slides for fs-07

Education: pain (FS-07)

Julia Hush (Australia)

Kathleen Sluka (United States of America)

Graciela Rovner (Sweden)

This material is provided with the permission of the presenters and is not endorsed by WCPT

FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY

Focussed Symposium 07

Meeting the global challenge of pain

education for physical therapists

Objectives

1. To understand how pain education for physical therapists, based on modern pain science, is critical for improving clinical outcomes in pain management.

1. To learn about evidence-based pain education resources available to enhance physical therapist training and clinical competencies.

1. To identify successful practical methods to teach pain science to physical therapists, in entry-level programs or in clinical education.

Professor Kathleen Sluka, University of Iowa

A/Professor Julia Hush Macquarie University

Graciela Rovner, University of Gothenburg

Outline

4.00 – 4.10: Introduction from Convener: A/Professor Julia Hush: Current Challenges in Pain Education.

4.10 – 4.30: Speaker 1: Professor Kathleen Sluka: Formation and Integration of Pain Competencies in Physical Therapy Education.

4.30 – 4.55: Speaker 2: A/Professor Julia Hush: Embedding the IASP Pain Curriculum in Pain Education for Physiotherapists in Australia – the Experience Down Under.

4.55 – 5.15: Speaker 3: Graciela Rovner: Sweden and Argentina: how Contextual and Cultural Factors may Influence Pain Paradigms in Education, Guidelines and Practice.

5.15 – 5.25: Discussion with audience and the panel of speakers

5.25 – 5.30: Convener: A/Professor Julia Hush: Summary and take-home messages.

Introduction from Convener

A/Professor Julia Hush Macquarie University, Australia

Current Challenges in Pain Education

Incidence of health problems: USA

Stroke Cancer Heart disease Diabetes Chronic pain

Institute of Medicine Report

IOM Key Findings:

• The total financial costs of this epidemic of pain exceed US$600 billion each year.

• This is higher than the costs for cancer, heart disease, and diabetes combined.

• Yet the treatment covered by these expenditures does NOT adequately alleviate Americans’ pain.

What are the challenges?

Pizzo and Clark, 2012

“A major challenge is the limited education that U.S. medical students and physicians receive about pain….training in pain management does not lead to competency.”

“Major impediments to relief include patients’ limited access to clinicians who are knowledgeable about acute and chronic pain –owing in part to the prevalence of outmoded or unscientific knowledge and attitudes about pain.”

Pain education: challenges and solutions

The Institute of Medicine recommends: “expanding and redesigning education programs to transform the understanding of pain and improved education for clinicians.”

is the number one reason people consult a physiotherapist

Pain education in physiotherapy

“Recent surveys of the curricula of health care professions (including physical therapy) at universities in Canada and the UK showed that current pain education is inadequate preparation for professional practice.”

Foster and Delitto, Phys Ther 2011

Meeting the global challenge of pain education for physical therapists

Professor Kathleen Sluka: Formation and Integration of Pain Competencies in Physical Therapy Education.

A/Professor Julia Hush: Embedding the IASP Pain Curriculum in Pain Education for Physiotherapists in Australia – the Experience Down Under.

Graciela Rovner: Sweden and Argentina: how Contextual and Cultural Factors may Influence Pain Paradigms in Education, Guidelines and Practice.

Essential Pain Knowledge for

the Physical Therapist

Kathleen A. Sluka, P.T, Ph.D.Professor

Physical Therapy and Rehabilitation Science Graduate Program

Neuroscience Graduate Program

Pain Research Program

University of Iowa

painexhibit.com

An unpleasant sensory

and emotional experience

associated with actual or

potential tissue damage, or described in terms as such

Subjective

Declaration of MontrealAccess to Pain Management Is a Fundamental Human Right (IASP 2010)

Article 1. The right of all people to have access to pain management without discrimination

Article 2. The right of people in pain to acknowledgment of their pain and to be informed about how it can be assessed and managed

Article 3. The right of all people with pain to have access to appropriate assessment and treatment of the pain by adequately trained health care professionals

Institute of Medicine Report on Pain Conclusions - 2011

Chronic pain affects more than a 100 million Americans, making its control of enormous value to individuals and society

Julie Meese: Chronic pain can make you despondent…I find dealing with pain is like riding a surf board -- I can get thrown into the debilitating turmoil that is pain along with fatigue, brain fog and depression at any moment.

