är vi framme snart? Aktivitetsträning ur ett biopsykosocialt perspektiv:

Transcription

1 Aktivitetsträning ur ett biopsykosocialt perspektiv: är vi framme snart? Steven J. Linton Professor i klinisk psykologi Center for Health And Medical Psychology Örebro Universitet Nationell Beteende- Medicinsk konferens Västerås, april 2013

2 Syfte Grundläggande om aktivitetsträning Smärta Träning vs funktion Har vi kommit så långt vi kan? Engagemang Komorbida problem

3 Focus on spinal pain: back pain

4 What is activity? Complex system= many aspects The movement/exercise itself Verbal reports about it BEHAVIORS

5 Activity behavior influenced by BIO PSYCHO SOCIAL Research Clinic

6 Biopsykosocial modell *Kontext (Miljö) *Kultur *Nociceptiva stimuli *Familj *Kön påverkar SMÄRTPERCEPTION: Emotion Kognition Beteende Fysiologi

7 Exercise: bioperspective Increase strength of certain muscles Restore balance in muscle system Increase mobility, tone, etc. Increase condition, lung capacity, etc.

8 Psychological perspective Emotion, thoughts and overt behavior might affect exercise

9 Exercise: social perspective Effects of society &interpersonal relationships

10 Pain as a result of injury Pain is a vital warning signal!

11 The Dilemma Injury=Pain Pain=Disability If it hurts= don t do it! REPORT OF DISABILITY VS ACTUAL BEHAVIOR (ACTIVITY LEVELS) PAIN VS ACTIVITY

12 Statistics: 2 studies in Sweden 73% reported an episode of back pain/year Activity hindrance: moderate % however >7 Work absenteeism: 31% Health care visits: 3.5/year 6% of sufferers consume >50% of resources

13 Impact of chronic pain on activities 1,250,000 Swedes Breivik et al, 2006

14 Reported relationship: Pain and activity activity provokes Activity does not provoke Breivik et al 2006

15 Activity training as a base Most patients report decrease in activity Many are fear-avoidant Many also suffer depression Therefore it is vital to re-establish physical activity Operant activity training is one means to do so!

16 Operant Activity Training (graded activity) Goal(s) Baseline level, without increasing pain Gradual increase of goal level Focus on improvement, not pain Reinforcement! Extinquish the connection between activity and pain

17 Beh. activation/graded activity Results Baseline Trials activity target Linton, et al, 1999, Jr Occ Rehab

18 Effects of exercise 37 RCTs exercise is effective (compared to usual care) to improve pain intensity and function middelkoop et al 2011 No type of exercise is superior Operant (Graded) Activity is effective in reducing pain and improving function Macedo et al, 2010

19 BUT Effect sizes appear to have gone DOWN, probably because of better studies Not everyone responds Most who respond do NOT reach prepain levels of functioning

20 Does pain cause disability? How is pain related to disability? Is disability related to actual activity levels?

21 Relationship: pain & activity % r e l a t i o n Self-report Believed Rating Scales Pain = function Monitoring Behavioral observation Actual

22 Pain versus psychosocial pain other Pain explains 10% of variance (disability) But Pain other >85% of resources go to treat pain symptom Sullivan et al, 2006

23 Systematic Review:activity & pain 18 studies that measured self-reported disability & objective measure of activity level in LBP Results: r=.08 subacute pain r=-.33 chronic pain level of disability level of selfreported activity

24 Activity & function How much you can do physically is related not only to BIO Psychosocial factors important as well!

25 Exercise: how much can you do? Baseline, instructed to do activity: until..pain, weakness, or fatigue cause you to wish to stop (fordyce 1976) Almost always stop on an even number if a clock is available!

26 Context: Schmidt, 1985 Treadmill, Pre test-post tests Control vs Clock or clock + expectation the average for a person of your age and gender is xx Results: Performance influenced by clock Tend to meet the expected average! Decreases in performance over tests attributed to greater physical exertion although not actually so

27 What drives disability then? Pain, of course Process over time!! What factors??

28 Working despite pain: background Epidemiological studies show great variety of pain and disability levels For every person off work because of back pain There are 4-8 people with similar levels of pain who are working

29 Working despite pain Compared nurses with sickleave (mean 90 days) Without sickleave Matched on pain intensity and duration during past year Moderate to severe; often always Controlled for workload, mobility,obesity etc How can copers work despite the pain? Linton & Buer, 1995

30 Results Beliefs Pain is harmful Should reduce activities Focus on pain Cannot stop thinking about it Perceived poor health Belief that have a serious illness Correctly predicts 83%

