psychologically informed physical therapy...

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Department of Physical Therapy

Psychologically Informed Physical Therapy (PIPT): Pragmatic Application for Low Back Pain

Jason Beneciuk, PT, PhD Assistant Professor Department of Physical Therapy University of Florida Brooks – PHHP Research Collaboration

Carol M. Greco, PhD Assistant Professor of Psychiatry Licensed Psychologist University of Pittsburgh School of Medicine

Steven George PT, PhD Associate Professor Department of Physical Therapy University of Florida Brooks – PHHP Research Collaboration


Learning Objectives

Upon completion of this course, you will be able to:

1. Summarize relationships between pain science, pain models, and the development and maintenance of chronic LBP

2. Implement psychologically informed physical therapy practice principles for patients with LBP

3. Identify patients at high risk for transitioning from acute to chronic LBP

4. Apply targeted treatment for patients at high risk for transitioning from acute to chronic LBP

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http://www.rstce.pitt.edu/pipt/


Steven George, PT, PhD

Pain Science Update: Need for Psychologically Informed Interventions


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Pain Science Update Objectives

1. Understand that variability is an inherent feature of the pain experience

2. Describe how psychological factors can be used to explain pain related patient differences

3. Understand that identification of pain associated psychological distress and use of targeted treatment approaches are key tenets of psychologically informed physical therapy

4. Identify that preventing transition to chronic back pain is a primary outcome goal for psychologically informed physical therapy


High Variability in Pain Experience

O’Neill et al, Pain. 2009

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Stimulus Temperature = 49ºC

Pain Intensity Rating (0-100)



1. Pain location with standard stimulus

2. High variability in pain intensity ratings with standard stimulus

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Clinical Implications

• High variation in pain experience

– Is evident, even with same peripheral generator

– Search for “the source” of pain may not be all that important

– Shifts need from tissue identification to focus on factors that influence variation


Variability in Pain Experience

• Influences on reporting pain (non-exhaustive list)

– Sex

– Age

– Genetics

– Psychological or psychosocial factors

– Nervous system processing

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Variability in Pain Experience

• Influences on reporting pain (non-exhaustive list)

– Sex

– Age

– Genetics

– Psychological or psychosocial factors

– Nervous system processing


General Psychological Model of Pain Perception

Linton & Shaw, Phys Ther. 2011

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Specific Psychological Models

• Fear-Avoidance Model – Activity avoidance leads to physical degeneration and social isolation

• Acceptance and Commitment Model – Repeated (futile) attempts to alleviate pain lead to frustration

• Misdirected Problem-Solving Model – Normal worrying; more worrying; less likely to solve problem

• Self-Efficacy Model – Fluctuating pain reduces perceptions of control

• Stress-Diathesis Model – Psychological stress & limited coping resources predispose one to pain

Linton & Shaw, Phys Ther. 2011


Specific Psychological Models

• Fear-Avoidance Model – Activity avoidance leads to physical degeneration and social isolation

• Acceptance and Commitment Model – Repeated (futile) attempts to alleviate pain lead to frustration

• Misdirected Problem-Solving Model – Normal worrying; more worrying; less likely to solve problem

• Self-Efficacy Model – Fluctuating pain reduces perceptions of control

• Stress-Diathesis Model – Psychological stress & limited coping resources predispose one to pain

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Fear-Avoidance Model of Musculoskeletal Pain

Leeuw et al, J Behav Med. 2007


• Catastrophizing

– Pain is interpreted as being extremely threatening

• Fear of Pain

– Present threat; defensive behavior

• Pain Anxiety

– Future-oriented; preventative behavior

• Negative Affect

• Threatening Illness Information

Fear-Avoidance Model of Musculoskeletal Pain

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Pain Intensity Rating (0-100)


Fear of Pain (30-150)

Pa

in I

nte

ns

ity R

ati

ng

(0

-10

0)

Psychological Factors Account for Variability


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Psychological Factors

• Consistent influence on elevated pain experiences

• Risk factors for poor patient outcomes

(Nicholas, et al. 2011; Chou & Shekelle, 2010)



• Opportunity for patient segmentation

– Risk stratification based on pain associated psychological distress subgroups

– Provide matched treatment based on subgroup assignment

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Psychologically Informed Physical Therapy Practice

Special Issue of PTJ - May 2011


Psychologically Informed Physical Therapy

Merges narrowly focused impairment based practice based on biomedical concepts with cognitive behavioral principles developed originally for

treatment of mental illness (Main & George, 2011)

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Psychologically Informed Physical Therapy (Fuentes et al, Phys Ther. 2014)



Integration

Physical Treatment Approach

Psychological Treatment Approach

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• Two important premises:

1. Identification of psychological processes that affect the perception of and response to pain as an expected and normal part of the musculoskeletal pain experience that are modifiable

2. Linking identification of psychological factors to the development of targeted treatment approaches



• Primary goals:

– Acknowledge and incorporate patient beliefs and emotional responses to pain into communication plan

– Incorporate key psychological principles into treatment plan

• Cognitive behavioral therapy

• Graded activity

• Graded exposure

– Prevent development of persistent or chronic pain conditions


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Pain Science Update Summary

1. Provided two examples of how variable the pain experience can be

2. Reviewed some of the evidence and a specific example of how psychological factors explain pain related patient differences

