Lecture 4 Flashcards
What is the definition of rehabilitation?
“The restoration of normal form and function
after injury or illness”
Please describe the concept of passive care?
Clinician as Healer, Patient as Recipient
Manipulation
Traction
Physical modalities (EMS, ultrasound, laser)
Please describe the concept of active care?
Clinician as Coach, Patient as Active Participant
Strengthening
Postural reeducation
Motor control
What categories are pain classified as?
ACUTE and CHRONIC pain
Please describe what acute pain is?
- Short term pain (
Please describe what chronic pain is?
- Persistent / longstanding
- Usually not an indicator of ongoing tissue damage
- Hurt usually does not = harm
- No longer a useful warning sign
- Biopsychosocial factors are very relevant
Victims of lifestyle?
Lack of physical fitness - Strength - Endurance - Flexibility Being overweight Smoking
What are some key assumptions of the traditional model about pain and tissue disease/ injury? (MAY NOW BE PROVEN INSUFFICIENT)
Pain is the result of tissue damage/injury
Pain transmission is directly from the periphery to the brain
The amount of pain is directly proportional
to the extent of tissue damage/injury
1% of LBP caused by serious disease such as?
Cancer
1% of LBP caused by inflammatory disease such as?
Arthritis
5% of LBP is what?
True sciatica
The vast majority of LBP is what?
nonspecific or “idiopathic”
The relationship between symptoms and pathology?
The relationship is quite poor. A patient may have severe pain but minimal-to-no tissue damage or disease, but on the other hand you may have a patient with severe pain and severe tissue damage/ disease etc
Name 4 poor predictors of disability?
- X-Rays and MRI scans
- History of trauma
- Type of work
- Back function/screening tools
Name 3 good predictors of disability?
- The “psychosocial” factors…
- Physical de-conditioning
- Mental health
What are some limitations of the traditional model?
• IN REALITY pathology and tissue damage not directly
related to pain intensity
• It is possible to have tissue damage without reporting pain
• It is possible to have pain without observable tissue
damage or pathology
• It is possible to have a very different outcome (e.g. pain
and function) from the same treatment for the same
problem.
Just read and know!
“The degree of reported pain, functional limitation and
disability are frequently disproportionate to any observed
pathology / impairment or disability”
Chronic pain is not ‘All in the mind’, made up,
psychosomatic or psychological and patients are
not malingering and do not have psychological
overlay, rather it is now recognised as?
• perceptual process
• a combination of biological, psychological and
social factors – the biopsychosocial framework (even in acute phase)
• We need to be mindful of these factors and we
need to be able to assess and address them.
Please describe the Freudian Approach- Psychoanalytic Thinking (Id, Ego, Superego)
- conscious or unconscious guilt with pain serving
as a form of atonement, or the development of pain to replace feelings of loss - serious methodological and conceptual concerns
Please describe the Behaviourist Models by
B.F. Skinner
The human mind is conceptualized as a black box
thinking
No consideration given to emotions
Rewards given to promote / extinguish behaviours
e.g., no RTW & get lots of attention
Please describe Cognitive Approaches by
Aaron Beck
Thought processes are at the heart of feelings and
behaviour and are all connected
Cognitive behavioural therapy
draw this out from lecture
How to change cognitive behaviour?
Cognitive restructuring; identify, challenge & reframe negative automatic negative thoughts
Behavioural activation; increase the pleasant event frequency & decrease avoidance behaviours
Relapse prevention
What are the best outcomes for a patient with LBP?
sudden onset of acute LBP of short duration
without multiple pain sites, with previous episodes,
good health
no psychological issues
constituted the vast majority of practice (85%)
What are poor outcomes for a patient with LBP?
Chronicity - Pain duration > 30 days - Pain in other locations Co-morbidity - General Health - Treatment reimbursed as indicator of recipient of social benefits for disability - Depression & Anxiety
The biopsychosocial framework
DRAW IT OUT OF LECTURE
What actually causes the “bio” bit in biopsychosocial chronic pain?
- Peripheral and central sensitisation
- Causes:
Hyperalgesia; There is an increase in the magnitude and
duration of response to stimuli. (i.e what was perceived as a painful stimuli is perceived as more painful)
Allodynia; There is a reduction in threshold causing an
increase in the frequency of neuron firing so that low intensity stimuli not normally noxious, become so (i.e. stimuli that was perceived as non-painful is now perceived as painful)
Changes may last from hours to years In certain cases these changes can become pathological leading to unresolved persistent pain, But also spontaneously resolve?
How important are psychosocial factors
Psychosocial factors are MORE important than physical, biomedical or tx factors in: Pain perception The continued report of symptoms Health care seeking Response to treatment Overall outcome The prediction of disability The development of disability The maintenance of disability Prolonged work loss
Name 5 key psychosocial issues?
Pain beliefs Fear avoidance Catastrophising Self Efficacy/Locus of control Co-morbid psychological problems Anxiety, depression, etc
Please describe the two main types of pain beliefs?
‘Organic’ Pain Beliefs Hurt = Harm More hurt = more harm ‘Psychological’ Pain Beliefs Worrying about pain makes it worse Relaxing makes pain easier
What are the 4 characteristics of fear?
