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The University Of Utah
Department of Physical Therapy
The BIOPSYCHOSOCIAL Model
Graded Exercise and Graded
Exposure Treatments
Clinical expression of pain
encompasses numerous
aspects besides physical
dysfunction:
Social & Vocational Environment
Emotional distress
Julie M. Fritz
Professor, University of Utah
Clinical Outcomes Research Scientist
Intermountain Healthcare
Salt Lake City, Utah, USA
Attitudes and beliefs
The social environment
Illness behavior of patient
Behaviour
Emotional
Distress
Attitudes
& Beliefs
PAIN
The University of Utah
Department of Physical Therapy
Fear Avoidance Model (Lethem et al., Behav Res Ther, 1983)
Individual response to pain is a continuum:
Confrontation
Avoidance
Minimal fear of pain Strong fear of pain
Gradual return to activity Avoid painful activities
Fear of pain and avoidance behavior is the most important
cognitive dimension because it fuels the development of
psychological distress and abnormal illness behavior
The University of Utah
Department of Physical Therapy
Identifying Fear‐Avoidance Beliefs (FABQ)
If pain is interpreted as threatening (pain catastrophizing), pain‐related fear evolves, leading to avoidance behaviors, hypervigilance to bodily sensations followed by disability, disuse and depression.
FABQ Observations:
 Scores are impacted by:
– Gender (males higher than females)
– Acuity (higher in acute < 1mo)
– Type
T
off onsett (higher
(hi h with
ith sudden
dd onset)
t)
– Payer type (higher in auto and worker compensation
versus other)
George et al 2001, Crombez et al 1999, Vlaeyen et al 1995, The University of Utah
Department of Physical Therapy
EMGO Institute - Common Mental Disorders
The University of Utah
Department of Physical Therapy
1
Management of Fear‐Avoidance Beliefs – Graded Activity
 Based on operant conditioning principles
(Fordyce et al, Arch Phys Med Rehabil, 1973)
 Primary goal is increase in activity through
quota attainment
 Intervention does not focus on symptom
abatement
Management of Fear‐Avoidance Beliefs – Graded Exposure
 Based on desensitization (phobia) model
 Primary goal is to increase exposure to
activities that are fearful in
i order
d tto reduce
d
fear.
The University of Utah
Department of Physical Therapy
Staal LB, et al. Graded Activity for Low Back Pain in
Occupational Health Care. Ann Intern Med. 140;77-84, 2004.
The University of Utah
Department of Physical Therapy
Treatment - Usual Care
• Management from Occupational
Inclusion Criteria: 1) Sick-listed due to low back pain
2) No signs of nerve root compression
3) Cardiovascular problems preventing exercise
Medicine Physician
• Education about value of activity
y and
return to work
R
• Permitted to receive medication and/or
Graded Activity
Usual Care
Treatment – Graded Activity
Feature
Description
Concept
Pain and its related behaviors, such as inactivity,
complaining, or work absence, are controlled by learning
(operant conditioning). Favorable consequences that follow
pain behavior will reinforce the future occurrence of pain
behavior. Exercise and physical activity are considered
incompatible with pain behavior. Stimulation of exercise
behavior may therefore lead to a decrease in competing
pain behavior.
Sessions
Two 1-hour per week, supervised by a PT, until full return
to work. Maximum duration 3 months.
Education
Messages
Pain does hurt, but this does not mean that it harms.
Exercise and physical activity are safe, despite pain
symptoms, improvement of function is the primary goal,
not pain relief
EMGO Institute - Common Mental Disorders
physical therapy
Treatment – Graded Activity
Feature
Description
Exercises
General exercises (aerobic, abdominal, back, and leg) and
individually tailored exercises to simulate and practice
problematic tasks at work or in daily living.
During the first 3 sessions, workers are asked to perform
Baseline
Assessment each exercise separately until the limits of pain (pain
contingent) are reached. The average results of these 3
of Maximal maximal performances are used as baseline values for the
Performance quota-based exercise program.
Return to
Work
After the third session, the worker proposes a date for
return to work (in consultation with the PT), which
corresponds with the end of the intervention period. The
worker may return to work partially or with modified duties
before returning to full regular work.
2
Treatment – Graded Activity
Treatment – Graded Activity
• Exercise Regimen
Feature
Description
Exercise
Program
The worker determines (in consultation with the PT) a
gradually increasing quota for each exercise. The quotas
start at a level below the average baseline value of
functional capacity (to ensure success) and are gradually
increased during the course of the intervention.
 Individually-tailored exercise
 Imitate physical tasks at work or home
Time
Exercise quotas are preset and not subject to change
Contingent during the course of the intervention, regardless of level of
Management pain.