3. Introduced the conceptual background for psychologically informed physical therapy

4. Identified key tenets and goals for psychologically informed physical therapy


Carol Greco, PhD

Cognitive Behavioral Therapy (CBT)

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Cognitive Behavioral Therapy (CBT)

1. What is CBT?

1. Principles

2. Practicalities

2. How can CBT skills help you to help your patients?


Cognitive-Behavioral Therapy (CBT)

• History / Context:

– A type of psychotherapy approach

– Brief, designed to improve coping

• Depression

• Anxiety

• Chronic illness

• Pain

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Principal Assumptions of CBT • Individuals actively process environmental events and

internal stimuli (thoughts, emotions, perceptions) and consequences of behaviors.

• Thoughts, emotional responses, physiological and behavioral responses interact and influence one another.

• Individuals’ behaviors also influence/change the environment.

External environment

Internal stimuli

Behavioral responses Turk DC, Rudy TE (1989) Handbook of chronic pain

management


Principal Assumptions of CBT

• Treatment must address the cognitive, emotional and behavioral dimensions of the presenting problem.

• The patient must become an active participant in treatment.

Turk DC, Rudy TE (1989) Handbook of chronic pain

management

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CBT: ACTIVE Processing of Internal Events

Behaviors

Thoughts

Emotions /

Moods

Sensations


CBT: ACTIVE Processing of Internal Events

Behaviors

Thoughts

Emotions /

Moods

Sensations Will this

EVER get

Better???

Pain

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CBT: External Events and Contexts also Actively Processed

Personal /

Cultural

Medical

systems

Socioeco-

nomic

context

Social /

family

context


The ‘vicious cycle’ of pain

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The ‘vicious cycle’ of pain

The other side of the story:

• Repeated visits to HCP*

• Increased sense of helplessness

• HCP angry, rejecting

• Patient’s isolation increases

*Health Care Provider

Pain

Fear of Injury

Fear of Movement

Less Movement

Deconditioning/Disuse Syndrome

Physical & Mental

Deconditioning


CBT and other Behavioral treatments for pain

The Foundation – A Collaborative

Interpersonal Relationship

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Principal Assumptions of CBT

• Treatment must address the cognitive, emotional and behavioral dimensions of the presenting problem, as well as the physical dimensions.

• The patient must become an active participant in treatment.


CBT components

• Education and goal setting

– your problem is NOT unmanageable

– You are a resourceful problem-solver - NOT helpless

• Monitoring

– symptoms, environmental and psychosocial factors

• Skills development and practice

– Physiologic relaxation, re-framing thoughts, other pain coping skills

• Maintenance

– Planning for end of treatment

– Generalizing skills to other situations

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CBT Specifics • Identify and Assess -monitoring (body / mind)

• Re-conceptualize using biopsychosocial model

• Pleasant activity scheduling

• Breath focus/Relaxation/guided imagery

• Target unhelpful thinking via Cognitive Reframing

• Communication skills/conflict resolution

• Skills practice and Generalization

• Develop long-term goals

BEHAVIOR

ACTIVATION

BUILD

NEW

HABITS

Gatchel RJ, Rollings KH. (2008). Evidence-informed management of chronic low back pain with

cognitive behavioral therapy. The Spine Journal 8 (1): 40–4. .


CBT Psychotherapy vs. CBT-informed Physical Therapy practice?

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CBT Principles and Practicalities for Physical Therapists

• How can CBT skills help you to help your patients?

– Enhance communication / understanding

– Active partnership – agree on goals

– Simple skills for managing pain and increasing resilience


Psychologically Informed PT Overall Intention

• Empower the person toward good self care

– Self manage pain and mood

– Not helpless

– Resilience

• How do we do that?

• Where is the roadmap?

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Psychologically Informed PT for pain

The Foundation – A Collaborative

Interpersonal Relationship



• Empower the Physical Therapist

toward resilience

– Awareness of your views of the patient

• Expectations/ assumptions/ moods

– How do these influence your behavior?

The way you work with the person?

• Simple skills for you to use with patients at high-risk for chronic pain

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• Communication Skills

– Active listening, goal-setting, problem-solving

• Pain coping skills for you to use with patients at high-risk for chronic pain

– Breath-focus, physiologic relaxation

– Distraction (e.g., pleasant place imagery

– Re-framing unhelpful thinking patterns


CBT Summary

• CBT – principles, practicalities

• Pain and CBT principles

• CBT components in psychotherapy

• CBT practicalities for Physical Therapists

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Jason Beneciuk, PT, PhD

Patient Subgrouping


Patient Subgrouping

• Identify Patients

• Goal:

– Increased “between-group” variability

– Decreased “within-group” variability

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Patient Subgrouping – Why?

• Clinicians believe in subgroups

• Ability to match what treatment works for whom

• Consistent research priority

– APTA

– NIH

Foster, et al. 2011


Patient Subgrouping – Key Features

Subgroups should be:

• Plausible (“they make sense”)

• Clinically useful

• Identified through efficient system

Foster, et al. 2011

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Risk Stratification

A feasible option for patient subgrouping

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Risk Stratification

“Matching groups of patients with the most appropriate treatment based on their risk profile”

Foster, et al. 2013


Risk Stratification

???