"Pool of Darkness" represents the times when I fall off my surf board and am unable to claw my way back to the surface.

Painexhibit.com

Institute of Medicine Report 2011

A moral imperative

Effective pain management is a moral imperative

A professional responsibility

The duty of people in the healing professions

Need for interdisciplinary approaches

Produces the best results for people with the most severe and persistent painAgainst The Barrier To Life

by Judith Ann Seabrook

painexhibit.com

Institute of Medicine Reporton Pain 2011-Conclusions

To reduce the impact of pain and suffering we need to transform how pain is perceived and judged by:

people with painsocietyhealth care providers who help care for them

Goals better understand pain of all types (research and education)improving efforts to prevent, assess, and treat pain (research and education)

Only 1/3 faculties could identify designated pain content hours in health sciences.

Veterinary Medicine had 3X more designated pain content hours on average, & 5x medicine.

Watt-Watson, McGillion et al., Pain Res Manage 2009 14(6), 439-444

Pain Education in Canada

J Watt-Watson 2015

Entry-Level EducationScudds et al., 2001

Pain in PT curriculum averages 4 h (US) (faculty survey)

Most faculty believe pain is adequately covered in curriculum (faculty survey)

Similar in all professional programs

Medicine

Nursing

Pharmacy

Average number of hours

31 contact hours

Range 5-115 hours

61% believe adequately covered

49% aware of IASP guidelines

48% aware of IOM report on Pain

96% use evidence-based approach

6% (11 schools) have an independent pain course

Current SurveyHoeger Bement and Sluka,

J Pain 2015 Feb;16(2):144-52

What is covered? Hoeger Bement and Sluka,

J Pain 2015 Feb;16(2):144-52

Content Categories Mean + S.E.M. Median Mode Range

Pain Science 9.5 + 0.38 8 6 2-27

Pain Assessment 4.0 + 0.22 3 2 0-10

Pain Intervention and Management 27.2 + 1.3 24 16 6-84

Education and self-management strategies 3.2 + 0.19 3 2 0-10

Exercise therapy for pain control 3.9 + 0.25 3 2 0-10

Manual therapy for pain control 4.4 + 0.26 3 2 0-10

Electrical agents for pain control (TENS and

4.6 + 0.23 4 2 0-10

Thermal agents for pain control 3.9 + 0.23 3 2 0-10

Psychological management 2.7 + 0.17 2 2 0-10

Physician Management 2.2 + 0.14 2 2 0-10

Multidisciplinary (interdisciplinary)

management

2.3 + 0.14 2 2 0-3

Science Category Assessment Category

Topic % covered Topic % covered

Gate Control Theory 95% Subjective Pain Scales 99%

Biopsychosocial Model 95% Pain Specific Questionnaires 83%

Acute vs. Chronic Pain 97% Disease Specific Questionnaires 91%

Pain Pathways 97% Functional Assessments 86%

Peripheral Sensitization 84% Psychological Assessments 80%

Central Sensitization 87% Pain across the lifespan 68%

Cortical Processing 85%

Central Inhibition 85%

Neurotransmitters and Receptors 93%

Outline

I. Multidimensional Nature of Pain

II. Pain Assessment and Measurement

III Management of Pain

IV. Clinical Conditions

IASP Curriculum Guidelines 2012Physical Therapy Pain EducationDrs. Slater, Sluka, Söderlund, Watson

http://www.iasp-pain.org/Education/CurriculumDetail.aspx?ItemNumber=2055

DOMAINSI. Multidimensional nature of pain

II. Pain assessment & measurement

III. Pain management

IV. Clinical conditions

www.ucdmc.ucdavis.edu/paineducation

Core Competencies in Pain Education 2013Interprofessional Consensus

http://onlinelibrary.wiley.com/doi/10.1111/pme.12107/fullFishman et al., Pain Medicine 14: 971-981, 2013

