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Dr. Worst Exam 1 > Fear avoidance and secondary gain > Flashcards

Fear avoidance and secondary gain Flashcards

1
Q

What is the purpose of the Fear Avoidance Belief Questionnaire?”

A

The FABQ was developed by Waddell to investigate fear-avoidance beliefs among LBP patients in the clinical setting. This survey can help predict those that have a high pain avoidance behavior. Clinically, these people may need to be supervised more than those that confront their pain.

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2
Q

How is the FABQ scored?

A

The FABQ consists of 2 subscales, which are reflected in the division of the outcome form into 2 separate sections.

  1. Subscale 1- (items 1-5) is the Physical Activity subscale (FABQPA), and
  2. Subscale 2- (items 6-16) is the Work subscale (FABQW).

Not all items contribute to the score for each subscale; however the patient should still complete all items as these items were included when the reliability and validity of the scale was initially established.

A low FABQW score (less than 19) was one of 5 variables in a clinical prediction rule that increased the probability of success from SI region manipulation in individuals with low back pain.

Each subscale is graded separately by summing the responses respective scale items (0 – 6 for each item); for scoring purposes, only 4 of the physical activity scale items are scored (24 possible points) and only 7 of the work items (42 possible points).

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3
Q

FABQPA

A

Fear Avoidance Beliefs Questionnaire Physical Activity

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4
Q

FABQW

A

Fear Avoidance Beliefs Questionnaire Work

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5
Q

Measurement characteristics of the FABQ

A

The FABQ has been demonstrated to be valid and reliable in a chronic LBP population, and appears to be a useful screening tool for identifying acute LBP patients who will not return to work by 4 wks.

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6
Q

How is the FABQPA subscale scored?

A

Sum items 2, 3, 4, and 5 (the score circled by the patient for these items).

  • Low Fear- 0-14
  • High Fear 15-24
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7
Q

How is the FABQW subscale scored?

A

Sum items 6, 7, 9, 10, 11, 12, and 15.

  • Low fear- 0-29
  • High fear- 30-42
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8
Q

Effects of Education on return to work status - Objective of study

A

To determine whether education and counseling on pain management, physical activity, and exercise could significantly decrease the number of days that people with LBI are off work

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9
Q

What is self efficacy?

A

An Individual’s belief in his/her capacity to perform a behavior”

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10
Q

What is pain related self efficacy?

A

The patient believes he/she is capable of pain-management

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11
Q

Prognosis of patients with high pain related self efficacy: (4)

A
  • Increased maintenance of treatment benefits (longer lasting effects)
  • Lower depression
  • Engages in active pain coping
  • Shorter duration LBP
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12
Q

Effects of Education on return to work status: Discussion & Conclusion:

A

Education & counseling regarding pain management, physical activity and exercise can reduce the number of days off work in people with FAB and acute LBP

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13
Q

PT Management: Strategies to Improve ILOC and Self-efficacy:

A

Educate patient that he/she is responsible for managing their pain

  • Reduces chance locus of control over treatment periods
  • Improved pain-related self-efficacy long term

(ILOC = internal locus of control)

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14
Q

Effects of Education on return to work: What are the three (3) Psychological factors that contribute to predicting which people have a greater likelihood of experiencing chronic disability in the future following an episode of acute LBP?

A
  • Maladaptive responses to movement-related pain
  • Beliefs about physical capabilities
  • Fear avoidance beliefs
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15
Q

Effects of Education on return to work: What variable is most predictive of who would be off work 4 weeks after onset of acute LBP?

A

The individual’s belief about his/her ability to return to work

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16
Q

Effects of Education on return to work: What variable may assist in the development of intervention strategies for preventing the transition of acute LBP into a chronic condition and the associated work related disability?

A

Early identification of people at risk of not being able to return to work following an episode of LBP

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17
Q

Effects of Education on return to work: What was the approach discussed in the case report by George and associates?

A

They used repeated reinforcement of exercises and pain management strategies described in an educational pamphlet “The back Book” which resulted in a reduction of FAB in pts with acute LBP and FAB

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18
Q

Effects of Education on return to work: What were the key principles for people to acknowledge as described in “The Back Book”? (5)

A
  1. LBP does not suggest the presence of a serious disease
  2. The spine is strong, and pain does not necessarily mean that the spine is damaged
  3. Lasting pain relief depends on what people do and not on medical treatments
  4. Activity is essential for restoring normal function and fitness and
  5. Positive attitudes and coping skills are helpful
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19
Q

Effects of Education on return to work: In occupational health Physical Therapy, what is the ultimate goal of any intervention strategy?