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Risk Stratification

Prognostic Factors

Prognostic factors that are: • Modifiable • Influence outcomes


Patients are risk-stratified based on prognostic profile

High level of adverse prognostic factors

Low level of adverse prognostic factors

Prognostic Risk Stratification

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High Risk

Medium Risk

Low Risk

Risk for persistent LBP disability


Identification

• Screening for persistent LBP disability

• Screening methods

– Unidimensional approach

– Multidimensional approach

• Key modifiable prognostic factors for LBP

– Physical factors (e.g., difficulty dressing or walking)

– Psychological factors (e.g., fear, pain catastrophizing)

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Screening Methods

• Fear avoidance beliefs • Pain related fear • Pain catastrophizing • Depressive symptoms • Anxiety

70 items

9 items


STarT Back Tool Thinking about the last 2 weeks tick your response to the following questions:

Disagree Agree

0 1

1 My back pain has spread down my leg(s) at some time in the last 2 weeks □ □

2 I have had pain in the shoulder or neck at some time in the last 2 weeks □ □

3 I have only walked short distances because of my back pain □ □

4 In the last 2 weeks, I have dressed more slowly than usual because of back pain □ □

5 It’s not really safe for a person with a condition like mine to be physically active □ □

6 Worrying thoughts have been going through my mind a lot of the time □ □

7 I feel that my back pain is terrible and it’s never going to get any better □ □

8 In general I have not enjoyed all the things I used to enjoy □ □

9 Overall, how bothersome has your back pain been in the last 2 weeks?

Not at all Slightly Moderately Very much Extremely

□ □ □ □ □ 0 0 0 1 1

Total score (all 9): _____________ Sub Score (Q5-9):______________

© Keele University 01/08/07

Funded by Arthritis Research UK

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Thinking about the last 2 weeks tick your response to the following questions:

Construct

1 My back pain has spread down my leg(s) at some time in the last 2 weeks Leg pain

2 I have had pain in the shoulder or neck at some time in the last 2 weeks Co-morbid pain

3 I have only walked short distances because of my back pain Disability (walking)

4 In the last 2 weeks, I have dressed more slowly than usual because of back pain Disability (dressing)

5 It’s not really safe for a person with a condition like mine to be physically active Pain related fear

6 Worrying thoughts have been going through my mind a lot of the time Anxiety

7 I feel that my back pain is terrible and it’s never going to get any better Pain catastrophizing

8 In general I have not enjoyed all the things I used to enjoy Depressive symptoms

9 Overall, how bothersome has your back pain been in the last 2 weeks? Bothersomeness


□ □ □ □ □ 0 0 0 1 1




STarT Back Tool – Item Constructs


Total score

3 or less 4 or more

Sub score Q5-9

3 or less 4 or more

Low Risk Medium Risk High Risk


Funded by Arthritis Research UK Risk for persistent LBP related disability

STarT Back Tool – Scoring System

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Low Risk

Medium Risk

High Risk

Few physical and/or psychological factors present

Physical and psychological factors present; psychological factors are not high

High level of psychological factors present; with or without physical factors

STarT Back Tool – Risk Groups


STarT Back Tool – Research Examples

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Convergent validity

10.7

17.1

25.3

0

5

10

15

20

25

30


Pain Catastrophizing

3.7

7.6

12.4

0

2

4

6

8

10

12

14


Depressive Symptoms

*

*

*

*

*

*


Matched treatment was not provided

Predictive validity

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STarT Back Tool: Clinical Implications

• Screening potential across different practice settings

• Convergent validity for pain intensity, disability, and psychological scores at intake

• Predictive validity for disability scores and recovery status at 6-months


STarT Back Tool 1. Identify patient subgroups

2. Provide targeted treatment ?

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Targeted Treatment

Prognostic

Factors

Targeted Treatment

Targeted Treatment


Targeted Treatment

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Prognostic Risk Stratified Care

Patients are risk-stratified based on prognostic profile

Few physical &

psychological factors

Physical & psychological factors;

psychological factors not elevated

Elevated psychological factors;

with or without physical factors

Advice, education &

self-management

Physical therapy to address

symptoms and function (primarily targeting physical characteristics)

Psychological informed

physical therapy

1) Identification 2) Targeted Treatment


STarT Risk: Targeted Treatment

• Psychologically Informed Physical Therapy:

– Assessment and management of pain related psychological risk factors

– Adopting cognitive-behavioral principles to address unhelpful beliefs and behaviors (Recall Dr. Greco)

High Risk

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Targeted Treatment: High Risk

1. Communication 2. Pain coping skills 3. Activity based 4. Physical impairment based 5. Treatment monitoring




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Thoughts?



