1/22/2016. Pain Science Update: Need for Psychologically Informed Interventions. Pain Science Update Objectives

Transcription

1 Pain Science Update: Need for Psychologically Informed Interventions Steven George PT, PhD Associate Professor University of Florida Brooks PHHP Research Collaboration Psychologically Informed Physical Therapy Practice: Pragmatic Application for Low Back Pain Jason Beneciuk, PT, PhD Research Assistant Professor Brooks PHHP Research Collaboration, University of Florida Carol M. Greco, PhD Assistant Professor of Psychiatry Licensed Psychologist University of Pittsburgh School of Medicine Steven George, PT, PhD Associate Professor Director, Doctor of Physical Therapy Program Director, Brooks-PHHP Research Collaboration, University of Florida; Pain Science Update Objectives 1. Understand that variability is an inherent feature of the pain experience 2. Describe how psychological factors can be used to explain pain related patient differences 3. Understand that identification of pain associated psychological distress and use of targeted treatment approaches are key tenets of psychologically informed physical therapy 4. Identify that preventing transition to chronic back pain is a primary outcome goal for psychologically informed physical therapy 1

2 High Variability in Pain Experience O Neill et al, Pain 2009 High Variability in Pain Experience Stimulus Temperature = 49ºC Pain Intensity Rating (0-100) High Variability in Pain Experience 1. Pain location with standard stimulus 2. High variability in pain intensity ratings with standard stimulus 2

3 Clinical Implications High variation in pain experience Is evident, even with same peripheral generator Search for the source of pain may not be all that important Shifts need from tissue identification to focus on factors that influence variation Variability in Pain Experience Influences on reporting pain (non-exhaustive list) Sex Age Genetics Psychological or psychosocial factors Nervous system processing Variability in Pain Experience Influences on reporting pain (non-exhaustive list) Sex Age Genetics Psychological or psychosocial factors Nervous system processing 3

4 General Psychological Model of Pain Perception Linton & Shaw, Phys Ther Specific Psychological Models Fear-Avoidance Model Activity avoidance leads to physical degeneration and social isolation Acceptance and Commitment Model Repeated (futile) attempts to alleviate pain lead to frustration Misdirected Problem-Solving Model Normal worrying; more worrying; less likely to solve problem Self-Efficacy Model Fluctuating pain reduces perceptions of control Stress-Diathesis Model Psychological stress & limited coping resources predispose one to pain Linton & Shaw, Phys Ther Specific Psychological Models Fear-Avoidance Model Activity avoidance leads to physical degeneration and social isolation Acceptance and Commitment Model Repeated (futile) attempts to alleviate pain lead to frustration Misdirected Problem-Solving Model Normal worrying; more worrying; less likely to solve problem Self-Efficacy Model Fluctuating pain reduces perceptions of control Stress-Diathesis Model Psychological stress & limited coping resources predispose one to pain 4

5 Fear-Avoidance Model of Musculoskeletal Pain Leeuw et al, J Behav Med, 2007 Fear-Avoidance Model of Musculoskeletal Pain Catastrophizing Pain is interpreted as being extremely threatening Fear of Pain Present threat; defensive behavior Pain Anxiety Future-oriented; preventative behavior Negative Affect Threatening Illness Information High Variability in Pain Experience Stimulus Temperature = 49ºC Pain Intensity Rating (0-100) 5

6 Pain Intensity Rating (0-100) 1/22/2016 Psychological Factors Account for Variability Stimulus Temperature = 49ºC Fear of Pain (30-150) Psychological Factors Consistent influence on elevated pain experiences Risk factors for poor patient outcomes (Nicholas, et al. 2011; Chou & Shekelle, 2010) Clinical Implications Opportunity for patient segmentation Risk stratification based on pain associated psychological distress subgroups Provide matched treatment based on subgroup assignment 6

7 PSYCHOLOGICALLY INFORMED PHYSICAL THERAPY PRACTICE Special Issue of PTJ - May 2011 Psychologically Informed Physical Therapy Merges narrowly focused impairment based practice based on biomedical concepts with cognitive behavioral principles developed originally for treatment of mental illness (Main & George, 2011) Psychologically Informed Physical Therapy (Fuentes et al, Phys Ther 2014) 7

8 Integration Physical Treatment Approach Psychological Treatment Approach Psychologically Informed Physical Therapy Two important premises: 1. Identification of psychological processes that affect the perception of and response to pain as an expected and normal part of the musculoskeletal pain experience that are modifiable 2. Linking identification of psychological factors to the development of targeted treatment approaches Psychologically Informed Physical Therapy Primary goals Acknowledge and incorporate patient beliefs and emotional responses to pain into communication plan Incorporate key psychological principles into treatment plan Cognitive behavioral therapy Graded activity Graded exposure Prevent development of persistent or chronic pain conditions 8

9 Pain Science Update Summary 1. Provided two examples of how variable the pain experience can be 2. Reviewed some of the evidence and a specific example of how psychological factors explain pain related patient differences 3. Introduced the conceptual background for psychologically informed physical therapy 4. Identified key tenets and goals for psychologically informed physical therapy Psychologically Informed Physical Therapy Practice: Pragmatic Application for Low Back Pain Jason Beneciuk, PT, PhD Research Assistant Professor Brooks PHHP Research Collaboration, University of Florida Carol M. Greco, PhD Assistant Professor of Psychiatry Licensed Psychologist University of Pittsburgh School of Medicine Steven George, PT, PhD Associate Professor Director, Doctor of Physical Therapy Program Director, Brooks-PHHP Research Collaboration, University of Florida; Thank you for your attention Steven George szgeorge@ufl.edu 9