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CHI442 - Primary Practice - Physical Rehab 1 > Lecture 4 > Flashcards

Lecture 4 Flashcards

1
Q

What is the definition of rehabilitation?

A

“The restoration of normal form and function

after injury or illness”

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2
Q

Please describe the concept of passive care?

A

Clinician as Healer, Patient as Recipient
 Manipulation
 Traction
 Physical modalities (EMS, ultrasound, laser)

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3
Q

Please describe the concept of active care?

A

Clinician as Coach, Patient as Active Participant
 Strengthening
 Postural reeducation
 Motor control

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4
Q

What categories are pain classified as?

A

ACUTE and CHRONIC pain

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5
Q

Please describe what acute pain is?

A
  1. Short term pain (
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6
Q

Please describe what chronic pain is?

A
  1. Persistent / longstanding
  2. Usually not an indicator of ongoing tissue damage
  3. Hurt usually does not = harm
  4. No longer a useful warning sign
  5. Biopsychosocial factors are very relevant
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7
Q

Victims of lifestyle?

A 
 Lack of physical fitness
- Strength
- Endurance
- Flexibility
 Being overweight
 Smoking
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8
Q

What are some key assumptions of the traditional model about pain and tissue disease/ injury? (MAY NOW BE PROVEN INSUFFICIENT)

A

 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

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9
Q

1% of LBP caused by serious disease such as?

A

Cancer

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10
Q

1% of LBP caused by inflammatory disease such as?

A

Arthritis

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11
Q

5% of LBP is what?

A

True sciatica

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12
Q

The vast majority of LBP is what?

A

nonspecific or “idiopathic”

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13
Q

The relationship between symptoms and pathology?

A

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

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14
Q

Name 4 poor predictors of disability?

A
  1. X-Rays and MRI scans
  2. History of trauma
  3. Type of work
  4. Back function/screening tools
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15
Q

Name 3 good predictors of disability?

A
  1. The “psychosocial” factors…
  2. Physical de-conditioning
  3. Mental health
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16
Q

What are some limitations of the traditional model?

A

• 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.

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17
Q

Just read and know!

A

“The degree of reported pain, functional limitation and
disability are frequently disproportionate to any observed
pathology / impairment or disability”

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18
Q

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?

A

• 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.

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19
Q

Please describe the Freudian Approach- Psychoanalytic Thinking (Id, Ego, Superego)

A
  • 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
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20
Q

Please describe the Behaviourist Models by

B.F. Skinner

A

 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

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21
Q

Please describe Cognitive Approaches by

Aaron Beck

A

Thought processes are at the heart of feelings and

behaviour and are all connected

22
Q

Cognitive behavioural therapy

A

draw this out from lecture

23
Q

How to change cognitive behaviour?

A

 Cognitive restructuring; identify, challenge & reframe negative automatic negative thoughts
 Behavioural activation; increase the pleasant event frequency & decrease avoidance behaviours
 Relapse prevention

24
Q

What are the best outcomes for a patient with LBP?

A

 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%)

25
Q

What are poor outcomes for a patient with LBP?

A 
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
26
Q

The biopsychosocial framework

A

DRAW IT OUT OF LECTURE

27
Q

What actually causes the “bio” bit in biopsychosocial chronic pain?

A
  • 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?
28
Q

How important are psychosocial factors

A 
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
29
Q

Name 5 key psychosocial issues?

A 
 Pain beliefs
 Fear avoidance
 Catastrophising
 Self Efficacy/Locus of control
 Co-morbid psychological problems
 Anxiety, depression, etc
30
Q

Please describe the two main types of pain beliefs?

A 
 ‘Organic’ Pain Beliefs
 Hurt = Harm
 More hurt = more harm
 ‘Psychological’ Pain Beliefs
 Worrying about pain makes it worse
 Relaxing makes pain easier
31
Q

What are the 4 characteristics of fear?

A
  • avoidance behaviour
  • psychophysiological reactivity
  • worry
  • attention processes: hypervigilance
32
Q

Treatment of phobias?

A
  • exposure in vivo
  • challenging catastrophic expectations
  • following a fear hierarchy
33
Q

Fear avoidance model

A

DRAW IT!

34
Q

Please explain graded- exposure and its 3 steps.

A

 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

35
Q

what is graded exercise?

A

 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

36
Q

please describe catastrophising?

A 
 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”
37
Q

Catastrophising is associated with increased what?

A

 Level of pain
 Risk of pain onset
 Risk of pain-related disability
 Psychological distress

38
Q

Catastrophisers are more likely to engage in

activities which?

A

communicate their pain than adopt strategies that might reduce it

39
Q

Clinicians as a psychosocial influence: latrogenic distress?

A

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

40
Q

What are the goals of a practitioner to help reduce/ avoid psychosocial patient behaviours?

A

 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

41
Q

How not to communicate with your LBP patients as a doctor?

A
  • “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”
42
Q

How not to tell your patient to cope with LBP?

A
  • “You have to be careful/take it easy from now on”
  • “Your back is weak”
  • “You should avoid bending/lifting”
43
Q

How we SHOULD communicate with our patient with LBP

A

•“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”

44
Q

How to promote resilience to your patient?

A

•“Your back is one of the strongest structures of
the body”
• “It’s very rare to do permanent damage to your
back”

45
Q

How to address concerns about imaging results and pain to your patient?

A

•“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”

46
Q

Why to teach your patients to be positive about their recovery?

A

“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.”

47
Q

Distress risk assessment method, what 2 things are used?

A

 Zung Depression Inventory (23 items)

 Modified Somatic Perceptions Qn (22 items)

48
Q

What are the PROMIS 8

A

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)

49
Q

BELIEFS

A

 catastrophizing, thinking the worst
 belief that pain is uncontrollable
 low educational background
 beliefs that pain must be completely gone before RTW

50
Q

BEHAVIOURS

A 
 passive attitude to rehabilitation
 reduced activity with significant withdrawal
from ADLs
 avoidance of normal activity
 impaired sleep because of pain
51
Q

EMOTIONS

A 
 depression
 feeling useless and not needed
 irritability, feeling under stress and no sense of control
 disinterest in social activity
 over-protective partner/spouse
52
Q

WORK

A

 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

CHI442 - Primary Practice - Physical Rehab 1 (6 decks)

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