ – it’s time to start searching for more information!

I suppose what I’m trying to say is that most of the time we work in a clinical framework where an individual comes to see us with a problem.

It might be a problem of pain itself, or it might be a problem of the effects of pain in some part of the person’s life. By carrying out a comprehensive assessment of the features of this person’s presentation we allow for lots of information to be available so we can sift through to find features that are stable:

• this person mostly avoids doing certain movements;
• this person takes three hours to get off to sleep and can’t stop his mind from racing;
• this person is 12 years old and everyone runs around helping her because she’s using crutches

By referring to our theory-based (and our theories are developed from and are confirmed by good empirical evidence), we can decide which theory generates hypotheses that best fit the person’s presentation.

For example, one explanation for avoiding certain movements could be that this person believes her fusion means she will inevitably wear away the vertebrae above and below the fusion, and her surgeon told her immediately after surgery to ‘be careful about moving’, and everyone has told her not to slump because it’s ‘bad for your back’.

What are our clinical options?
– provide information about degeneration in the vertebrae above and below a fusion site (and no, there isn’t much evidence that these vertebrae do degenerate more quickly than others)
– if she’s fearful because she thinks she might do further damage, and it’s simply about protecting her spine, this information should reduce her fear, and help her feel safer about moving.
– if we add in the suggestion that immediately postsurgery it makes sense to be a little careful, but now it’s 12 months later, so any healing that needs to occur has already, this may also help her revise her beliefs about harm from moving.
– and if we demonstrate that any body position becomes uncomfortable if you haven’t done it for a while, if you’re a bit worried about doing it because people have said it’s not good, and that lots of people do sit in very poor posture without any problem at all, then once again we might help her revise her beliefs, reduce her fear and help her feel more confident about moving.

At the same time we can draw from very robust evidence from anxiety management to suggest that

• if we start her moving again using activities she’s not too worried about,
• gradually progress towards more demanding activities;
• we make an attempt to understand what she is worried about
• demonstrate that these things don’t happen (using applied experiments),
• help her develop ways of coping with any increased physiological arousal (based on our knowledge from anxiety disorders) –

once again we have an intervention that is really practical, based on theory.

And you thought theory was only for academics!

Dana S. Dunn, Timothy R. Elliott (2008). The place and promise of theory in rehabilitation psychology research. Rehabilitation Psychology, 53 (3), 254-267 DOI: 10.1037/a0012962

Dembo, T. (1969). Rehabilitation psychology and its immediate future: A
problem of utilization of psychological knowledge. Rehabilitation Psychology,
16, 63–72.

Fordyce, W. E. (1971). Behavioral methods in rehabilitation. In W. S. Neff
(Ed.), Rehabilitation psychology (pp. 74–108). Washington, DC: American
Psychological Association.
Fordyce, W. E. (1976). Behavioral methods in chronic pain and illness. St.
Louis, MO: Mosby.

Patterson, D. R. (2005). Behavioral methods for chronic pain and illness:
A reconsideration and appreciation. Rehabilitation Psychology, 50, 312–
315.

An introduction to case formulation

One definition of case formulation is ‘Case formulation aims to describe a person’s presenting problems and use theory to make explanatory inferences about causes and maintaining factors that can inform interventions’. What this means is that it is essentially a story not just to describe, but explain, how a person’s problem has developed, and how it is maintained so that treatments can be based on influencing those factors.

There are many different frameworks for case formulation, but several key elements are usually present:

1. a description of the presenting issues;
2. the factors that act to create vulnerability or precipitate the problems developing;
3. factors that may not have been involved in the initial problem developing, but are helping to maintain the problems; and finally,
4. factors that can help the person cope or act as resources.

To move beyond just describing these factors, a case formulation should describe the relationships between these various factors and the problems that are present – and should reflect not just the visible features of the problem (ie what we can see, or what the person reports that are unique to his or her situation), but also the underlying phenomena or stable, recognisable features that are present.

Exposure therapy – not so fast buddy!

From what I’ve posted so far this week, you might think that I would propose exposure therapy be something for all therapists to use with people, but no! I think it’s something that only some people will adopt, and it’s only useful for some people. Although all of us can incorporate some aspects of it in our practice, I don’t think everyone is suited to actually doing this type of work.

Some of my colleagues (and probably my kids too!!) would say that I’m ideally suited to doing this type of therapy – I don’t have any qualms about asking someone to do something that may (read usually…!) increase their distress and often their pain. Just hand me a whip and I’ll use it (no, not really!).
But if you are not like this, and do feel a little worried about possibly causing harm, or at least increasing someone’s pain, then don’t feel you have to do it. The reason for this is simple: if you inadvertently suggest, through nonverbal or verbal means, that they do have a good reason to fear doing the activity, then you may well inadvertently reinforce their anxiety.

