How does it work? Pick your theory

I’m working with a man who has neuropathic pain in his right (dominant) hand.  He developed his pain some 8 years ago after he caught it in a woodworking machine and basically mashed it, damaging most of the carpal tunnel area.  After numerous orthopaedic, and plastic surgical procedures, he’s now left with nasty scarring, and even nastier neuropathic pain with some central sensitisation elements.  While he has almost full range of movement in his wrist and fingers, he rarely uses his hand and instead, cradles it or leaves it sitting half-curled, palm up.

We’ve been working together for a month or so, along with physiotherapy and psychology, and my parts of this programme have been to help him develop a personalised model of the factors that contribute to his pain; help him develop some self regulatory skills particularly to downregulate his very sensitive sympathetic drive; and to start the process of him being mindful of his hand rather than ignoring it or focusing on it.

I’m using a combination of approaches – Socratic questioning and guided discovery to help him develop a better understanding of his pain – particularly focusing on helping him recognise that trying to control his pain through either avoiding the use of his hand, or using distraction is counter-productive.  When he avoids using his hand, he’s either limiting the activities he can get through during the day and gets bored, frustrated and is probably contributing to the pain because his neuromatrix isn’t receiving normal movement patterns.  When he uses distraction, he can almost completely ignore the pain while pushing himself to ‘do everything’ – but then he gets an overwhelming increase in pain when he stops, which is distressing.

We’ve spent quite a while discussing the nature of control – is it pain we’re trying to control? Is it his activities we’re controlling? Is it is thoughts and emotions that we’re controlling?  I’ve been using mindfulness and some of the concepts from ACT and suggesting that try as hard as we might, pain is not something to control, and neither are thoughts or emotions.  In fact it seems the harder we try to control any of these things, the more they dominate and control us!

As a result, much of what I’m working on is helping this guy to non-judgementally regard his body sensations as simply sensations, allowing his attention to go to his hand without trying to ignore it (you can’t!) or to over-attend to it, but simply to notice it.

Taking this a little further, we’ve been working on breathing and mindfully attending to breathing as one way of introducing self regulation. This involves gently guiding his attention to his breath, and just as gently, noticing when his attention drifts away and bringing it back to his breathing.  Not as easy as you’d think!

I’ve been using biofeedback as part of this process because this guy is a practical man.  He’s not one to just accept doing something without having some feedback about what is actually going on.  I’ve used skin conductance, surface EMG, heart rate, respiration rate and skin temperature to monitor his overall arousal level.  He’s aware now that he can influence usually unconscious processes just by breathing or even thinking differently!

Yesterday I took it a little further.  I asked him to look at his painful hand, and simply describe the sensations without judging them.  What this means is he told me about the tingly, burning sensation over his palm, the throbbing aching in his fingers, he noticed where the pain started and stopped on his hand and fingers, the sensation of heat where his fingers touched each other, the sensation of pressure on his forearm where it rested against the arm of the chair, the sensation where the fabric of his T-shirt touched his skin – and so on.

It was interesting for him to notice that the painful area isn’t as big as he’d imagined.  When he really started to notice the quality of his pain, it wasn’t nauseating or particularly intense, it varied in sensation.  What I noticed was that initially his readings on biofeedback jumped – but they gradually settled down as he looked at his hand and really noticed it.

We then did some deep relaxation, really a kind of hypnosis.  In this we used an imagery device I’d discussed with him before the session.  I guided him in to using his attention to become aware of his hand and in particular, its position in space and the sensations over his whole hand and forearm.  I then guided him through an imagery process where he imagined holding his hand in warm water, allowing his hand to ‘thaw’ and open.  We then spent some time imagining his hand feeling normal, moving normally and imagined opening and closing his hand to lift a cup, pour milk, and flex and extend his wrist.  Throughout I was monitoring his biofeedback readings, and using words like ‘relax’ and ‘warm’ and ‘comfortable’ whenever the readings suggested he was becoming ‘stressed’.

When we completed the session, he had achieved sustained attention to his hand for about 35 minutes, completed a guided imagery of his hand doing normal activities, and had remained calm throughout.  He reported some increased discomfort around his wrist particularly after imagining wrist extension and flexion, but what really excited me was that he’d been able to increase the skin temperature on the finger of his right hand.

So, lots of choices in terms of theory to explain what I’d been doing.

1. Graded motor imagery and sustained attention gives the neuromatrix normalised input, while not activating what Lorimer Moseley and David Butler call ‘neurotags’ or emotionally-laden pathways in the brain.
2. Graded exposure using visual imagery as described by Johan Vlaeyen and following the exposure paradigm used in phobia reduction.
3. Using a behavioural model, biofeedback providing immediate feedback on progress and arousal levels, influencing both my behaviour (guided imagery) and the clients responses
4. Hypnosis allowing the ‘judgemental’ aspects of the mind to be quietened, thus allowing the client to experience sensations without distress
5. Mindfulness where sensations are experienced but judgements are stilled.

Take your pick!  I’m not entirely sure myself, but whatever the mechanism, I’ll be continuing with this approach to the point where this client can carry the same process out with eyes open, then when actually moving.  Oh, and at the same time, the rest of the team will be working (along with me) on helping him set and achieve goals, manage difficult emotions and maintain a regulated activity pattern, as well as work on his relationship, look to the future of work, and help him communicate effectively with his case manager.  This is why pain is often not the main focus in pain management!

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

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

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.

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!

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’