A

To make it possible for people to return to work

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20
Q

What should be addressed in your patient education? (3)

A
  • Psychosocial factors
  • De-emphasise anatomical injury
  • Reinforce importance of movement and physical activity
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21
Q

Strategies for PT management of “Avoiders” (4)

A
  • Screen for depression (cofactor to developing LBP and transition to CLBP)
  • Passive, pain-limited protocols may perpetuate fear-avoidance
  • Early education and graded exercise to slowly introduce patient to feared behavior
  • During subject evaluation (beginning of therapy and during treatment)- Don’t remind them of their pain. Constantly asking about pain makes them focus on pain
22
Q

PT management of Avoiders: Graded exercise: what is it? (4)

A
  • Quota driven exercise program
  • Primary goal is not early abatement of pain
  • Used to reduce fear-avoidance
  • Pain does not limit progression/quota
23
Q

What is the FABQ?

A

A 16 item measure of individual beliefs about whether physical activity and work should be avoided.

24
Q

How many subscales /components does the FABQ have?

A

Two (2)

  • General physical activity and
  • Work
25
Q

Are all the items 16 items the FABQ utilized to score the FABQ?

A

NO only;

  • 4 items on the FABQPA, and
  • 7 items on the FABQW
26
Q

With graded exercise, what is the appropriate increase in intensity over treatment periods?

Is pain ok?

Do you reduce the intensity based on the patient’s pain?

A
  • Minimum 10% over treatment periods. Pain intensity does not dictate intensity increase.
  • Don’t remind them of pain.. constantly asking them about their pain makes them focus on their pain
  • Ask them how they are , not necesaroily about pain
27
Q

Effects of Education on return to work: What materials were provided to both groups?

A

An education pamphlet that provided descriptions of commonly used therapeutic exercises and commonly taught ergonomic principles

28
Q

Effects of Education on return to work: What booklet were subjects in the education group given?

A

Back pain; How to control a nagging back ache. Pts were instructed to read this booklet during their initial PT visit.

29
Q

Effects of education on return to work: What were the 3 structured inquiries used to initiate discussion and to reinforce the info in the booklet?

A
  • Did you learn anything new from the booklet?
  • Are there any points that you found unclear in the booklet?
  • Do you think that this booklet has provided info that will help you manage your back pain more easily?
30
Q

Effects of education on return to work: How was “regular work duties” defined in the study?

A

The ability to perform the same job duties and tasks that the subject was able to perform prior to the injury that caused this current episode of LBP & assoc. work-related disability.

31
Q

Effects of education on return to work: Final Conclusion:

A
  • An intervention including individualized education & counseling on pain management tactics and on the value of physical activity and exercise was effective in reducing the # of days required to return to regular work duties in people with work related LBP and high FABQ scores.
  • The results of this study suggests that PT interventions for people with FAB assoc. with work related LBP should include education and counseling on pain management and on physical activity & exercise.
32
Q

The biopsychosocial Approach and 3 points about it

A

A general model or approach stating that biological, psychological (which entails thoughts, emotions, and behaviors), and social (socio-economical, socio-environmental, and cultural) factors, all play a significant role in human functioning in the context of disease or illness. It posits that, health is best understood in terms of a combination of biological, psychological, and social factors rather than purely in biological terms

  • Typically, PTs tend to focus on the physical aspects of patient care
  • Physical factors and history have proven to be less effective predictors of patient success after acute LBP
  • There is evidence that psychosocial factors are most influential in determining patient return to work and regular activity
33
Q

How could PTs develop psychologically informed practice?

A

By incorporating psychosocial factors into regular practice, applying what is known as the biopsychosocial approach.

34
Q

Psychosocial factors that might influence a PTs decision-making when confronted with a new patient.

12

A
  1. Depression
  2. FAB
  3. Severity of functional impairment
  4. Self-efficacy
  5. Perception of personal control
  6. Catastrophizing or expectations of outcome
  7. Previous treatment
  8. Somatization
  9. Coping strategies
  10. Previous medical history or experiences of back pain
  11. Job satisfaction
  12. Illness identity
35
Q

Adaptive Response- Confronters (4)

A
  • Patient confronts painful situation and accepts it as a step toward improvement
  • Often less fearful and more willing to work with therapy
  • Better chance for improvement, less likelihood of disability
  • Often accepting of the role of pain in life and more willing to take responsibility for rehab
36
Q

What is Fear Avoidance?

