Graded Exposure/Exercise Flashcards
What primary impairment do patients with fear have?
Cognition/Beliefs
BELIEF BASE: Belief that an activity is harmful and how we restructure those beliefs to get them functioning back at a level where they can function.
Graded Exposure
Gradual exposure to specific situations or functions which patient states they are fearful of doing while reinforcing that they are SAFE while doing it. Intended to change the person’s perceptions of their pain and response to an activity!
Graded Exercise
Gradual exposure to specific exercises which patients state they are **fearful **of performing while verbally reinforcing that they are SAFE while doing it
Most people believe that pain is harmful. Pain is a good thing, it is a protective mechanism. Ex: someone touches hot stove and can’t tell. Pain is a good thing however it can become dysfunctional. People don’t get input of pain for protection but rather holds them back from activities.
Explain the Fear Avoidance Belief Model
Catastrophize pain due to negative emotions or being told they should be scared. This creates anxiety and fear leading to acoidance and eventually disability. May eventually lead to depression.
Neuroplasticity - Central Sensitization
Hippocampal atrophy
Amygdala hypertrophy
Prefrontal cortex atrophy
Less activity or more activity in different areas. More/less sensitized to information.
Hippocampusis abrainstructure embedded deep in the temporal lobe of each cerebral cortex. It is animportantpart of the limbic system, a cortical region that regulates motivation, emotion, learning, and memory
The amygdala may be best known as the part of the brain that drives the so-called “fight or flight” response. While it is often associated with the body’s fear and stress responses, it also plays a pivotal role inmemory.
Who is GE for?
- Pts with increased attention to pain which is associated with an “affect response” (fear, altered emotion or mood tied to pain) that NEGATIVELY affects overall ability to return to activities they participated in prior to their pain
- Tends to be more CHRONIC/PERSISTENT PAIN btu can be acute (easier to treat when acute)
- Affective response to pain: catastrophization, fear, anxiety, hypervigilance, depression
Catastrophization
Expect worst case scenario; every time something happens they expect the worst.
Hypervigilance
Always anticipating something will happen
Things that can create an affective response
Threatening Illness information
* Health care providers (Words that harm vs. words that heal)
* Significant others or neighbors
* Imaging findings that do not have direct correlation with symptoms
* Google images
Conflicting Information from all sources leads to frustration and emotion
Before addressing FAB and AFFECTIVE response to pain…
- First must perform a through medical screen to rule out the bad stuff
- Rule out red flags that would cause the patient experience other sources of pain (Ex: Cancer, pathologies)
Examination findings with GE patients
Standardized tools
* Pain diagram
* FAB questionnaire
Subjective interview
* Pt states they cannot do something because:
* they are “afraid it will hurt after”
* They think they will get injured from it
* Feels they have no control of their condition
* Repeated treatment failures
* Difficulty to describe aggravating and alleviating factors
* Negative contextual factors in their life (job, home life, relationships, stress, anxiety)
* Multiple body regions of pain (spreading symptoms over time)
Objective exam:
* Empty end feels: don’t allow PT to get to end range
* AROM: “Aberrant motions”(abnormal motions)
* Sensitivity to very light touch (Allodynia)
* MMT: Multiple muscles display “weakness”
* Refusal to do some things that is asked
Response to interventions:
* MAY go up and down a lot for no specific reason
* Difficulty to identify a pattern of symptoms
* Do not respond as you would expect to treatment
Foundation of Pain Education
ADDRESS WHAT YOU IDENTIFY – We cannot ignore this!
* Listen to their “Pain Story” or their “pain experience”
* Do NOT tell them that their pain is in their head!
* UNDERSTAND what their fears are. Tell patients what it is NOT!!
Cognition – Diminish fear and catastrophic beliefs (“Cognitive Restructuring”)
* Use appropriate terminology – “Words that heal”
* Minimize use of threatening models/pictures
* Use stories to diminish pain
* Talk about “sensitivity of tissue” vs. “tissue damage”
* Educate the patient on the physiology of pain
* The more they know, the less fear/anxiety
Behavioral – what are their FUNCTIONAL GOALS
* Engage the patient in the process – PATIENT CENTERED GOALS and PROBLEM SOLVING
* Graded Exposure to Activity – Goal is to not decrease pain but to increase tolerance to activity
* Maintenance Strategies (i.e.: coping strategies)
Addressing Current Beliefs
- It is understandable for patient to be frustrated
- Patient has full control: “I want your full consent on anything I do”
- Explain what is NOT going on. Ruled out the bad stuff
- Fear of motion vs. true limitation of motion? (compare passive vs. active motion)
- Even if it is the condition they believe they have, provide literature about outcomes! (more to come)
Running and knee pain
OA is less prevalent in recreation runners that non-runners. We need a stimulus to help with joint health.
Educating regarding imaging
VOMIT (Victims of Modern Imaging
OR
BARF (Brainlessly Applying Radiologic Findings)
