Success! Why measuring outcome is so rewarding

Not a research post today, but a great experience that I hope will encourage anyone who is not already a fan of regular outcome measurement to get on with it!

I saw a person yesterday who has had pain for about 3 years.  Superficially she’d been managing quite well – still working, having a social life, managing all her household activities and in general, looking good.  BUT – and you knew there would be a ‘but’ – once I started to look a little deeper, it was absolutely amazing to see how much she had adapted her life to avoid specific movements.

I used the PHODA (photographs of daily activities) to assess the specific movements and activities she didn’t like to do.  I’ve blogged about PHODA (Kugler et al, 1999) before – a set of photographs of everyday activities in a variety of settings that can be used to identify and score fearfulness and avoidance.  The findings showed that although this woman was able to do things, the way she did them was to avoid ANY bending, twisting, reaching, jarring or lifting.  She was the original Gadget Queen with things to help her do everything WITHOUT bending.  An occupational therapists dream!

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

Working with a kinesiophobic person

One of the biggest challenges when working with someone who is fearful of pain and avoids movement is that although it’s very much like any sort of phobia, it differs on one essential point: people who are spider phobic, socially phobic, fearful of flying or heights or whatever are usually aware at some level that their fear is out of proportion to the ‘real’ risk. People who are kinesiophobic (kinesio – movement, phobic – fearful) are much more likely to believe that their fear is realistic and to have their concerns about moving despite pain reinforced both inadvertently and deliberately by others (including health professionals!).

So, to introduce the idea of beginning to move despite fear of pain or harm requires a bit of a delicate touch!

Some people advocate ‘just tell them’, and spend a good deal of time going through a psychoeducational approach about the difference between hurt and harm until they believe they have convinced the person that it’s OK to move. And sometimes this does reduce the ‘threat value’ of pain.
But just as the spider phobic person (and I was one!) is not reassured by the knowledge that in New Zealand we have very few poisonous spiders, and the one or two we do have are quite rare, the person who is afraid of moving when they are sore can remain unconvinced and continue to avoid moving despite the best ‘information’ or education available.

So, what can you do?
Well, let me tell you how I’ve started working with my current client. The man I’m working with is in his late 20’s, he has a slight disc bulge in his lumbar spine, with little evidence of nerve compression, and he has a 12 month history of low back pain.

His back pain started after he lifted some timber at work, and tripped, falling onto his side with the wood on top of him. He has had a very thorough orthopaedic examination, been seen by a neurosurgeon who doesn’t want to pursue surgery because of the somewhat equivocal findings both neurologically and on imaging studies. He’s now being seen by me and a physiotherapist, and having his low mood treated with pharmacology. He uses paracetamol for pain relief but no other medications.

Functionally, he still has good power in his lower limbs, has no neurological findings, but his activity level and movement patterns are extremely limited. He sits for about 3 – 5 minutes before getting up and slowly stretching. He walks (albeit slowly) to keep comfortable, and can stand for only a few minutes before leaning or stretching.

He has completed a set of questionnaires, including the short version of the Tampa Kinesiophobia Scale, and his score on this questionnaire was well above the cut-off we use to identify those a risk of kinesiophobia.

When I completed the 99 picture PHODA with him, he indicated he would not attempt nearly 70 of the pictures, including any pictures of bending forward, twisting his trunk, jarring (eg going up and down stairs, or riding a bike over a kerb or using a mini-trampoline), carrying anything, or reaching above his head. In his daily activities, he is not working, he makes his bed (he has a duvet only), carries out his personal activities of daily living, but is otherwise either inactive (lying down to rest), or he walks.

He is living with family who are doing all of the household activities, so his responsibilities are very low. In addition, he is quite depressed although starting to look more future-oriented, he has an unsupportive family who are quite critical of his limitations despite carrying out his household responsibilities, and he has broken up from a long-term relationship about six months ago.

I started with using a motivational interviewing approach, and suggested we review some of the areas that other people often find helpful when they are thinking about managing pain. Using a menu of options, he identified sleep, medication use, relationships and work as his main concerns.

I asked him what he had found useful about previous therapies, and also what he had found not so helpful about those approaches. My aim was to help him identify that his previous attempts to control his pain by avoiding activities had not reduced his pain, and had increased the difficulties he faced living his life according to the values he holds.

I asked him whether he thought his movement patterns were helping him or whether there were some not so good features about the way he moved. He agreed that although sometimes it meant that he could avoid doing a movement that he thought increased his pain, for much of the time his pain remained and he had to keep on being ‘careful’ of any movements he did, and this was exhausting!

I then asked him how important it was to him to be able to return to normal activities even if it meant he needed to bring his pain along as well – and he indicated that it was very important. Using the ‘scaling questions’ (Why do you think it’s so important to you? Why give it a 9/10 and not a 6/10?), he told me that he thought his life was becoming very restricted, he wasn’t able to work, and he didn’t think there was going to be a medical way to reduce his pain.

I then went through his confidence that he would be able to carry out normal activities despite his pain, and he told me it was 3/10. Once again, using ‘scaling questions’, I asked him what it would take to help him move his confidence up a little, had he ever successfully made a change in his life despite it being quite hard, and he was able to talk about how he had worked his way up in the workplace despite not being a proficient reader, and that he knew he could make changes because if he took things one step at a time, he could see progress.

I then went through the PHODA pictures, and asked him which of the images he thought were most important for him to be able to do. He indicated that bending forward (eg to do dishes and clean teeth) was important, and also to put on shoes and pick things up from the floor.

I suggested to him that we weren’t sure why he thought he shouldn’t do these things, and asked him what went through his mind when he thought of himself doing these activities. He told me immediately that as he looked at photographs of people bending he could see himself falling forward and hitting the ground, or he could see his vertebrae grinding ‘bone on bone’ and see himself clutching his back because of the pain saying ‘I couldn’t cope with that sort of pain’.

Three things to note here:

1. the catastrophic image which generates an emotional response,
2. the misbelief that his vertebrae had no ‘padding’ so they were ‘grinding’ when he moved, and
3. the belief that he ‘couldn’t cope’ with high levels of pain

Each of these automatic thoughts/images are open to reappraisal, but unless they’re paired with actual movement, they are not likely to help him actually do things.

So – tomorrow I’ll discuss the next step in his programme: working towards ‘exposure’

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