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.

One size does not fit all – people with pain are not clones

On a similar theme from my post ‘Pain management can’t be cloned’, I want to post about the need to tailor therapy to suit the person.  Pain management does not follow a recipe – principles yes, protocols … not quite so sure.

What do I mean by this?  Well let’s take two people with back pain that is making it difficult for them to work.  Both have trouble bending forward, sitting, walking and sleeping.  Both are male, mid-30’s, hard workers in manual labouring jobs.  Same date of onset, same reported pain intensity.   Neither man responding very well to NSAIDs with gastric problems and now taking regular paracetamol but no other medications.  ‘Objective’ measures of forward flexion, straight leg raising, lower limb strength are only slightly limited, and neurological testing is normal, and both present with paravertebral spasm, localised tenderness to palpation over L4/5, and localised pain over the central low back.  There are no changes on X-ray, and MRI/CT is not indicated.

Robbie is a surfer in his spare time, hasn’t been surfing recently but has been swimming, and until now had back pain intermittently but had never stopped working.  He comes from a family where pain has been ‘toughed out’, and he expects that this episode will eventually settle too.   He is surprised that his back pain hasn’t settled, but is carrying on with regular walking and intends to return to work as soon as he is able.  His main concern is that he finds during exacerbations of his pain, he has trouble settling his body down – his breathing changes, he feels nauseous, giddy, his heart rate rapidly increases, he becomes sweaty and quite distressed.  He has difficulty getting off to sleep and his sleep is interrupted.  He is typically active when his pain is settled, but then experiences a long period of intense discomfort (boom and bust pattern of activity).  He is quite careful with his movements, and in particular takes care not to move into certain positions that he has found have been associated with pain.

Andrew is a motorcyclist and is continuing with recreational motorcycling despite having had what he calls ‘grumbling’ back pain for most of his adult life.  His back pain hasn’t really settled completely, and this episode has got him quite worried because it is more intense than ever before.  His family are becoming quite irritated with the ongoing saga of his back – and want him to ‘get on with it’.  He has stopped walking, going to the gym and doesn’t like swimming.  He stays fit by using an exercycle, but doesn’t enjoy it.  His main concern is his lack of energy, and his increasing need for sleep. He does have trouble getting off to sleep on occasion, and goes to bed quite early because he is fatigued, but wakes regularly through the night and about an hour earlier than he would really like to.  He has even had an occasional afternoon nap.  He doesn’t really avoid movements that increase his pain – but has reduced his overall activity level because of his fatigue.  He notices that he has gained weight because he is not doing very much.

Sound familiar?  Clients like both of these men often attend pain management centres – and often they receive exactly the same treatment.  Lots of ‘core stability’, fitness training, daily scheduling, relaxation training and a graded return to work programme.   And these probably help in some way… but let’s take a closer look at what might be a more targeted and individualised strategy.

Robbie may have pain-related anxiety and avoidance. He describes increased physiological arousal and has learned that certain movements are best avoided.  He’s not deactivated or unfit – his cardiovascular fitness as measured by a 3-minute step test has remained high.  Treatment should probably focus on helping him develop skills to manage his physiological arousal (eg biofeedback, relaxation training, cognitive behavioural therapy to help identify automatic thoughts and replace with more helpful thoughts and behaviours), alongside graded exposure to those movements and activities that he finds concerning.   Sleep management would focus on strategies to improve sleep hygiene, reduction of unhelpful rumination as he goes off to sleep, and possibly sleep restriction.  A graded return to work would have a greater chance of success if he develops strategies to work to quota, and addresses his automatic thoughts and beliefs about needing to get everything done very fast (and very well).  He can probably return to work quite quickly once he has overcome his concerns about activities such as lifting and bending.

Andrew on the other hand, has lost fitness and lacks energy to increase his activity level.  He is assessed as being depressed and is treated with a combination of both antidepressant medication and cognitive therapy for this.  His family need to be brought into his treatment and it would help if he developed ways of communicating with them.  He needs to develop a daily activity plan with a schedule for both active and pleasurable activities.  Because he normally attends the gym and walks, his programme needs to be developed around this – swimming or hydrotherapy probably won’t be helpful.  He may need some help with ‘efficient’ ways for relaxing through the day, but doesn’t have the need for specific methods to reduce physiological arousal that Robbie does.  He may need to have a similar programme of sleep hygiene and sleep restriction, but because worry isn’t a problem for him, he may not need to focus on ways to address this before sleep.  His ‘pacing’ will need to focus on gradual increases in activity – and increases set by his fitness level.  Graded return to work will need to be progressed according to his cardiovascular fitness and fatigue/depression levels rather than avoided activities.

In effect, the two men have quite different treatment programmes despite experiencing very similar functional limitations.   This is why it’s so important to assess their presentation very carefully and develop hypotheses about what might be perpetuating their problems.  Any ‘protocol’ should ensure that the following principles are followed:

  • good assessment
  • generation of a number of competing hypotheses about cause and maintenance of the problems
  • interventions designed to confirm or disconfirm the hypotheses or based on a confirmed hypothesis
  • pre and post as well as follow-up outcome measures

A protocol may be less effective when it specifies the content of each session or the processes used to facilitate learning.  People learn at different rates, have different learning styles, varying automatic thoughts and underlying beliefs and attitudes, and live in different environments.

Health professionals have skills in applying concepts to specific situations.  This is why people are professionals, not computers or robots.

Sorry I don’t have any references for this post – unusual for me!  If you’ve got some – or any comments – let me know! And if you’ve been provoked by this post and don’t want to miss any others – use the RSS feed above, and subscribe!