Threaded throughout curriculum

Core principles and assessments

Specialized courses in orthopedics, neurology, cardiopulmonary

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4023081/table/T1/

Stand-alone course

Detailed pain science

Psychological barriers to management

Importance of interdisciplinary management

Integration into curriculumBement et al., Physical Therapy 94: 451-465, 2014

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4023081/#app2

Didactic lecture

Group discussions

Pain Laboratory

Small Assignments

Practical Exams

Case-based learning

Simulated patients

Learning activities

painexhibit.com

Experimental Pain LaboratoryStudents Share Personal Pain Experiences from Biopsychosocial Perspective

Students perform Temporal Summation and Conditioned Pain Modulation

Rate pain to different chemical, mechanical, thermal and ischemic stimuli

Students fill out pain questionnaires

Learning Activities

Simulated Patient Evaluation

Evaluation

Write an evidence based treatment plan

Search and grade evidence

Assigned pain condition and PT intervention

Discuss findings

Write and practice explaining

Referral to psychology to patient

Mechanisms of pain to patient

Effectiveness of intervention to physician

Learning experiences

painexhibit.com

Search and share scientific literature on a basic science subject not discussed in class

Do search in 30 minutes, write in 15 minutes

From case studies identify potential underlying mechanisms

Peripheral sensitization

Central sensitization

Neuropathic

Psychosocial concerns

Learning experiences

painexhibit.com

Lack of faculty expertise

Educate faculty

Designated faculty to coordinate

Incentives needed

Accreditation needs to include pain competencies

Licensure exam needs to test over competencies

Public demand and knowledge

Implementation

Pain Mechanisms and Management for the Physical Therapists, Sluka KA, IASP Press, 2009 (update in 2015)-textbook for PT students

Explain Pain, Butler DS and Moseley GL, 2013

Centers of Excellence in Pain Education (CoEPE), National Institute of Health http://painconsortium.nih.gov/NIH_Pain_Programs/CoEPES.html

International Association for the Study of Pain, www.iasp-pain.org

Hoeger Bement and Sluka, J Pain 2015 Feb;16(2):144-52 http://onlinelibrary.wiley.com/doi/10.1111/pme.12107/full

Fishman et al., Pain Medicine 14: 971-981, 2013 http://onlinelibrary.wiley.com/doi/10.1111/pme.12107/full

Bement et al., Physical Therapy 94: 451-465, 2014http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4023081/#app2

painHEALTH http://painhealth.csse.uwa.edu.au/

Interprofessional Pain Management Competency Program

http://www.ucdmc.ucdavis.edu/paineducation/Happenings/index.html

Resources

Improved education in PT over last decade

Need to expand education

Pain Science

Biopsychosocial approach

Education, self-management and active approach critical

Interdisciplinary approach

Summary

Kathleen A. Sluka, P.T, Ph.D.Professor

Physical Therapy and Rehabilitation Science Graduate Program

Neuroscience Graduate Program

Pain Research Program

University of Iowa

painexhibit.com

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms as such

Subjective

Article 1. The right of all people to have access to pain management without discrimination

Article 2. The right of people in pain to acknowledgment of their pain and to be informed about how it can be assessed and managed

Article 3. The right of all people with pain to have access to appropriate assessment and treatment of the pain by adequately trained health care professionals

Chronic pain affects more than a 100 million Americans, making its control of enormous value to individuals and society

Julie Meese: Chronic pain can make you

despondent…I find dealing with pain is

like riding a surf board -- I can get thrown

into the debilitating turmoil that is pain

along with fatigue, brain fog and

depression at any moment.

"Pool of Darkness" represents the times

when I fall off my surf board and am

unable to claw my way back to the surface.

Painexhibit.com

A moral imperative◦ Effective pain management is a

moral imperative

◦ A professional responsibility

◦ The duty of people in the healing professions

Need for interdisciplinary approaches◦ Produces the best results for

people with the most severe and persistent pain

Against The Barrier To

by Judith Ann Seabrookpainexhibit.com

To reduce the impact of pain and suffering we need to transform how pain is perceived and judged by:◦ people with pain◦ society◦ health care providers who help care for them

Goals ◦ better understand pain of all types (research

and education)◦ improving efforts to prevent, assess, and treat

pain (research and education)

Only 1/3 faculties could identify designated pain content hours in health sciences.

