1/27/16. Targeted Treatment: Activity Based Intervention. Activity Based Objectives

Transcription

1 1/27/16 Targeted Treatment: Activity Based Intervention 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; Activity Based Objectives 1. Review foundation of applying targeted treatment using risk stratification 2. Identify two different methods of applying activity based intervention 3. Differentiate key principles and application between graded activity and graded exposure 1

2 Learning Module TARGETED TREATMENT Risk Stratified Care 1) Identification 2) Targeted Treatment Elevated psychological factors; with or without physical factors Physical & psychological factors; psychological factors not elevated Few physical & psychological factors Psychological informed physical therapy Physical therapy to address symptoms and function (primarily targeting physical characteristics) Advice, education & self-management Patients are risk-stratified based on prognostic profile STarT Risk: Targeted Treatment High Risk Psychological informed physical therapy: Assessment and management of pain related psychological risk factors Adopting cognitive-behavioral principles to address unhelpful beliefs and behaviors 2

3 TARGETED TREATMENT: HIGH RISK 1. Communication 2. Pain coping skills 3. Activity based 4. Physical impairment based TARGETED TREATMENT: HIGH RISK 1. Communication 2. Pain coping skills 3. Activity based 4. Physical impairment based Activity Based Intervention Two broad behavioral approaches: Graded exercise or activity Graded exposure 3

4 Graded Exercise or Activity Principles Encourages continued activity, despite presence of pain Dosage: quota-based system Baseline level: ability to perform exercise or activity to pain tolerance (duration, intensity, frequency) Subsequent sessions based on this initial quota Graded Exercise or Activity Principles Reinforcement provided for achievement of quota Reinforcement not provided if quota is not met Quota is gradually increased across sessions Important that patient understands process!!! Graded Exercise or Activity Patient walks on treadmill (2 level 2) before stopping because of pain tolerance Initial quota: 2 level 2 Subsequent sessions: Meets quota Does not meet quota Progress quota Maintain quota 4

5 Suggested as a more effective alternative than quota driven approaches Difference? Graded activity = increase in generic functional capacity (operant conditioning model) Graded exposure = increase in activities that are fearful (exposure/phobia model) Principles Based on classic exposure principles Gradually expose patient to what they are fearful Increase exposure as fear decreases An exposure based system Exercise progression based on decreasing fear of activity Pain does not normally figure in exercise progression Primarily for patients reporting high levels of fear and avoidance behaviors Feared or avoided activities determine focus of treatment Dosage: hierarchical exposure approach; subsequent progression based on fear levels with specific activities 5

6 1. Identification of feared activity (via FDAQ) 2. Incorporate activity into treatment plan (low level) 3. Increase activity to increase level of fear (mod level) 4. Increase activity to further increase level of fear (high level) As level of fear decreases, level of activity increases Progression of activity based on: Position Intensity Frequency Duration First Session: Identify most fearful activities (FDAQ) Patient reports level of activity he/she is willing to perform with increase in fear Subsequent Sessions: Patient performs fearful activities (level of determined based on previous session) PT monitors session FDAQ reassessment Does patient have less fear of activities? YES + Reinforcement Increase activity level 10% (duration, frequency, intensity) NO Reinforcement of Importance No change in activity level (duration, frequency, intensity) Repeat Psychologically Process Informed Physical Therapy Repeat (PIPT) Process 6

7 Example Fear of bending forward identified 1. Lumbar flexion in supine 2. Lumbar flexion in sitting 3. Lumbar flexion in standing 4. Lumbar flexion while retrieving weighted object from ground 5. Must be reinforced as part of HEP *** Activity Based Summary Graded exercise or activity Not based on fearful activities Exercise or activity that is limited by pain Graded exposure Based on fearful activities Activities identified via FDAQ Activity Based Objectives 1. Described targeted treatment specific to high risk patients stratification 2. Identified graded activity and graded exposure as two methods of applying activity based intervention 3. Differentiated key principles and application between graded activity and graded exposure 7

8 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 Brooks-PHHP Research Collabora2on 8