It’s true that we as health providers are often as fear-avoidant as the people we work with! What I mean is, we tend to be ‘nicer’ and less assertive in our requirements than when we allow people with pain to set goals for themselves and others. Vlaeyen & Linton (2006), and others have identified that treatment providers who have fear-avoidant beliefs themselves are more likely to suggest passive treatments than those who are not. Some years ago it Hazard (1996) found that people who are given no activity restrictions when they return to work actually return to work more quickly than those who are provided with selected activities.

I’ve observed too, that once the exposure process is underway, progress quickly gains pace. So the first few steps on the hierarchy are quite slow, but provided that the person is generalising their skill, they start to set their own goals and these are often quite a lot higher up the hierarchy than I would have put the target!

So, bringing together some of the factors identified in the Craske, et al. (2008) article I referred to yesterday, here are some thoughts about ways to make exposure therapy effective.

1. Practicing exposure in different contexts, with and without ‘warning’, and maintaining this exposure over time
2. Encouraging tolerance to experiencing anxiety – it’s OK to not feel entirely comfortable with a movement that has been uncomfortable in the past, it’s just not OK to avoid it!
3. Practicing in different situations with or without feedback and encouragement – it seems that too much verbal feedback can ‘seduce’ the person into believing that they have their fear conquered, but this can be a temporary effect that can disappear quite quickly. It seems to be more effective to have a delay between sessions during which the person practices alone than to have multiple practices with support.
4. Avoid the use of ‘safety behaviours’ – especially ‘special’ movements such as a special ‘safe lifting’ technique, but also the presence of another person (especially you!), or special preparations such as counting or breathing or using equipment. Although you may start with this, in the end it’s important that the person learns to do the movement without any props or rituals.
5. Generalising the exposure into the ‘real’ world needs to happen throughout and after the therapy. Integrating the new learning into life is the aim of therapy, but needs to be structured to actually occur. A plan to make this learning happen should be developed and monitored, as well as a ‘relapse’ plan.

I hope you’ve enjoyed this tour through exposure therapy and the pain-related anxiety and avoidance model. I’ll keep you posted on progress with my client – today he made it into the hydrotherapy pool, so here’s hoping he’ll be well on his way to returning to a normal level of activity in the next few months.

Learning to ‘feel the fear and do it anyway’

If ever there was an over-used quote from a pop-psychology book the ‘feel the fear’ quote has to be a prime contender! However, in exposure therapy for kinesiophobia, this is exactly what we are doing. If we don’t activate the feeling of anxiety just a teeny tiny bit, then we are not going to achieve an awful lot!

So, the steps from yesterday are to identify a range of activities that the person doesn’t feel they can do (and therefore avoids doing), get the person to rank them in order from ‘least bothersome’ to ‘most bothersome’ (or whatever scale you want to call it – some people call it the ‘yukkiness’ scale!).

Then it’s time to find out exactly what the person really fears about the movement. To do this, I ask the person ‘what goes through your mind when you think of yourself doing this movement?’ – it can be an image, a phrase, or some sort of prediction. It’s this prediction, or hypothesis, that is being tested in our ‘behavioural experiments’.

By exposing the person to the opportunity to test their belief that something ‘horrible’ or ‘awful’ will happen if they carry out the movement, several things happen:

1. their anxiety level increases initially
2. they get the opportunity to see that their feared consequence either doesn’t happen, or if it does, it is something they can tolerate
3. their elevated anxiety subsides (we simply can’t maintain high levels of anxiety for very long)

It’s important to work out exactly what the person is concerned about.

• Is it that they think some damage will occur? – how will they tell it has?
• Is it that they think their pain will inevitably increase – and more importantly, that this will be ‘horrible’? – what does ‘horrible’ look like or mean?
• Is it that they can see themselves falling, being looked at, being laughed at? – what does this mean to them, or about them?

We can then run through several different ways of addressing their underlying beliefs.

• We can using cognitive therapy to work with their automatic thought, and evaluate the probability that the negative event will happen.

• We can use cognitive therapy to probe more deeply to find out what it means for this event to happen, and perhaps uncover a more significant belief or attitude that can be worked on in therapy.

• We can also find out what the worst possible consequence could be, and why it might be so awful. Or what the most likely consequence could be, and whether they could cope with that.

Having done this, we can then start to ask the person if they’re prepared to see what happens if they try one of the movements that bothers them. This is the ‘behavioural’ part of this process and it’s critical to include this as well as the cognitive aspects indicated above.

Reassuring the person that we are certain that they can handle the situation (that they have the skills not to freak out!), or that we are clear that the harm they think will happen won’t occur gives the person a sense of your confidence in their skills. I always make sure that they do have skills to reduce their physiological arousal – usually using diaphragmatic breathing, and calming self statements – before starting this process. I also make sure that we start low enough on the hierarchy so that their anxiety is only just increased so they don’t refuse altogether.