Treatment – Graded Activity
• Instructions to Therapists
Pain Intensity Outcomes (VAS)
8
 Verbally praise the patient on achievement of a
goal
Graded
Usual
7
6
 Pay
Pa pa
particular
tic la attention to patients’ improvement
imp o ement
rather than pain
5
4
 The primary goal was not improving aerobic
capacity or strength, but making the individual
aware that it was safe to move and to be
physically active despite pain.
3
2
p >0.20
1
0
Baseline
3 months
6 months
Boersma et al. Lowering Fear-Avoidance and
Enhancing Function through Exposure in
vivo. Pain, 2004.
Results
• Mean provider visits:
• Current psychological therapies for fears
 Graded Activity - mean 13 visits (sd=5),
and phobias are based on systematic
desensitization (Wolpe, 1958)
 Usual Care - mean 13 visits (sd=8)
(sd 8) from
• Progressive exposure to fearful stimuli
average duration 7 weeks.
various providers
 Individual hierarchy of fear stimuli is
• Median total days of work absence
because of LBP after randomization:
 87 days – Usual Care
established, therapy involves progressive
exposure to these stimuli
 Goal is to produce disconfirmations of fear
and catastrophic expectations
 50 days – Graded Activity
P<0.05
EMGO Institute - Common Mental Disorders
3
Boersma et al. Lowering Fear-Avoidance and
Enhancing Function through Exposure in
vivo. Pain, 2004.
• Multiple baseline single-subject design
• Six subjects with chronic LBP (>6
months), with difficulty functioning and
high fear of pain (TSK>35)
Baseline 1 - 4 weeks of treatment - Baseline 2
Treatment
• Conducted by a team of PTs and
psychologists
• Began with education and reassurance
thatt nothing
th
thi
is
i seriously
i
l wrong and
d
activity is encouraged.
• The fear-avoidance model was presented
• PHODA was used to create a hierarchy of
fear activities
Patient #3
• 61 year-old female with LBP for 5 years
• Telephone operator, 50% sick-listed
• Beliefs:
 Pain caused by “worn-out spine”
 Back bones are “pressed together and fragile
so it could snap”
Measurements
• Daily assessment of fear-avoidance (4
individual items from other scales)
• PHODA (Photographic measure of daily
activities)
ti iti )
 98 photographs of daily activities ranked
by patient from 0 (no concern) to 100
(maximum concern)
Treatment
• Personal goals/activities were incorporated if not
included in the PHODA
• Sessions began with patient explaining
expectations and anticipated consequences from
a movement or an activity
• The patient performed the movement
• After each movement the patient rated the
consequences of the movement
• Homework to incorporate movements into daily
life was given.
Patient #3
• PHODA items over 80
 Working while bending forward
 Rotating the body
 Lifting
 Carrying
 Reaching overhead
 Jumping
EMGO Institute - Common Mental Disorders
4
Outcomes – patient #3
TSK
Function
PHODA
80
70
60
50
40
30
20
10
0
Pre
Post
3 month
Daily ratings of fear and avoidance beliefs
Summary
• All patients showed decreases in fear
and increases in function, although
some improved more than others
• Improvements generally persisted in
follow-up period
• Therapists reported some difficulty in
pinpointing the specific fears in some
patients
Biopsychosocial
group
Patients with LBP (< 8 wks) Receiving Physical Therapy
Biomedical Group
Biopsychosocial Group
• Classification-based management
• Classification-based management
• Exercise prescription based on
limits of pain
• Exercise prescription based
setting goals and quotas
• Education in anatomy and
pathology of spine (Handy Hints
pamphlet, reinforcement of
message in clinic)
• Education to remain active (Back
Book pamphlet, reinforcement of
message in clinic)
The University of Utah
Department of Physical Therapy
Traditional group
Patients (15-60 yrs old) with LBP (< 24 wks) Receiving
Physical Therapy
The University of Utah
Department of Physical Therapy
EMGO Institute - Common Mental Disorders
Classification-Based
Cl
ifi ti
B
d
Treatment
Classification-Based
Cl
ifi ti
B
d
Treatment
+
+
Graded Exposure
Graded Exercise
Classification-Based
Treatment
The University of Utah
Department of Physical Therapy
5
The University of Utah
Department of Physical Therapy
The results suggest that supplementing
TBC with GA or GX was not effective for
improving important outcomes related to
the development
p
of chronic LBP.
 Results question the additional benefit of GX or GA
when a robust exercise therapy is used.
 Contrary to prior results, level of fear avoidance
beliefs did not moderate treatment effects.
 The change in pain at 6 months was explained by
changes in fear avoidance beliefs and pain
catastrophizing.
–These variables may be appropriate targets for treatment
The University of Utah
Department of Physical Therapy
Thank You
The University of Utah
Department of Physical Therapy
EMGO Institute - Common Mental Disorders
6