• Important that patient agrees with approach

• Outcomes aligned with patient expectations (patient-centered)

• Optimal communication between clinician and patient is crucial

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Communication with Patients

• Common Errors

– Not exploring patient beliefs

– Not referring to patient beliefs during explanation of condition

– Not verifying patient understands explanations provided

Main et al. Best Pract Res Clin Rheumatol. 2010


Example 1

“Based on responses to one of the questionnaires you have completed you are at high risk for chronic pain; therefore we are going to address psychological aspects of your pain in physical therapy.”

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Example 1

“Based on responses to one of the questionnaires you have completed you are at high risk for chronic pain; therefore we are going to address psychological aspects of your pain in physical therapy.”


Example 2

“Based on some of the initial information you have provided, I strongly believe you would benefit if we also address how you think and cope with your pain; in addition to other physical therapy treatment – does this sound like a reasonable strategy?”

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Example 2

“Based on some of the initial information you have provided, I strongly believe you would benefit if we also address how you think and cope with your pain; in addition to other physical therapy treatment – does this sound like a reasonable strategy?”


Treatment Decisions

Expected Outcomes

Enhanced Communication

Shared Decision Making

Patients

Clinicians

Family Caregivers

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Effective Communication Skills

• Active listening

• Motivational interviewing

• Goal-setting





• Goal-setting

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Active Listening

• Undivided attention to the patient (speaker)

• Listening with interest and appreciating without interrupting

• Improves mutual understanding

K. Robertson (2005)


Active Listening – “Roadblocks”

• Judging – Criticizing, labelling, expressing personal biases

• Suggesting solutions (difficult for clinicians)

– Ordering, excessive or inappropriate questioning – Risk of disempowering patient (more to follow)

• Avoiding patient concerns – Diverting (at times), defensive arguments

R. Bolton (1986)

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Active Listening – Strategies

• Non-verbal – Direct eye contact

– Posture & gestures indicating involvement and engagement

– Facial expression (eg, reflect empathy)

• Verbal – Discussion-based (avoid temptation to lecture)

– Clarification (accurate perception of patient concerns)

– Summarization (paraphrasing what patient has described)





• Goal-setting

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Motivational Interviewing

• Guides patient to explore and resolve mixed feelings about changing

• Strategy to help patient realize potential misperceptions between current behaviors, goals and values

Miller & Rollnick (1991, 2002)



• Collaborative and respectful approach to enhance patient motivation toward behavioral change efforts

• Strategies: – Support self-efficacy (increase patient confidence for success)

– Open-ended questioning (talk less, listen more)

– Affirmation (acknowledge patient effort to change)***

– Reflection (clinician provided summary)

Miller & Rollnick (2002)

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• Self Efficacy & Affirmation (closely linked)

– Focus on positive patient efforts

– Highlight accomplishments

– Reinforce patient confidence and commitment (support self-efficacy)


Facilitation of Self-Disclosure

• Explore patient concerns about problem

• Patient is asked to elaborate on provided information

– Example: STarT Back Tool items

• *Important – we are not critiquing or judging patient responses; only asking for elaboration

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Disagree Agree

0 1

1 My back pain has spread down my leg(s) at some time in the last 2 weeks □ □

2 I have had pain in the shoulder or neck at some time in the last 2 weeks □ □

3 I have only walked short distances because of my back pain □ □

4 In the last 2 weeks, I have dressed more slowly than usual because of back pain □ □

5 It’s not really safe for a person with a condition like mine to be physically active □ □

6 Worrying thoughts have been going through my mind a lot of the time □ □

7 I feel that my back pain is terrible and it’s never going to get any better □ □

8 In general I have not enjoyed all the things I used to enjoy □ □

Thinking about the last 2 weeks tick your response to the following questions:

9 Overall, how bothersome has your back pain been in the last 2 weeks?


□ □ □ □ □

0 0 0 1 1




Have patient elaborate on why they agree with this statement

STarT Back Tool





• Goal-setting

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Goal Setting

• Collaborative process between clinician and patient

• Are goals aligned with patient expectations? – If not, what are our options?

• Goals should be: – Realistic

– Specific

– Measureable


Goal Setting

• Other important components:

– Patient confidence?

– Patient commitment?

– Patient barriers?

• Collaborative process

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Direct link between communication and education


Activation Philosophy

“…unambiguously educating the patient in a way such that the patient views his or her pain as a common condition, rather than

as a serious disease that needs careful protection.”

Vlaeyan & Linton, Pain, 2000

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Activation Philosophy

• Reassurance – “no permanent damage”

– “the spine is strong even when painful”

• Encourage patient to resume normal activities (if appropriate)

• Encourage active (not passive) role in recovery process

• Emphasize positive attitude & adaptive coping styles


Time Efficiency

• Strategic process

• Ongoing process

– Not complete after initial patient encounter

• Risk-benefit analysis

– May require some additional time

– Strengthens patient-clinician collaborative relationship in recovery process

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Carol M. Greco, PhD

Communication Skills


Skill Building for PTs

• You have many skills!

• But…there may be barriers

– To using existing skills

– To implementing PIPT skills

Empowering you to Resilience

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PIPT – Overall Intention

• Empower the Physical Therapist

toward resilience

– Awareness of your views of the patient

• Expectations/ assumptions/ moods

– How do these influence your behavior?

The way you work with the person?


PIPT – Communication

• Case example: – You look at your schedule for the day.