Veterinary Medicine had 3X more designated pain content hours on average, & 5x medicine.

Watt-Watson, McGillion et al., Pain Res Manage 2009 14(6), 439-444

Pain Education in Canada

J Watt-Watson 2015

Pain in PT curriculum averages 4 h (US) (faculty survey)

Most faculty believe pain is adequately covered in curriculum (faculty survey)

Similar in all professional programs◦ Medicine

◦ Nursing

◦ Pharmacy

Average number of hours◦ 31 contact hours

◦ Range 5-115 hours

61% believe adequately covered

49% aware of IASP guidelines

48% aware of IOM report on Pain

96% use evidence-based approach

6% (11 schools) have an independent pain course

Content Categories Mean + S.E.M. Median Mode Range

Pain Science 9.5 + 0.38 8 6 2-27

Pain Assessment 4.0 + 0.22 3 2 0-10

Pain Intervention and Management 27.2 + 1.3 24 16 6-84

Education and self-management

strategies

3.2 + 0.19 3 2 0-10

Exercise therapy for pain control 3.9 + 0.25 3 2 0-10

Manual therapy for pain control 4.4 + 0.26 3 2 0-10

Electrical agents for pain control

(TENS and IFC)

4.6 + 0.23 4 2 0-10

Thermal agents for pain control 3.9 + 0.23 3 2 0-10

Psychological management 2.7 + 0.17 2 2 0-10

Physician Management 2.2 + 0.14 2 2 0-10

Multidisciplinary (interdisciplinary)

management

2.3 + 0.14 2 2 0-3

Science Category Assessment Category

Topic % covered Topic % covered

Gate Control Theory 95% Subjective Pain Scales 99%

Biopsychosocial Model 95% Pain Specific Questionnaires 83%

Acute vs. Chronic Pain 97% Disease Specific Questionnaires 91%

Pain Pathways 97% Functional Assessments 86%

Peripheral Sensitization 84% Psychological Assessments 80%

Central Sensitization 87% Pain across the lifespan 68%

Cortical Processing 85%

Central Inhibition 85%

Neurotransmitters and

Receptors

Outline◦ I. Multidimensional Nature of Pain

◦ II. Pain Assessment and Measurement

◦ III Management of Pain

◦ IV. Clinical Conditions

DOMAINSI. Multidimensional nature of pain

II. Pain assessment & measurement

III. Pain management

IV. Clinical conditions

www.ucdmc.ucdavis.edu/paineducation

Threaded throughout curriculum◦ Core principles and assessments

◦ Specialized courses in orthopedics, neurology, cardiopulmonary

◦ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4023081/table/T1/

Stand-alone course◦ Detailed pain science

◦ Psychological barriers to management

◦ Importance of interdisciplinary management

Didactic lecture

Group discussions

Pain Laboratory

Small Assignments

Practical Exams

Case-based learning

Simulated patients

painexhibit.com

Experimental Pain Laboratory◦ Students Share Personal Pain Experiences from Biopsychosocial Perspective

◦ Students perform Temporal Summation and Conditioned Pain Modulation

◦ Rate pain to different chemical, mechanical, thermal and ischemic stimuli

◦ Students fill out pain questionnaires

Simulated Patient Evaluation◦ Evaluation

◦ Write an evidence based treatment plan

Search and grade evidence◦ Assigned pain condition and PT intervention

◦ Discuss findings

Write and practice explaining ◦ Referral to psychology to patient

◦ Mechanisms of pain to patient

◦ Effectiveness of intervention to physician

painexhibit.com

Search and share scientific literature on a basic science subject not discussed in class◦ Do search in 30 minutes, write in 15 minutes

From case studies identify potential underlying mechanisms◦ Peripheral sensitization

