MAKING THE GRADEZACHARY HUFF, PT, DPT, OCS

COURSE OBJECTIVES

▸ Explore the biopsychosocial treatment paradigm

▸ Identify psychosocial influences and their affects on biology and behavior

▸ Develop a goal-focused graded exposure program based on cognition/behavioral components

▸ Integrate a graded exposure into a comprehensive program based on individual patient characteristics

INFLUENCES

▸ HOW DO WE APPLY THE INFORMATION?

▸ WHERE DO WE START?

WHAT IS PAIN?

▸ “Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” - International Association for the Study of Pain

▸ “Pain is a distressing experience associated with actual or potential tissue damage with sensory, emotional, cognitive and social components.” - Williams & Craig (2016)

THAT LAST PATIENT OF THE DAY…

▸ Jack is a 47 y/o male with persistent lower back pain that radiates across his entire lower back and into his bilateral LE (R > L). His symptoms have been gradually worsening, despite several changes/increases in Lyrica/Morphine/Norco and a series of epidural injections. He has received PT several times in the past with little benefit.

▸ Duration: 14 years

▸ Past hx: L5-S1 Lumbar fusion following initial injury, “re-injury” 3 months later; gradual loss of life/self

PARADIGM SHIFT

▸ Biomedical paradigm - Dysfunction/disease purely biological/neurological in nature

▸ Biopsychosocial paradigm - A shift in how we think/view the patient and their experience

▸ Biological/biomedical

▸ Psychological

▸ Sociological

BIOPSYCHOSOCIAL COMPONENTS - PSCEBSM?!

▸ Wijma, van Wilgen, Meeus, & Nijs (2016) proposed the following factors for assessment:

▸ Pain mechanisms

▸ Somatic/medical factors

▸ Cognitions/perceptions

▸ Emotional factors

▸ Behavioral

▸ Social

▸ Motivation

“WHERE WE’RE GOING, WE DON’T NEED ROADS.”

Doc Brown

IN FLUX

▸ There is no pre-drawn road map or plan

▸ All factors may play a role in a pain experience

▸ All factors are likely fluctuating throughout a pain experience

▸ How can we visualize this?

PERSON

BEHAVIOR

PAIN MECHANISMS

COGNITION/PERCEPTION

SOCIAL

EMOTION

SOMATIC/MEDICAL

MATURE ORGANISM MODEL

▸ Developed in 1998 by Louis Gifford

▸ Displays the interconnectedness of various factors/pain characteristics

▸ Characterized by 3 components:

▸ Sample

▸ Scrutinize

▸ Respond

▸ Interaction between sample/scrutinization process MAY result in a response

Gifford (1998)

FOCUS…

▸ Psychosocial/emotional factors are prognostic

▸ Fear

▸ Catastrophization

▸ Pain problems often coincide with behavior problems

▸ Pacing, lifestyle factors

▸ Learned behaviors

▸ Physical behaviors

WHY?

WHAT IS “BEHAVIOR?”

▸ Merriam-Webster define behavior as:

▸ The manner in which one acts or conducts oneself, especially toward others

▸ Anything an organism does involving action and response to stimulation

▸ The response of an individual, group, or species to its environment

▸ The way in which someone conducts oneself or behaves

▸ The way in which something operates or functions

HELPFUL OR HINDERING?

▸ Adaptive vs Maladaptive Behavior

▸ Mature Organism Model - “Outputs”

▸ Often impacted by the various aspects of “scrutinization”

▸ Psychological factors

▸ Social

▸ Work

▸ Culture

▸ Past Experiences

ADAPTIVE VS MALDAPAPTIVE

▸ Psychological

▸ Work

▸ Past Experiences

▸ Culture

▸ Biological

▸ Social

FACTORS?

BRING IT BACK TO JACK

▸ Jack had been dealing with persistent back pain for 14 years and had developed numerous beliefs/behaviors that correlated with his pain. He walked/transferred c a stiff spine, demonstrated bracing/facial grimace with all movement/transfers, and believe his spine were “unstable” and his core was not strong enough to stabilize his spine.

▸ In this situation, where did our assessment start?

ASSESSING PSYCHOSOCIAL FACTORS

▸ Cognitions/beliefs

▸ ABCDEFW

▸ Fear-avoidance

▸ Self-reported

▸ PHODA

▸ Motivation/Direction

▸ Motivational Interviewing techniques

ABCD…

▸ Attitudes/Beliefs: Spine was unstable, required bracing/tensing of core prior to movement, pain indicated damage

▸ Behaviors: Avoidant with most activities; persistent avoidant with others

▸ Compensation: Granted disability several years prior

▸ Diagnosis/Treatment: Arthritis, disc bulge, “weak core,” several rounds of PT, several epidural injections, opioids

EFW?

▸ Emotion: Frustrated, angry, helpless/hopeless, depressive feelings in regards to his role in the family, fearful of flexion/lifting/walking

▸ Family: Supportive, but frustrated with situation; father cannot play with children,

▸ Work: Unable to work due to pain, indicates he was let go from another job secondary to narcotic use. Currently acts as a substitute teacher, though is unable to sit through classes which have affected his employability

THE BIG PICTURE? DOES IT MAKE SENSE?

