PIPT pt 2 Flashcards
Typical evaluation and treatment prior to PIP training
Evaluation: assessed impairments
> Strength
> ROM
> movement dysfunction
> repeated motions to centralize pain
> palpation of soft tissues
> spina mobility
Related impairments to functional limitations
> Difficulty sitting, difficulty standing, limited walking, limited lifting/bending
Assessed Disability: Used measures including Modified Low Back Pain Disability Questionnaire.
Treatment =
Educated patient on findings of evaluation and related those to diagnostic tests
Focused treatment on impairments, with the goal of treatment being resolution of pain as well as increasing function
Treatment included manual therapy, therapeutic exercise, neuromuscular re-education, and more
In almost all cases, advised patient to limit activity/exercise based on pain (some exercises to be performed with pain as long as pain resolves within 30 minutes)
Typical “non-responders” to treatment
Patients that didn’t respond tended to have:
> Long histories of pain, with many failed treatments.
> Many areas of pain, a lot of shaded body parts on patient information intake sheet.
Psychologically Informed Practice (PIP) =
offers a systematic approach to the integration of physical and psychological approaches to treatment for the management of people with low back pain by physiotherapists
Why is psychology important in pain?
People have cognitive, emotional and behavioural responses to pain, these can be more helpful/adaptive or unhelpful/maladaptive, depending on the context.
Psychosocial factors are repeatedly found to be some of the best predictors of pain intensity, long-term disability and treatment outcome
Whether and to what extent people experience pain is determined by:
What they think (cognitions), feel (emotions) and do or don’t do (behaviours).
Any sensory input into the nervous system (e.g. nociception)
Neurophysiological changes (e.g. central and peripheral sensitisation)
The context (e.g. the situation or circumstances)
pain =
An unpleasant sensory and emotional experience associated with actual or
potential tissue damage, or described in terms of such damage
Understanding pain psychology and greater utilisation of psychological
principles and practice will help the physical therapist to:
Understand why your patients may be behaving the way they are
Build a better therapeutic relationship with them
Better assess and manage them (e.g. better clinical outcomes)
Improve your and your patients overall experience (job satisfaction, patient satisfaction)
Kinesiophobic behavior =
highly fear-avoidant
underpinning belief is that pain is a sign of bodily harm and activity causing pain is dangerous and should be avoided
defined as the fear of pain with movement (i.e. movements which a patient is hesitant to perform due to fear that the movement will elicit pain) due to the fear of re-injury
Importance of Measuring Kinesiophobia
Fear of movement/re-injury may be a predictor of self-reported disability levels and lead to increased avoidance
Avoidance behavior is postulated to be a mechanism related to sustaining chronic pain disability
A decrease in fear-avoidance beliefs about work and physical activity are related to a reduction in disability
Background – Pain Catastrophizing
person’s tendency to magnify the threat value of a pain stimulus and the feeling of helplessness in the presence of pain, as well as, by a relative inability to prevent or inhibit pain-related thoughts in anticipation of, during, or following a painful event
Pain catastrophizing affects how individuals experience pain
People who catastrophize tend to do three things, all of which are measured by the Pain Catastrophizing Scale (PCS):
Ruminate about their pain: (“I can´t stop thinking about how much it hurts”)
Magnify their pain (e.g. “I´m afraid that something serious might happen”)
Feel helpless to manage their pain (“There is nothing I can do to reduce the intensity of my pain”).
Core Concepts of PIPT
Identify psychosocial factors and coping strategies (behaviors) contributing to pain/suffering
Help the patient change their beliefs about pain and increase behavioral flexibility
> Pain Neuroscience Education
> Physical Experiences
How do we get people to change behavior?
Want to break the Fear-Avoidance cycle.
Need to identify cognitions and how they relate to behavior.
Psychological therapies –
> Cognitive Behavioral Therapy
> ACT Acceptance and Commitment Therapy
ACT =
Acceptance and Commitment Therapy
chronic pain patients engage in persistent behavior patterns searching for physical relief and reducing physical and emotional discomfort- psychological inflexibility
Experiential avoidance can reduce pain tolerance and increase severity of pain.
Goals of ACT
> Reduce the dominance of pain in person’s life through increased psychological flexibility
> Psychological flexibility- capacity to persist or to change behavior, guided by goals and values.
> Once the brain has other things to take up it’s time/activity, pain will often decrease.
> It’s not about not caring about the pain, it’s about making the commitment to live a meaningful life even with pain.
How do we use ACT?
Establish therapeutic relationship- most important part of process
Motivational Interviewing is KEY!
Open ended questions, affirmations, reflections and summaries (OARS)
Validating patient’s experience
Accepting them for where they are and how they got there
Helping them see what they’ve lost as a result of their avoidance-psychological inflexibility.
Helping them identify value based goals.
Motivational Interviewing =
collaborative conversation style for strengthening a person’s own motivation for and commitment to change
How do we know if psychosocial factors are important?
Keele STarT Back Screening Tool for low back pain (prognostic tool-informs who is at risk for developing chronic pain related disability)
Tampa Scale of Kinesiophobia
Pain Catastrophizing Scale
Fear Avoidance Beliefs Questionnaire (FABQ)
The Keele STarT Back Screening Tool
The tool aims to identify independent modifiable predictors of pain related-disability.
The Keele STaRT Back Tool has been translated into 44 languages suggesting global adoption
How do we address fear?First Step: Pain Neuroscience Education
Use of metaphors: pain as alarm system, sensitive alarm system.
How our previous experiences and expectations shape pain: example of farmer stepping on large nail and man getting bit by snake.
Use of materials:
Why You Hurt by Adriaan Louw, PT, PhD
Increasing physical activity with pain
Pain neuroscience education alone is not enough
Need to get patient to engage in pain provoking activities despite pain “can you be willing to live a more meaningful life and move more with pain?”
Most importantly, need to identify value based goals that make the exercises/activity worthwhile
Need to create buy in to trying something new.
This experience is about trying something different
What quality of life have they lost by staying the same?
What are the pros/cons of doing things differently/staying the same?
What would you be doing if you didn’t have this pain?
Creative Hopelessness = Allows them to give up the illusion that they are going to be pain free.
When confidence is low, help people have enough buy in to try an experience, to create new evidence over time.
Billing - Self Care/Home Management
Spending time doing motivational interviewing, pain education, etc.
Motivational Interviewing used to identify value based goals and barriers/obstacles to progress. Assessed patient’s confidence in ability to make behavioral changes regarding activity.
Billing - Therapeutic Exercise
Will often do patient education and assessing psychosocial factors while patient is doing exercises.
Psychologically Informed Physical Therapy versus Psychotherapy
Not treating depression, trying to decrease disability in a person with depression.
As with any patient, if there is a mental health issue that needs to be addressed, refer to specialist.
Use of motivational interviewing, empathy to establish a therapeutic relationship with patient.
Understanding the central sensitization of pain, we can not ignore how depression, anxiety, fear contribute to patient’s pain perception and fear avoidance model.
Can almost see it as negligent by not addressing these issues and educating patient.
telling the patient “it’s all in her head.”
this approach/one of the unintended consequences of pain education
This reflects old concepts such as somatization and psychogenic pain
MUS- medically unexplained symptoms is contrary to what we know about the neuromatrix of pain and central sensitization.
Theme 3: contradicting previous information supplied by doctor or other health professional/confronting patients’ views about what’s wrong with them
We can accept as truth that along the way, those assessments were/may have been accurate, there is degeneration of the lumbar discs; is part of normal aging, “wrinkles on the inside.”
Use clinical reasoning and take into account the whole person, not just the diagnostic test. “Do no harm.”