◦ Central sensitization

◦ Neuropathic

◦ Psychosocial concerns

painexhibit.com

Lack of faculty expertise◦ Educate faculty

◦ Designated faculty to coordinate

Incentives needed◦ Accreditation needs to include pain competencies

◦ Licensure exam needs to test over competencies

◦ Public demand and knowledge

Pain Mechanisms and Management for the Physical Therapists, Sluka KA, IASP Press, 2009 (update in 2015)-textbook for PT students

Explain Pain, Butler DS and Moseley GL, 2013

Centers of Excellence in Pain Education (CoEPE), National Institute of Health http://painconsortium.nih.gov/NIH_Pain_Programs/CoEPES.html

International Association for the Study of Pain, www.iasp-pain.org

Hoeger Bement and Sluka, J Pain 2015 Feb;16(2):144-52 http://onlinelibrary.wiley.com/doi/10.1111/pme.12107/full

Fishman et al., Pain Medicine 14: 971-981, 2013 http://onlinelibrary.wiley.com/doi/10.1111/pme.12107/full

Bement et al., Physical Therapy 94: 451-465, 2014http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4023081/#app2

painHEALTH http://painhealth.csse.uwa.edu.au/

Interprofessional Pain Management Competency Program

http://www.ucdmc.ucdavis.edu/paineducation/Happenings/index.html

Improved education in PT over last decade

Need to expand education◦ Pain Science

◦ Biopsychosocial approach

◦ Education, self-management and active approach critical

◦ Interdisciplinary approach

Embedding the IASP Pain Curriculum in

Pain Education for Physiotherapists in

Australia – the Experience Down Under.

A/Professor Julia Hush

Outline

• IASP Pain Curriculum for Physical Therapists

• Doctor of Physiotherapy Program at Macquarie University

• Integration of the IASP Curriculum into the DPT Program at MQ

o Principles

o Practice

o Simple teaching tools

o Evaluation

• Pain education resources

63http://www.iasp-pain.org

International Association for the Study of Pain

64http://www.iasp-pain.org

IASP Pain Education Curricula

“These curricula outlines are helpful for establishing teaching courses

on acute, chronic, and cancer pain at both the undergraduate and

graduate level” (IASP, May 2012)

Physical Therapy Task Force Committee:• Helen Slater• Kathleen Sluka• Anne Söderlund• Paul Watson (Chair)

The DPT Program at Macquarie University

• Three-year entry-level Doctor of Physiotherapy Program (DPT)

commenced in 2012 at Macquarie University, in Sydney, Australia.

• Extended Masters (Level 9 in Australian Qualifications Framework)

• The program was designed to meet international benchmarks as well as

national regulatory and professional standards.

The DPT Program at Macquarie University

Is unique in its co-location within Australia’s first University private hospital (Macquarie

University Hospital and Clinic) – now integrating with the new Faculty of Medicine and

Health Sciences to form Australia’s first academic health campus.

IASP Pain Education Curriculum for PTs

1. The multidimensional nature of pain

2. Pain assessment and measurement

3. Management of pain

4. Clinical conditions

Integrating the IASP curriculum into the DPT Program - principles

• Vertical and horizontal integration of content – embedded in units

rather than stand alone subjects

• Build complexity throughout program

• > 30 hours of core pain education

• Integration with clinical education (embedded in DPT program)

• Blended learning

• Evaluate pain-specific knowledge and clinical competencies

IASP Pain Education Curriculum for PTs

1. The multidimensional nature of pain

2. Pain assessment and measurement

3. Management of pain

4. Clinical conditions

Mapping the IASP Curriculum in the MQ DPT Program

Pedagogical Framework

Knowledge

Skills and competencies

Attitudes and beliefs

IOM recommendation: “expanding and redesigning education programs to transform the understanding of pain and improved education for clinicians.”

Pizzo, NEJM 2012

Bringing 21st C pain neuroscience into PT education

How pain works: From Descartes to the 21st C.

Bingel et al. Physiology 2008

Consider

Pain education requirements for:

• Faculty

• Sessional teaching staff

• Clinical educators

Training:

• Pain neuroscience and clinical models

• Workshops

• Provide resources

MQ DPT Pain curriculum

Semester A:

• Intensive training in current pain neuroscience, the biopsychosocial model and it’s integration into the assessment and management of pain.