JACK

BEHAVIOR

PAIN MECHANISMS

COGNITION/PERCEPTION

SOCIAL

EMOTION

SOMATIC/MEDICAL ▸ ICF

▸ Fear-avoidance

▸ Onion layers

▸ Disability Model

▸ Pain Neuroscience Education

▸ Biopsychosocial

JACK’S EXPLANATIONInjury

Fear-Avoidance

Thoughts/beliefs

Learned behaviors

Bracing, tensing

Pain/Flare

Focus on symptoms

Anger/frustration

Loss of self

Helpless/hopeless

Withdrawal

Iatrogenic

SET THE AGENDA

▸ Change Questions

▸ Where are you now?

▸ Where do you want to be?

▸ What will it take to get there?

▸ What is the next step?

▸ Assess readiness

▸ Scaling questions

▸ Importance vs confidence

MOTIVATIONAL INTERVIEWING

▸ A collaborative, person-centered form of guiding to elicit and strengthen motivation for change

▸ Spirit of MI: Collaborative, Evocative, Autonomy

▸ Guiding principles

▸ Resist the righting reflex

▸ Understand their motivations

▸ Listen

▸ Empower

THE GRADE

GRADED EXPOSURE (GIFFORD, 2014)

▸ Process of gradually exposing a person to a feared/avoided activity

▸ Cognitively challenging. Requires a patient to:

▸ Realize they have a problem

▸ Are prepared to challenge and confront the issue

▸ Trust you

▸ Are prepared to start easy and build slowly

FEAR?!

▸ Where do we start?

▸ Subjective examination

▸ Goals

▸ PHODA?

▸ Allow them to have input on where you start and how you progress

▸ Develop “behavioral experiments” to challenge beliefs

FEAR-AVOIDANCE

▸ Determined through subjective evaluation

▸ Flexion/bending, walking, exercising, jogging, working on his farm, lifting/carrying items, loading/unloading the dishwasher

▸ PHODA

▸ Provides insight into their perception of their ability to perform various physical activities

▸ Long form/short form

CREATING A BEHAVIORAL EXPERIMENT

▸ Identify an activity/goal

▸ What do they the expect to happen? Why?

▸ Break it down into doable chunks

▸ Better yet, ask THEM to break it down

▸ Scaling questions?

▸ Goal? DISCONFIRMATION!

MAKING IT STICK

▸ Craske et al (2014)

▸ Expectancy violation

▸ Deepened extinction

▸ Occasional reinforced extinction

▸ Removal of safety signals

▸ Variability

▸ Retrieval cues

▸ Multiple contexts

BUT…IT HURTS!

▸ Defocus on pain, focus on behavior

▸ Identify maladaptive behaviors, provide alternative behaviors

▸ Breathing, pre-tensing, grimacing

▸ Teach -> Coach -> Watch -> Give Feedback -> Reassure

▸ We are aiming for “thoughtless, fearless movement” (Gifford 2014)

IS IT ANY BETTER THAN ANY OTHER INTERVENTION?

▸ Comparable to Graded Activity in pain reduction, though has shown better results in reducing catastrophization, reduced fear-avoidance, improved function

▸ Cognitive functional therapy (CFT), which relies on graded-exposure while addressing cognitive alterations has shown favorable response in many with chronic lower back pain (Fersum et al 2013)

BACK TO JACK

▸ Goals:

▸ Start exercising/lifting weights again

▸ Walk for 10 minutes in his home environment

▸ Help around the house

▸ Load the dishwasher for 5 minutes

▸ Sweep one room of the house

▸ Pick something up from the ground

▸ Bending forward in a seated position

JACK’S GRADE

Loading dishwasher

Lifting feedLifting

laundry

Standing flexionSeated

flexion

CONFIDENCE?

IMPORTANCE?

EXPECTATION?

IS THAT IT?!

THE BIGGER PICTURE

JACK

BEHAVIOR

PAIN MECHANISMS

COGNITION/PERCEPTION

SOCIAL

EMOTION

SOMATIC/MEDICAL

▸ Did you find any other issues that you could address?

▸ Pop them into the “shopping basket!” (Gifford 2014)

▸ Develop a plan to address each issue

▸ Again, get their input!

JACK…OF ALL TRADES?

▸ Pain mechanisms: Mixed (central + nociceptive)

▸ Emotional: Anger, stress (household), depressive feelings

▸ Somatic/medical: Physical habits/movement patterns, bracing, tense/rigid movement, general fitness, sleep

▸ Behavior: Mixed (persistent-avoidant), particularly of flexion-based activities and load

▸ Social: Isolated, worthless to family, household/paternal role, unable to provide, unable to work on farm

JACK’S SELF-MANAGEMENT PLAN

▸ Graded exposure program for life tasks

▸ Lifting, carrying, bending

▸ Wellness program to address image of self/fitness

▸ Coping strategies

▸ TENS, heat, stress management, recognition of “triggers”

▸ Gradual return to meaningful activities

▸ Family, friends, dogs

SUMMARY

▸ We’re dealing with people…and people are complex

▸ Focus on function and return to preferred activities

▸ Be patient! Physical therapy and recovery are largely about behavioral change; this takes time

▸ Don’t be afraid to refer out! The longer pain has been present, the broader your management program needs to be

THANK YOU!

REFERENCES▸ Bittencourt, N. F., Meeuwisse, W. H., Mendonça, L. D., Nettel-Aguirre, A., Ocarino, J. M., & Fonseca, S. T. (2016).

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