– Steve G is coming at 11.

– Steve is 46, has back pain following a fall 5 weeks ago.

– He moves in a guarded manner, expresses fear about engaging in any exercise.

– Reluctant to resume his usual level of general activity.

– He has not been doing his home exercise program.

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• 1st step – communication with yourself!

“Steve G is coming in.”

Listen to what is going on in you - acknowledge

Thoughts?

Moods?

How does your body feel?



• Communication with yourself…

Acknowledge – it is OK to have that reaction, and…

What else is going on?

– As a PT – what is your goal / intent?

– Can you understand how Steve feels, to some extent?

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Communication with Steve…

Ideas?




• Some alternatives:

– Confrontation / Authoritarian style

– Advice giving

– Shaming / Judging

Anticipated outcomes?

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• Reflection

– Express understanding (connecting statement)

And

• Connecting over shared goals

– Acknowledge Steve’s desire to feel better




• Reflection

– Express understanding (connecting statement)

And

• Connecting over shared goals

– Acknowledge Steve’s desire to feel better

Possible outcomes?

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Questions?




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Carol M. Greco, PhD

Pain Coping Skills

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• Breath training / physiologic relaxation – Can decrease pain and muscle tension

• Pleasant imagery / memory – Induces a positive mood / distracts from discomfort

• Replace unhelpful thinking styles with balanced / adaptive attitudes – Important to use patient’s own words

Pain Coping Skills – Examples


We will address:

• Physiologic relaxation / breathing methods

• Pleasant place imagery

• Replacing cognitive distortions / unhelpful thinking

Pain Coping Skills

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Pain Coping Skills: Physiologic Relaxation / Breathing methods


Physiologic Relaxation

What it is…

• Muscle tension reduced

• Heartbeat may slow

• Increased temperature in hands/feet

• Feeling of calm

What it is not…

• Reading a book

• Watching the game

• Socializing

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• Pain often leads to bracing or tensing the muscles

• Stress of pain heightens physiologic arousal

– heart rate, BP, stress hormones

All this can Increase Pain

• Physiologic Relaxation counteracts the stress reaction to pain

Why use Physiologic Relaxation for Coping with Pain?


Simple methods:

• Deep breathing

• Diaphragmatic (Belly) breathing

• Progressive Muscle Relaxation (tense, then let go, various body regions)

Physiologic Relaxation

Davis M, Eshelman ER, McKay M (1995) The Relaxation and

Stress Reduction Workbook. New Harbinger Publications, Inc.

Oakland, CA

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Pain Coping Skills: Pleasant Place Imagery


Pleasant place imagery

• Human attention is limited

• Pleasant memory, visualization of pleasant place can distract from pain, worry

Pain Coping Skills

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• Often associated with physiologic relaxation, and with reduced sensations of pain

• Image or memory from the Patient, ideally

• Uses can range from simple distraction to hypnotherapy

Pleasant place imagery

Gatchel RJ, Turk DC (1996) Psyhological Approaches to Pain Management.

New York: Guilford Press


Pain Coping Skills: Replacing cognitive distortions / unhelpful thinking with balanced thinking

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Replacing unhelpful thinking / cognitive distortions

• Identify the unhelpful pattern(s)

• Acknowledge importance of thinking styles

• Develop ‘balanced’ alternatives (with patient)

Pain Coping Skills


Identify: STarT Back Tool clues

• “I feel my back pain is terrible and it’s never going to get any better”

– Tendency to ‘awful-ize’ (catastrophize) and ‘predict the future’

• “I have not enjoyed all the things I used to enjoy”

– Possible clue to depression – feeling helpless

• “…not really safe to be physically active… “Worrying thoughts going through my mind”

– Rumination, distortion

Replacing Unhelpful Thinking

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Example: the Role of Thoughts and Beliefs

Behaviors

Thoughts

Emotions /

Moods

Sensations This Will

NEVER

get

Better!!!

Pain More

Pain


Acknowledge the importance of thinking styles

• Clarify – ask patient to elaborate if needed

• Acknowledge that thoughts and beliefs may seem ‘true’ but they may slow progress to recovery

– Thoughts influence mood, behavior

• Keeping an open mind / being willing to consider alternative beliefs may improve mood, energy, and enhance progress toward PT goals


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Communication:

• Having good rapport / trust is important

• Reassure – appropriate Activity is Safe

• Brainstorm with patient – more realistic, balanced ways of thinking

– use the patient’s own words if possible




Unhelpful / distorted

• I have no control over this!

• This shouldn’t have happened to me! It’s not fair!

• This pain makes me so anxious that I can’t stand it!

Balanced / realistic

• I can cope. I’m learning new skills.

• Back pain is really common – and so is recovery.

• Relax. I’ve managed difficulties before and will do so again.

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Replacing unhelpful thinking with more balanced thinking

Behaviors

Thoughts

Emotions /

Moods

Sensations

Pain

Things take

time. My PT

and I are

working on

it…


Challenges for the PT:

• Adding and using a new skill set

• Limited about of time with each patient

Opportunity:

• Greater success with patients at high risk for chronicity…

– You may have more energy and a better mood yourself!