• Commence clinical education

Semester B:

• Consolidate in discipline-specific content (MSK, CR, Neuro) and EBP

• Extend clinical education

• Semester C:

• Application in block clinical placements

MQ DPT Pain curriculum

Semester D:

• Pain across the lifespan

• Reintegration into sport / work

• Chronic and complex conditions

• Introduction to chronic pain management

Semester E:

• Develop advanced competencies in pain management – full day workshop

Semester F:

• Elective clinical placements – include pain management programs

Advanced pain management workshop

• Key components of pain management programs for chronic pain

• Explaining pain to patients

o Different approaches – discussion and videos

o Principles

o Content – tailored to individual patients

o Case-based clinical simulation practice

• Resources for clinicians and patients

• Addressing psychological factors

• Novel treatments for chronic pain

Clinical simulation student practice

• Case based – different pain vignettes

• Small group identifies relevant issues and develops content of education

• In-class simulation of explaining pain to “patient”

• Peer feedback and evaluation

Student practice of explaining pain

Simple teaching tools

• Six core concepts of pain

• Clinical model of pain

injury Signal generator

Amplifier

Gain setter

injury Signal generatorAmplifier

Gain setter

Clinical model of pain

Pain is driven by 3 interrelated and almost universally present factors:• A signal (from the periphery)• An amplifier (central sensitisation)• A gain setter (descending controls from the brain)

Adapted with permission from Siddall, P (2012) Neurobiological contributors to pain [study guide],

Postgraduate Degree Program in Pain Management, University of Sydney

Evaluation of students’ knowledge and competencies - examples

Semester 1:

• Pain neuroscience knowledge – Questionnaire

• Ability to apply knowledge to fundamental principles of patient assessment and treatment – Assignment

• Competencies in patient assessment and management of painful conditions – Clinical simulation exams

Evaluation: Pain Neurophysiology Knowledge

First year students (2014 intake)

Increase in knowledge from week 1 to week 12 (Semester 1)

Catley et al, J Pain 2013

WEEK 1 WEEK 12

Neurophysiology of Pain Questionnaire: DPT 3.0 Semester A

Pain education resources

Resources - books

Manage Your Pain. 3rd edition, ABC Books; Nicholas et al.

The Pain Book: finding hope when it hurts. Siddall et al.

Explain Pain. D. Butler & L. Moseley. NOIgroup

Therapeutic Neuroscience Education. Louw & Puentedura

Pain: Why and how does it hurt? G.L. Moseley. In: Brukner and Kahn: Clinical Sports Medicine.4th edition.

Resources - online

• TEDxAdelaide video Professor Moseley: “Why Things Hurt”

• ACI Pain Management Network website (NSW)

• Hunter Brainman videos (NSW)

• painHEALTH website (WA)

• HealthTalk Online website (Oxford University)

ACI Pain Management Network - NSW

ACI Pain Management Network.

• 7 episodes presented in short video clips

• Download a Health Care Plan for the patient to fill out and take to their GP for review and to establish a pain management plan

• Other useful resources on this website tailor this information for:

o Teenagers PainBytes

o SCI pain Spinal Cord Injury Pain

o Healthcare practitioners For healthcare professionals

Hunter Brainman Videos

Hunter Brainman videos: the “brainchild” of the team at Hunter Integrated Pain Service at John Hunter Hospital and Hunter Medicare Local, Australia.

3 videos:• Understanding pain and what to do about it in less than five minutes• Understanding Pain: Brainman chooses• Understanding Pain Brainman stops his opioids

painHEALTH website (Western Australia)

HealthTalk Online website

Videos of real patients with chronic pain talking about their experiences of using specific elements of pain management.

julia.hush@mq.edu.au

6/25/2015 108

Filling the GAP… with Continuing Education in

Behavioral & Lifestyle- based PT

SWEDEN AND ARGENTINA: How contextual and cultural factors may influence pain paradigms in education, guidelines and practice

Graciela Rovner, PT & PhD in Rehabilitation MedicineInternational ACT trainer, peer reviewed by

the Association for Contextual Behavioral Sciences (ACBS)Dept. Neurosciences and Physiology

University of Gothenburg SWEDEN

THE GAPS & DIFFERENCES

• Pain Education in Sweden-overview

• Continuing education

COMMONALITIES

• Behaviors

• Myths and misconceptions we carry

from education

• Pitfalls in the clinic

POTENTIAL GLOBAL MODEL?