The activities in the PHODA are daily activities that almost everyone has to do in life. For this reason it’s usually not too hard to get the person to agree that the activity is something they think is important to learn to do. If the person starts to balk, it may be because the activity isn’t that important to them, or that they really lack confidence that they can do it successfully. If this is happening, it’s time to return to exploring importance, and increasing confidence using motivational interviewing strategies. Moving down the hierarchy gives the message to the person that they don’t have the skills to cope, and that they have every right to be afraid, and that you’re not confident that it will be OK.

Then the process is reasonably straightforward.
Demonstrate the movement using efficient biomechanics. Note that I’m not suggesting ‘safe’ movements, or ‘proper’ movements – because this suggests that if and only if the person uses the right technique they will be safe. This is a form of safety behaviour that reduces the anxiety that we really want to have present. What safety behaviours do is act as a sort of lucky charm, and when the lucky charm isn’t present, the avoidance that has maintained the fear returns. Nothing is actually learned!

Then ask the person to rate how much concern they have right now about doing the movement.
Continue with asking the person to then rate how strongly they believe that their hypothesis will come true if they do the movement.

Then it’s their turn to do it. I move quite swiftly into this phase, because it’s the anticipation of doing the movement that generates the anxiety. The longer you delay, the more anxiety, the less likely they are to be able to settle their anxiety level down after the movement.

Once they’ve carried the movement out using efficient biomechanics, it’s time to ask them to re-rate their concern about doing the movement, then re-rate the probability that their feared consequence will occur if they do it again. Most times the rating has reduced, but sometimes it hasn’t gone down by much.

If their rating of the probability hasn’t changed, you can ask ‘how often do you think you need to do this to change your rating?’ You can use logic (How many times have you seen people actually fall over when they bend forward? How many times have you fallen over when you bend forward?) or you use other cognitive strategies to help them re-evaluate their belief, then re-test using the behavioural experiment again. You can also ask the person to develop a new experiment that might be a better test of their belief (to make it more likely that their feared outcome occurs).

For a really good article reviewing models of inhibitory learning in exposure therapy, Craske et al. (2008) have written ‘Optimizing inhibitory learning during exposure therapy’ for Behaviour Research and Therapy. Worth a read, even if you’re inclined to go glassy-eyed at loads of psychological stuff. But if you’re reading this, you’re probably quite happy to read psychological stuff, so head on over to it!

More tomorrow on exposure therapy – so y’all come back now!

CRASKE, M., KIRCANSKI, K., ZELIKOWSKY, M., MYSTKOWSKI, J., CHOWDHURY, N., BAKER, A. (2008). Optimizing inhibitory learning during exposure therapy. Behaviour Research and Therapy, 46(1), 5-27. DOI: 10.1016/j.brat.2007.10.003

Fear/anxiety, pain and movement…

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.

Photographs of activities of daily living – cervical spine

Assessing fear in patients with cervical pain: Development and validation of the Pictorial Fear of Activity Scale-Cervical (PFActS-C).
Turk DC, Robinson JP, Sherman JJ, Burwinkle T, Swanson K.

Ever since the PHODA or photographs of activities of daily living was developed, I’ve used pictures to help establish exactly what movements and contexts people are worried about. Pictures say so much more than a set of words!

So it’s great to see that Turk and colleagues have got together to develop a cervical spine version.

This study examines the reliability and development of ‘a set of photographs depicting movements in which four factors that determine biomechanical demands on the neck are systematically varied – Direction of Movement, Arm Position, Weight Bearing, and Extremity of Movement.’

Although the initial findings are quite interesting the authors acknowledge that further work needs to be carried out. I am curious to see whether there are differences between what is reported by people using photographs compared with their ‘real’ performance as assessed in their own home, perhaps by occupational therapists. I’m also curious to see whether, as I’ve found with the PHODA, there are problems transferring the photographs across different countries. Despite the PHODA being reasonably culturally neutral, there are differences in the type of building, items being carried, equipment, surfaces and so on, and these have been commented on by patients. Similarly, I would expect that a set of photographs developed in North America may also reflect cultural bias, and not be quite as useful in a Southern Hemisphere setting.

The process of developing this instrument is also really fascinating, and I wonder whether there are many areas of pain research where photographers and therapists work together!!

Let me know if you have used photographs to assess anxiety and avoidance – I’m interested to see how far this type of assessment and therapy has spread, and whether it has gained popularity amongst people like occupational therapists and physiotherapists, who work to help people generalise their skill and improve function.

TURK, D., ROBINSON, J., SHERMAN, 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 DOI: 10.1016/j.pain.2008.03.001