Pain Coping Skills

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How to implement Pain Coping Skills training:

• While assessing symptoms / monitoring progress

• As part of teaching an exercise

• As you observe pain behaviors

– Grimacing, bracing, hunched shoulders

• As a response to patient’s fear, anxiety

But I don’t have time…


Practice pain coping skills in day-long training

• Breath training / physiologic relaxation

– Focus attention – body sensations of breathing

• Pleasant imagery / pleasant memory

– Needs to come from the patient (though you can give them an example from your life)

• Replace unhelpful with adaptive attitudes

– ‘together we will move forward’ ‘stay in the here-and-now,’ etc.

Teaching Pain Coping Skills

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Pain Coping Skills

BREAKOUT SESSION


Pain Coping Skills – Case Example

• Gloria B, 35, has back pain subsequent to MVA 8 weeks ago.

• She frequently cancels appointments stating that her pain is too severe to engage in PT.

• When she arrives, she is nearly in tears, and is reluctant to engage in your work together.

• She says she is afraid that this pain will never improve.

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Closing comments regarding

Communication & Pain Coping Skills…


Communication & Pain Coping Skills

Acknowledgement:

• There is no cook-book!

• It’s OK to be uncertain

• Adding these skill sets to your repertoire is not trivial, but may be worth it!

• “Don’t let Perfect be the enemy of Good”

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Communication & Pain Coping Skills

• Potential challenges?

• Potential benefits?

• Help us to be of benefit to you. We need to hear from you. Give us your reflections, suggestions, further needs…


Clinical Application – HEP

Direct link between communication, pain coping

skills, and HEPs

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Stephen T. Wegener, PhD, ABPP

Professor Department of Physical Medicine and Rehabilitation Director, Division of Rehabilitation Psychology and Neuropsychology Department of Health Policy and Management Johns Hopkins University




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Activity Based Objectives

1. Review foundation of applying targeted treatment using risk stratification

2. Identify two different methods of applying activity based intervention

3. Differentiate key principles and application between graded activity and graded exposure

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Activity Based Intervention

• Two broad behavioral approaches:

– Graded exercise or activity

– Graded exposure


Graded Exercise or Activity

• Principles

– Encourages continued activity, despite presence of pain

– Dosage: quota-based system

– Baseline level: ability to perform exercise or activity to pain tolerance (duration, intensity, frequency)

– Subsequent sessions based on “initial quota”

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• Principles

– Reinforcement provided for quota achievement

– Reinforcement not provided if quota is not achieved

– Quota is gradually increased across sessions

– Important that patient understands process!!!


Patient walks on treadmill (2 min. @ level 2)

before stopping because of pain tolerance

Initial quota: 2 min. @ level 2

Subsequent sessions:

Meets quota Does not meet quota

Progress quota Maintain quota


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• Suggested as a more effective alternative than quota driven approaches

• Difference?

– Graded activity = increase in generic functional capacity (operant conditioning model)

– Graded exposure = increase in activities that are fearful (exposure/phobia model)

Graded Exposure


• Principles

– Based on classic exposure principles

• Gradually expose patient to what they are fearful

• Increase exposure as fear decreases

– An exposure based system

• Exercise progression based on decreasing fear of activity

• Pain does not normally figure in exercise progression

Graded Exposure

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• Primarily for patients reporting high levels of fear and avoidance behaviors

• Feared or avoided activities determine focus of treatment

• Dosage: hierarchical exposure approach; subsequent progression based on fear levels with specific activities

Graded Exposure


1. Identification of feared activity (via FDAQ)

2. Incorporate feared activity into treatment plan (low level)

3. Increase feared activity to increase level of fear (mod level)

4. Increase feared activity to further increase level of fear (high level)

Graded Exposure

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• As level of “fear” decreases, level of activity increases

• Progression of activity based on:

– Position

– Intensity

– Frequency

– Duration

Graded Exposure


September, 2009

• Potentially viable measure for fear of specific activities in physical therapy settings

• Determining graded exposure treatment plans

• Monitoring changes in fear levels

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40

50

60

20

40 20

40

10

20 30

60

60

Folding laundry

Walking up incline

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First Session: • Identify most fearful activities (FDAQ)

• Patient reports level of activity he/she is willing to perform with increase in fear

Subsequent Sessions: • Patient performs fearful activities (level of determined based on previous session)

• PT monitors session

• FDAQ reassessment

Does patient have less fear of activities?