- avoidance behaviour
- psychophysiological reactivity
- worry
- attention processes: hypervigilance
Treatment of phobias?
- exposure in vivo
- challenging catastrophic expectations
- following a fear hierarchy
Fear avoidance model
DRAW IT!
Please explain graded- exposure and its 3 steps.
Graded exposure (GE): exposes patients to specific
situations of which they are fearful during rehabilitation
Step 1: identify specific activities feared by the patient
Step 2: expose patient to activity which elicits minimal
amounts of fear
Step 2: gradually increase to situations that elicit larger
amounts of fear
what is graded exercise?
Graded exercise (GEX): encourages
confrontation by improving patients’ exercise or activity tolerance.
- GEX is not based on what the patient is fearful of; instead, it is based on whether the patient meets predetermined quota levels set by the clinician.
- More evidence of benefit for GEX than GE
- Very little evidence for or against GE
please describe catastrophising?
Characterised by excessively negative thoughts An exaggerated focus on pain sensation - e.g. "I can’t stop thinking about how much it hurts“ A magnification of level of threat - e.g. “I might make it much worse” A perceived inability to cope - e.g. “There’s nothing I can do to control the pain”
Catastrophising is associated with increased what?
Level of pain
Risk of pain onset
Risk of pain-related disability
Psychological distress
Catastrophisers are more likely to engage in
activities which?
communicate their pain than adopt strategies that might reduce it
Clinicians as a psychosocial influence: latrogenic distress?
Diagnosis
Conflicting diagnosis or explanations resulting in
confusion, frustration, anger and loss of faith in
health profession(s)
Unfamiliar diagnostic language leading to
catastrophising (fear of an inevitable poor outcome)
Treatment
Dramatisation of condition by health professional -
results in dependency on treatments
Continuation of passive treatment
Vague, inappropriate, alarming, contradictory,
advice, information and management
Function
Advice from professional to change or
withdraw from activities or job, PABS.PT?
Health professionals have sanctioned
disability, not providing interventions geared
towards improving function
Explanations not related to patients function
and future prognosis
What are the goals of a practitioner to help reduce/ avoid psychosocial patient behaviours?
Discourage passive / negative coping strategies
Challenge misconceptions, unhelpful thoughts,
beliefs and behaviour
Address FAB’s
Help ID what they are avoiding/ finding difficult and
how they can gradually build up to it
Encourage active self management
Avoid / discourage work absence
How not to communicate with your LBP patients as a doctor?
- “Your back is damaged”
- “You have the back of a 70-year-old”
- “It’s wear and tear”
- “You have degeneration/ arthritis/ disc bulge/ disc disease/a slipped disc”
How not to tell your patient to cope with LBP?
- “You have to be careful/take it easy from now on”
- “Your back is weak”
- “You should avoid bending/lifting”
How we SHOULD communicate with our patient with LBP
•“Back pain does not mean your back is damaged –
it means it is sensitised”
• “Your back can be sensitised by awkward
movements and postures, muscle tension,
inactivity, lack of sleep, stress, worry and low
mood”
• “Most back pain is linked to minor sprains that can
be very painful”
• “Sleeping well, exercise, a healthy diet and cutting
down on your smoking will help your back as well”
• “The brain acts as an amplifier - the more you
worry and think about your pain, the worse it gets”
How to promote resilience to your patient?
•“Your back is one of the strongest structures of
the body”
• “It’s very rare to do permanent damage to your
back”
How to address concerns about imaging results and pain to your patient?
•“Your scans changes are normal, like grey hair”
• “The pain does not mean you are doing damage
– your back is sensitive”
• “movements will be painful at first – like an
sprained ankle – but they will get better as you
get active”
Why to teach your patients to be positive about their recovery?
“Our results suggest that patients with high levels of fear-avoidance beliefs about work activities are unlikely to respond to manipulation. These individuals likely require
an alternative treatment approach.”
Distress risk assessment method, what 2 things are used?
Zung Depression Inventory (23 items)
Modified Somatic Perceptions Qn (22 items)
What are the PROMIS 8
Emotional Distress: 4 items
I felt fearful; never (1) through to always(5)
I found it hard to focus on anything other than
my anxiety;
My worries overwhelm me
I felt uneasy
Depression; 4 items I felt worthless I felt helpless I felt depressed I felt hopeless
Classification of scores
Normal Depression & Anxiety scores (t 50)
Distressed Anxiety (t > 50)
BELIEFS
catastrophizing, thinking the worst
belief that pain is uncontrollable
low educational background
beliefs that pain must be completely gone before RTW
BEHAVIOURS
passive attitude to rehabilitation reduced activity with significant withdrawal from ADLs avoidance of normal activity impaired sleep because of pain
EMOTIONS
depression feeling useless and not needed irritability, feeling under stress and no sense of control disinterest in social activity over-protective partner/spouse
WORK
belief that pain is harmful, resulting in fear avoidance
behaviour
belief that all pain must be abolished before attempting
to RTW or normal activity
expectation of increased pain with activity or work
belief that work is harmful