(and 2 points about it)

A
  • The tendency of some patients to shy away from activities or therapy that has historically caused them pain or that they fear might cause/exacerbate pain.
  • It is a predictor of long-term disability following acute LBP
  • Also affects individual treatment sessions
37
Q

Maladaptive response- Avoiders (6)

A
  1. Patient blames external factors for pain and inability to improve
  2. Patient expects doctors and other clinicians to give a magic cure
  3. Patient takes little responsibility for his or her own treatment
  4. Patient avoids activity they fear might exacerbate pain
  5. Patient is often fearful, angry, and frustrated
  6. Often considered “passive:” patient merely waits for pain to subside
38
Q

PTs role in the eliminating/ reducing fear avoidance in patients (chart)

A
39
Q

Characeristics observed in people with an internal locus of control: (9)

A
  1. Are more likely to take responsibility for their actions
  2. Tend to be less influenced by the opinions of other people
  3. Often do better at tasks when they are allowed to work at their own pace
  4. Usually have a strong sense of self-efficacy
  5. Tend to work hard to achieve the things they want
  6. eel confident in the face of challenges

Tend to be physically healthier

Report being happier and more independent

Often achieve greater success in the workplace

40
Q

What is Locus of control?

A

“A patient’s expectancies regarding whether health is controlled by one’s own behaviors as opposed to factors such as chance, luck, fate, or powerful others”

Chance

  • Related to poorer physical and mental well-being

Powerful others

  • Adhere to medical recommendations but high likelihood of chronic pain and disability
41
Q

5 characteristics of people with an external locus of control:

A
  • Blame outside forces for their circumstances
  • Often credit luck or chance for any successes
  • Don’t believe that they can change their situation through their own efforts
  • Frequently feel hopeless or powerless in the face of difficult situations
  • Are more prone to experiencing learned helplessness
42
Q

5 Key points for patients listed in the “back book”:

A
  • Back problems are common
  • Rare to find serious damage
  • Rest >1-2 days is usually bad
  • Staying active gets you better faster
  • If you don’t get back to activities quickly, seek additional help
43
Q

Cognitive behavioral therapy is conducted by psychologist to treat issues such as: (4)

A
  • Depression
  • LBP
  • Anxiety
  • Eating disorders
44
Q

A recap of FABQ (6)

A
  • Investigates fear-avoidance beliefs among LBP patients in the clinical setting.
  • Pts w/ ↑ fear avoidance may require more supervision than those that confront pain
  • 2 subscales: Physical Activity and Work
  • Physical Activity: 6 questions (5 scored)
  • Work: 10 questions (7 scored)
  • Clinically significant threshold not determined (MCID)
45
Q

More on FABQW (5)

A
  • Work related scale
  • Items 6,7,9,10,11,12,15
  • Low fear: 0-29
  • High fear: 30-42
  • MDC: ~12
46
Q

More on FABQPA (5)

A
  • Physical Activity scale:
  • 6 questions
  • Low fear: 0-14
  • High fear: 15-24
  • MDC: ~9
47
Q

How is FABQ utilized in PT practice (3)

A
  • Easy to administer
  • Predictor of return to work/transition to chronic LBP
  • Allows clinician to identify high-risk patient and implement targeted interventions or suggest additional treatment options (addressing psychological issues)
48
Q

What is secondary gain?

A
  • Defined as external benefits a patient might get from a diagnosis

Some examples of secondary gain?

  • If patient is exaggerating severity in order to achieve secondary gain, does that mean PT has no obligation to treat? no
49
Q

Non Organic symptoms vs conversion disorder

A

● Non-organic symptoms are defined as “physical findings that do not have a direct anatomical cause and are distinct from physical findings of organic pathology”

  • Waddell’s non-organic index is a good screening technique. Label as faking/malingering in documentation?

●Conversion disorder: psychological stress shown in physical symptoms

50
Q

Conclusion- fear avoidance presentation (4)

A
  • While PT is focused on physical healing, psychosocial factors have been shown to have a greater influence on patient outcomes than physical factors.
  • PTs should take this into account and use the proper screening tools and observation of psychosocial factors to determine amount of educational intervention necessary.
  • When appropriate, cognitive behavior therapy has been shown to be beneficial for those at high-risk of long-term disability.

Graded exercise and patient education are the PT’s two best tools for managing psychosocial factors.

Dr. Worst Exam 1 (5 decks)

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