YES NO

+ Reinforcement

Increase activity level ≥10%

(duration, frequency, intensity)

Reinforcement of Importance

No change in activity level

(duration, frequency, intensity)

Repeat Process Repeat Process


Example

Fear of bending forward identified

1. Lumbar flexion in supine

2. Lumbar flexion in sitting

3. Lumbar flexion in standing

4. Lumbar flexion while retrieving weighted object from ground

5. Must be reinforced as part of HEP ***

Graded Exposure

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Activity Based Summary

• Graded exercise or activity

– Not based on fearful activities

– Exercise or activity that is limited by pain

• Graded exposure

– Based on fearful activities

– Activities identified via FDAQ


Activity Based Objectives

1. Described targeted treatment specific to high risk patients stratification

2. Identified graded activity and graded exposure as two methods of applying activity based intervention

3. Differentiated key principles and application between graded activity and graded exposure

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July, 2009




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LBP Clinical Practice Guidelines

ICF-Based Classification

1. Acute LBP with Mobility Deficits

2. Subacute LBP with Mobility Deficits

3. Acute LBP with Movement Coordination Impairments

4. Subacute LBP with Movement Coordination Impairments

5. Chronic LBP with Movement Coordination Impairments

6. Acute LBP with Related (Referred) LE Pain

7. Acute LBP with Radiating Pain

8. Subacute LBP with Radiating Pain

9. Chronic LBP with Radiating Pain

10. Acute or Subacute LBP with Related Cognitive or Affective Tendencies

11. Chronic LBP with Related Generalized Pain


Grades of Evidence

These recommendations and CPGs are based on scientific accepted for publication prior to January, 2011.

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Recommended LBP Impairment / Function-Based Classification Criteria with Recommended

Interventions

Refer to CPGs: pages A40 – A43















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ICF-Based Category

Symptoms Impairments of Body Function

Primary Intervention Strategies

Acute LBP with Mobility Deficits

• Acute low back, buttock, or thigh pain (duration ≤1 month

• Unilateral pain • Onset of symptoms

often linked to recent unguarded/awkward movement or position

• Lumbar ROM limitations

• Restricted lower thoracic and lumbar segmental mobility

• Low back and low back related lower extremity symptoms reproduced with provocation of involved lower thoracic, lumbar, or sacroiliac segments

• Manual therapy interventions (thrust manipulation and other non-thrust mobilization techniques) to diminish pain and improve segmental spinal or lumbopelvic motion

• Therapeutic exercises to improve or maintain spinal mobility

• Patient education that encourages the patient to return to or pursue an active lifestyle















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ICF-Based Category

Symptoms Impairments of Body Function

Primary Intervention Strategies

Acute LBP with Movement Coordination Impairments

• Acute exacerbation of recurring LBP commonly associated with referred lower extremity pain

• Symptoms often include multiple episodes of LBP and/or low back related lower extremity pain in recent years

• LBP and/or low back related LE pain related at rest or produced with initial to midrange spinal movements

• LBP and/or low back related LE pain reproduced with provocation of the involved lumbar segment(s)

• Movement coordination impairments of lumbopelvic region with low back FLX and EXT movements

• Neuromuscular re-education to promote dynamic stability to maintain involved lumbosacral structures in less symptomatic mid-range positions

• Consider use of temporary external devices for passive restraint to maintain involved structures in less symptomatic mid-range positions

• Self-care training re: 1) postures and motions (neutral or symptom alleviating positions) 2) recommendations to pursue or maintain active lifestyle


Risk Stratified Care

Few physical &

psychological factors

Physical & psychological factors;

psychological factors not elevated

Elevated psychological factors;

with or without physical factors

Advice, education &

self-management

Physical therapy to address

symptoms and function (primarily targeting physical characteristics)

Psychological informed

physical therapy

1) Identification 2) Targeted Treatment

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Merges narrowly focused impairment based practice based on biomedical

concepts with cognitive behavioral principles developed originally for

treatment of mental illness (Main & George, 2011)


“Let’s not throw the baby out with the bathwater”

We are well trained in addressing physical impairments…CPGs

provide us with recommendations

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TREATMENT MONITORING


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Treatment Monitoring

• Initial assessment findings are likely to change early during an episode of care…

• …Support for ongoing treatment monitoring process

Dunn & Croft, 2006; Hayden, et al. 2010; Van der Windt, et al. 2008

Initial

Assessment

Clinical

Reasoning?



Early during episode of care

Later during episode of care

Initial assessment

Do changes inform clinical reasoning?

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Treatment Mediator (baseline factor level needs to

change after treatment to

influence outcome)

Pain related

fear

Outcome Treatment



influence outcome)

Pain related

fear

Outcome Treatment

Decreased Fear ~ Good Outcome

Increased Fear ~ Poor Outcome


Outcomes Measures

• Numerical Pain Rating Scale (NPRS)

– MCID: 2 points (Childs, et al. 2005)

– ≥30% improvement from baseline (Ostelo, et al. 2008)

• Oswestry Disability Index (ODI)

– MCID: 10 percentage points (Ostelo, et al. 2008)

– ≥30% improvement from baseline (Ostelo, et al. 2008)

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Treatment Monitoring Process

Follow-up Assessment

Options

Initial Assessment

STarT Back Tool

Self-selected unidimensional

measures

OSPRO-YF Assessment Tool


OPTION #1

Re-administer STarT Back Tool

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Option #1

• Is patient still high risk?

• Has patient changed from high to medium or low risk?