• Behavioral physiotherapy in Sweden

• Acceptance & Commitment Therapy

(ACT pronounced ‘act’)

COMMONALITITES: People with chronic pain presents:

• Besides physiological signs…

• Emotional distress, and cognitive, and…and…..

…and other typical behaviors….

When the problem is not longer the problem…

…and the solution became

the biggest problem…

6/25/2015 116

Control excercise

Pain formulae:

Suffering= pain x control(or rejection or avoidance)

Suffering= 10 x ?

?= 20 Suffering= 200?= 2 Suffering= 20

Serenity Prayer

God, give us grace to accept with serenity the things that cannot be

changed, courage to change the things that can be changed, and the wisdom to

distinguish one from the other

Accept Changeadiction

depression

painisolation

anxiety

inactivity

Reinhold Niebuhr

Case conceptualization

Desired outcome

BIOMEDICALMODEL

Illness, presence of symptom, disruption of homeostasis

Symptom elimination or relief.

BIOPSYCHOSOCIALMODEL

Illness, interaction between psychological, social and pathophysiological aspects & ‘maladaptive behaviors.’

Symptoms relief with pharmacological and non-pharmacological interventions offered by several professions.

Case conceptualization Desired outcome

CBT Evaluates & control negative (”maladaptive”) behaviors.

Eliminate behaviors with exposure or transform their content into something positive. Behave well!

ACT Identification of non-flexible and non-functional avoidance behaviors

Clarify the patients’ values and help them to take the necessary steps/behaviors towards living a meaningful life despite pain of discomfort.

6/25/2015 Graciela Rovner 123

PAIN: six core concepts

1. Mental processes

2. tissue damage

3. Influenced by behaviors

4. Acute chronic pain

5. Chronic pain dysfunctional NS

6. Modifying behaviors non-inflammatory lifestyles ‘turns down’ NS increases functional level (physical and psychological) and thus quality of life.

Non-communicable diseases (NCDs)

NCDs disproportionately affect low- and middle-income countries

Lifestyle changes as first line intervention for chronic diseases

LIFESTYLES

Review of ACT- pain & Physical Function PerspectiveBarrable, C. & Rovner, GR (master diss, 2015 )

6/25/2015 Graciela Rovner 125

What is relevant to measure and focus on in behavioral and lifestyle-based pain rehabilitation?

WE need more focus on:•FUNCTION •Behaviors healthy ones!•Lifestyles increase non-inflamatoryactivities (physical, dietary, social, etc)

•Detect Myths and Misconceptions

What is relevant to measure and focus on in behavioral and lifestyle-based pain rehabilitation?

They say WHAT I should do, but not HOW…

GAPS:• how do we implement

these recommendations in ‘real life?

• How is assessment done and systematized?

• Are really important the different diagoses and syndromes in rehabilitation?

• Are these diferent pains predicting outcome for rehabilitation?

Want to know more?• GENERAL ACT BOOKS

ACT made simple by Russ Harris

ACT for Chronic pain by J. Dahl

Focused ACT by Strosahl, Robinson & Gustavsson (2014)

Acceptance and Commitment Therapy (ACT) for the mindful physiotherapist. By Rovner. In Probst, M & Skjærven, L.H. (Eds.), Physiotherapy in Mental Health and Psychiatry: a Scientific and Clinical Based Approach. IOPTMH Book in press.

• BOOKLET for physios

ACTivePhysio, basic guidelines how to assess, motivate and outline the ACTivePhysio rehab-plan (in press)

graciela.rovner@neuro.gu.se

Find the e-book link at: smartrehab.nu

If you want to buy the hard copy (20 USD), please approach me!

graciela.rovner@neuro.gu.se

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