PIPT pt 2

Question 1

Typical evaluation and treatment prior to PIP training

Answer 1

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.

Question 2

Treatment =

Answer 2

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)

Question 3

Typical “non-responders” to treatment

Answer 3

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.

Question 4

Psychologically Informed Practice (PIP) =

Answer 4

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

Question 5

Why is psychology important in pain?

Answer 5

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

Question 6

Whether and to what extent people experience pain is determined by:

Answer 6

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)

Question 7

pain =

Answer 7

An unpleasant sensory and emotional experience associated with actual or
potential tissue damage, or described in terms of such damage

Question 8

Understanding pain psychology and greater utilisation of psychological
principles and practice will help the physical therapist to:

Answer 8

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)

Question 9

Kinesiophobic behavior =

Answer 9

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

Question 10

Importance of Measuring Kinesiophobia

Answer 10

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

Question 11

Background – Pain Catastrophizing

Answer 11

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

Question 12

People who catastrophize tend to do three things, all of which are measured by the Pain Catastrophizing Scale (PCS):

Answer 12

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”).

Question 13

Core Concepts of PIPT

Answer 13

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

Question 14

How do we get people to change behavior?

Answer 14

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

Question 15

ACT =

Answer 15

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.

Question 16

Goals of ACT

Answer 16

> 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.

Question 17

How do we use ACT?

Answer 17

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.

Question 18

Motivational Interviewing =

Answer 18

collaborative conversation style for strengthening a person’s own motivation for and commitment to change

Question 19

How do we know if psychosocial factors are important?

Answer 19

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)

Question 20

The Keele STarT Back Screening Tool

Answer 20

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

Question 21

How do we address fear?First Step: Pain Neuroscience Education

Answer 21

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

Question 22

Increasing physical activity with pain

Answer 22

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

Question 23

Need to create buy in to trying something new.

Answer 23

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.

Question 24

Billing - Self Care/Home Management

Answer 24

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.

Question 25

Billing - Therapeutic Exercise

Answer 25

Will often do patient education and assessing psychosocial factors while patient is doing exercises.

Question 26

Psychologically Informed Physical Therapy versus Psychotherapy

Answer 26

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.

Question 27

telling the patient “it’s all in her head.”

Answer 27

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.

Question 28

Theme 3: contradicting previous information supplied by doctor or other health professional/confronting patients’ views about what’s wrong with them

Answer 28

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.”