Purpose: Describe changes in SBT categorization following 4-weeks of physical therapy and to evaluate predictive capabilities of SBT categorization when administered at multiple time points

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Disability Change Patterns Intake SBT Risk

SBT Risk Change Pattern



• Repeated SBT assessment has potential to provide additional prognostic information for 6-month disability

• Provides follow-up SBT risk status information

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OPTION #2

Administer self-selected unidimensional psychological measures


Option #2

• Would require baseline (or near baseline) initial assessment to if changes are observed

• Useful to detect changes in specific psychological constructs (eg, pain catastrophizing)



influence outcome)

Pain catastrophizing

Outcome Treatment

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Unidimensional Psychological Measures

• Useful to identify specific treatment targets

• Changes scores for treatment monitoring

• Examples

– FABQ

– PCS

– TSK-11

– PHQ-9


OPTION #3

Administer OSPRO-YF Assessment Tool

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OSPRO Yellow Flag Assessment Tool

• Orthopaedic Physical Therapy Investigative Network (OPT-IN)

• Optimal Screening for Prediction of Referral and Outcome (OSPRO) Cohort Study


OSPRO Yellow Flag Assessment Tool

• Multiple psychological constructs

– Negative mood

– Fear avoidance

– Positive affect / coping

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• Negative mood – Patient Health Questionnaire (PHQ-9)

– State-Trait Anxiety Inventory (STAI-T)

– State-Trait Anger Expression Inventory (STAXI)


• Fear avoidance – Fear Avoidance Beliefs Questionnaire

• (FABQ-PA) • (FABQ-W)

– Pain Catastrophizing Scale (PCS)

– Tampa Scale of Kinesiophobia (TSK-11)

– Pain Anxiety Symptoms Scale (PASS-20)

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• Positive affect / coping – Pain Self-Efficacy Questionnaire (PSEQ)

– Self-Efficacy for Rehabilitation Outcome Scale (SER)

– Chronic Pain Acceptance Questionnaire (CPAQ)


Trevor A. Lentz, PT, SCS Jason M. Beneciuk, PT, PhD, MPH Joel E. Bialosky, PT, PhD Giorgio Zeppieri, Jr. PT, MPT, SCS Yunfeng Dai, MS Samuel S. Wu PhD Steven Z. George, PT, PhD

Development of a Yellow Flag Assessment Tool for Orthopaedic Physical Therapists: Results from the Optimal Screening for Prediction of Referral and Outcome (OSPRO) Cohort

Manuscript in press

• OSPRO-YF provides estimate for individual psychological measure scores (upper/lower quartile)

• 17, 10, and 7 item versions

• 85%, 81%, and 75% accuracy

• Scoring algorithms provided

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Important to communicate this information with patients…


Treatment Monitoring Suggestions

1. STarT Back Tool – Changes from high risk status

2. Unidimensional psychological measures – Change scores

– Requires baseline assessment

3. OSPRO-YF Assessment Tool – Upper/lower quartiles

– Requires baseline assessment

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Questions?


CHALLENGES & OPPORTUNITIES

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• Poor understanding of the role of psychosocial factors during patient clinical presentation

• Unclear about psychosocial factor assessment

• Lack of formal education in psychosocial theory and assessment skills (consistent barrier)


• Significant challenges • Further specific training • Mentor support needed

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Key Challenges


Key Challenges

• Current Physical Therapy Practice

– Physical therapy “culture” and current practice propagate anatomical, biomechanical , and biomedical models

– Focus of continuing education reinforces biomedical emphasis from entry-level training

– Uncertainty about how to assess and mange key psychological factors in ways that fit into busy clinical practice

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Key Challenges

Biomedical or impairment based perspectives are predominantly emphasized during the

education and clinical practice of many physical therapists with little, if any content being

provided from a biopsychosocial perspective

Main & George, 2011 Foster & Delitto, 2011 Smart & Doody, 2007 Daykin & Richardson, 2004 Bishop & Foster, 2005 Simmonds, et al. 2012


Clinician Attitudes & Beliefs

• Healthcare provider attitudes and beliefs can influence how patients are perceived and subsequent management strategies (Rainville, et al. 2000)

• Commonly described management approaches

– Biomedical

– Biopsychosocial

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Biomedical Management Approach

• Pathology-based

• Identification of specific tissue(s)

• Causal relationship

– Physical pathology → signs and symptoms


Biopsychosocial Management Approach

• Psychological and social factors are important in development and maintenance of chronic pain

• Pain can still be present following tissue healing

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Key Challenges

Sustained attitudes and beliefs toward biomedical treatment orientations may

serve as a barrier for adoption of stratified care approaches in clinical practice

because some rely heavily on psychological informed principles (Foster & Delitto, 2011; Sanders, et al. 2013)


As a clinician, what are your perceived barriers to

implementation?

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Key Opportunities


Key Opportunities

• Current Physical Therapy Practice

– Gather more evidence about the outcomes of patients managed through biopsychosocial management approaches

– Determine how to facilitate tangible shifts in clinical practice

– Identify and target key psychosocial factors more systematically and use them in treatment decision making

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Key Opportunities • Evaluate strategies for shifting clinician

attitudes and beliefs from a predominant biomedical to a biopsychosocial treatment orientation (Sanders, et al. 2013)

• Consistent with improving knowledge about current conceptualization of pain experiences (Institute of Medicine, 2011)

Important for implementation of stratified care approaches

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QUESTIONS? COMMENTS?




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THANK YOU!

[email protected] [email protected]

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psychologically informed physical therapy...

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