Pain-related anxiety and avoidance: a practical application of theory and research to clinical practice

In 1995 I started work at the Burwood Pain Management Centre.  It wasn’t my first foray into pain management, but it was the first time I had worked in a fully integrated interdiscipinary team environment.  It was also significant because of the use of the words ‘fear-avoidance’, ‘guarding’ and ‘anticipatory anxiety’.

What the team had observed was that there were a specific group of patients who were not just worried about experiencing pain, but were also showing the signs of increased physiological arousal, avoidance of specific activities, and firm beliefs about harm, reinjury, or doing further damage.

At the time we used an operant conditioning model (based on Fordyce, 1971 & 1976), along with graded reactivation using a physical conditioning model, to help these people learn to be more functional.  We had some successes – but a number of less successful responses too.

Towards the end of the 1990’s, a new model started to emerge.  It was the ‘fear-avoidance’ model proposed firstly by Lethem et al (Lethem et al. 1983), then elaborated on by Vlaeyen and colleagues (1999, 2000).

This model proposed that people demonstrating avoidance of activities may be developing a ‘phobic’ response to their situation: based on catastrophic interpretations of their pain, beliefs that their body will be dangerously harmed by movements, increased physiological arousal in response to these beliefs, avoidance of situations the same as or similar to those that provoke their beliefs, and subsequent reward of this avoidance by negative reinforcement (ie, by avoiding a negative experience, they increase the avoidance behaviour).

Basic biofeedback in pain management

I’m no techno-whizz in biofeedback – you have to speak to one of my colleagues (she knows who she is!) to get the technical data on things like heart rate variability – but I do use several modalities reasonably often. So today I thought I’d discuss some of the ways I use biofeedback with the people I work with.

Biofeedback basically provides visual or auditory information about normally undetectable physiological processes. It ranges from temperature sensors through to skin conduction (galvanic skin response), and includes surface EMG, respiration, blood volume pulse and sometimes these are put together to provide feedback on heart rate variability. I’m not going into HRV yet, that’s for another day!

The most common sensors I use everyday are GSR, which is a reasonably sensitive measure of general arousal level; respiration because it provides immediate feedback on the way the person is breathing and is helpful for developing diaphragmatic breathing; BVP because it responds quickly to respiration and can demonstrate to the person the effect of slowing their breathing down; and I often use surface EMG because it can provide immediate feedback on posture changes

Virtual Symposium on Pain

Just a quick link to the Canadian Physiotherapy Association web page with details on their Virtual Symposium on Pain.

Just like a traditional face-to-face conference, this unique online event will feature interactive learning sessions highlighting the most recent advances in pain science, and provide a forum for an energizing exchange of ideas focused on the treatment of patients with painful conditions.

This event will be relevant to all physiotherapists working with people with painful conditions. Sessions will be of particular interest to those working in multidisciplinary, return-to-work and pain management programs. Sessions are designed at an introductory to intermediate level.

How does it work?
By participating in three self-paced, interactive workshops throughout November, participants will be introduced to the vocabulary, evidence base, and current best practices in pain management. Each workshop will include one formal presentation, followed by a combination of reflective and collaborative exercises and online discussion with fellow participants, allowing you to apply your learning and explore the state of the art with colleagues across Canada and around the world.

Workshop 1: The Birth of the Pain Experience
with Dave Walton
(Begins November 3)

Workshop 2: How Pain Becomes Persistent
with Debbie Patterson
(Begins November 10)

Workshop 3: Assessment and Management Trends
with Neil Pearson
(Begins November 17)

Synthesis and Panel Discussion (Live) (Date TBC)

Cost?  Canadian $  $375 for non-members of the Canadian Physiotherapy Association.

Pain management strategy worksheet and activity

It’s been a while since I directly posted on practical pain management strategies that can be used as part of activity.  A while ago I developed an activity to use with our pain management programme that involves identifying the skills you might use during three common activities.  I’ve uploaded it here for you to use. Be aware that the photographs are from Google images, so are both of variable quality and some may be copyright.

The way you can use this activity is to ask the person to match the title to the definition of the coping strategy (and yes, there are a lot of debates about the definitions so they are by no means definitive!).  You could ask the person to talk you through the strategies he or she uses, or you could use it during assessment as a means of identifying coping resources the person already has, or could develop.  The three common activities (grocery shopping, going out to a restaurant or bar, gardening) were selected because these three are the sort of things people describe as being difficult and often avoided or carried out with difficulty.

Mulling over balance in the biopsychosocial…

For some years I’ve taught a postgraduate course in pain and pain management – my responsibility is to teach the psychosocial components, while I coordinate the content of both papers.  Recently I had a discussion with a colleague who suggested that the psychosocial component was over-represented, while the biophysical was under-represented.

At the time I didn’t agree, and on reflection I still don’t agree.

For years undergraduates in most health professions have received information on pain that consists almost entirely of biophysical data, coming from a biomedical model.  There is still minimal information at an undergraduate level in medicine, physiotherapy, occupational therapy, nursing or psychology training that covers pain in any shape or form, and what information there is tends to be about neurophysiology, acute pain, and about ‘injury’ or tissue damage.  When psychosocial material is given any time at all, it’s represented as a ‘response’ to pain (ie physical injury), or referred to in the same breath as chronic pain (ie a confounding factor only in individuals who are having trouble coping with persistent pain).

The definition of pain as given by the International Association for the Study of Pain is “… an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” By definition, people who experience pain are feeling it as an emotional event. ‘Psychosocial factors’ are integral to the experience of pain! We can’t experience pain without it being a psychological event…

The problem is, that while most health professionals gain a grounding in anatomy and physiology, and even in tissue pathology, nerve conduction – and healing… not nearly as many are aware of the fundamentals of pain behaviour, the place of psychosocial factors as both integral to the experience of pain and as factors that may complicate recovery (from acute onset of pain right through to coping with persistent pain and ongoing disability).

So in teaching postgraduate pain and pain management, people like me who teach ‘behavioural medicine’ or psychosocial aspects of pain and pain management to health professionals have to start with the basics of the difference between pain and pain behaviour, health and pain anxiety, measurement concepts, the role of the brain and emotions and attention and cognition, not to mention learning and reinforcement and allied concepts!

So if, in teaching at postgraduate level, I am emphasising the psychosocial, I hope that it’s in an effort to redress the imbalance of undergraduate knowledge that is carried over into professional health care.  Roll on the day when undergraduates receive sufficient training in pain as a complex, multidimensional experience that involves the biophysical, psychological and social aspects of being human.   Until then I think I need to spend a good deal of time just covering the basics…