31 Significant psychological risk factors Self-report of functional limitation Depressed mood Pain level Catastrophic worry Fear avoidant beliefs Poor expectations for recovery Pain behavior coping Nicholas, Linton, Watson & Main, 2011

32 Lessons learned Motivation/engagement Comorbidity: When activity training fails WHAT TO DO? Communication Goal setting/values Early id Treatment that includes psych

33 Linton & Flink: 12 verktyg för KBT, 2011 Process of positive change Shared Understanding Contact Goals Psycho- Problem Engage Values education Solving Intervention: activity Success Maintain

34 Communication the patient and HCP! anxiety fear vigilance fear-avoidance anxiety fear of mistakes selective listening misinterpretation unclear double messages

35 The challenge Difficult Patients have different needs : emotions Context may be different Time constraints Need to provide correct info/psychoed

36 Anger Anger increases pain intensity (Burns 2011) When we attempt to suppress anger: Pain intensity and dysfunction increases Pain behavior e.g. sighs and grimacing increase These pain behaviors are experienced negatively by others. Person not likeable, not friendly, difficult (Martel, 2012)

37 Anger and entitlement The more one feels entitlement because the pain is unjust: Increased catastrophizing Less social support from others More invalidation from healthcare professionals Cano & Leong, 2012

38 NEEDED: Patient focused, empathetic communication Motivational interviewing Dialectical Behavior Therapy Focus on understanding patient s experience Stimulate patient s own problem solving skills

39 VALIDATION Explicitly expressing understanding of what a patient says, feels or experiences as true Acceptance without judgement Acknowledge & recognize: (restate, reflect upon) INVALIDATION Expressing that what a Pt. says, feels or experiences is doubtful or untrue Judgement. E.g. pain sensitive catastrophizer Nonrecognition: disbelief, discounting, patronizing, denying

40 Results: Adherence test

41 Developing personally relevant goals Goal setting Operational definition Small steps

42 valuing Defining life directions Separating values from social, family and other pressures Defining activities consistent with directions Identifying barriers Identifying and fostering action to achieve

43 The Compass of Life Social, friends citizenship/public service Spirituality Intimate partnership Leisure Health/ well-being Family Parenting Career personal development /education

44 When treatment fails Despite our knowledge, intentions, and delivery NOT EVERYONE RESPONDS WHY?

45 Co-morbidity: pain & psych Patients often have other problems including depression, anxiety, fear, & insomnia Co-morbidity might be associated with treatment failure

46 FEAR: Impact on treatment Fear avoidance increases the risk for chronic pain, sickleave and poor treatment results Associated with the development of chronic pain (a driver) Present early on

47 Jessica A. Lohnberg,2007 Review of the literature The author concludes that graded exposure in vivo appears to be the most effective treatment for chronic pain in individuals with increased fear and avoidance.

48 Depression (post) and RTW % % RTW maximized by early intervention 60% that reduces depression 26% 0 None Mild Mod-severe Sullivan et al, Jr of Occ Rehab, 2006

49 Örebro model of pain and depression Flare-up: negative emotions or pain Linton & Bergbom, 2011 Reactivation catastrophic worry, Cognitive avoidance Emotion Regulation taxed Relapse Dysregulation Increased neg. emotions Attention to threat No relapse Regulation Skills hold emotions in balance Attention on others

50 Depression & Catastrophizing Two samples of primary care Ratings of depression, and catastrophizing Categorized by combinations Low Cat Hi Cat Low Dep High Dep 57 37

51 Odds for dysfunction at FU 4,5 Odds Ratio 4 3,5 3 2,5 2 1,5 1 0,5 0 AND, up to 14 x greater risk for sickleave!!! LoCat, LoDep HiCat, LoDep LoCat,HiDep HiCat, HiDept Linton et al, European Journal of Pain, 2011

52 10 Improvements in function by early changes in catastrophizing, depression, and anxiety Function improvement EARLY CHANGES MARKERS OF SUCCESS! # of psych. variables changed by session 3 Bergbom et al, 2010

53 Screening for psychological factors Why bother? Back pain in primary care 158 pts seeking care for MSP Compared profiles Lo catastrophizing, fear, distress HI catastrophizing, fear, distress Westman, et al, 2011

54 Results: pain 10 8 Similar! Different** 6 4 HI CFD LO CFD 2 0 Base 3yrs

55 Screening: Örebro scores and longterm problem New Zealand ACC claims N= 328 Örebro Screen, 2nd visit Followed until claim was closed Outcomes: costs, days off work Grimmer-Somers et al. 2008

56 AverageCase Cost by Level of Risk

57 Review of early psychosocial interventions 18 RCTs of early psych intervention Musculoskeletal pain Most in primary care settings Nicholas, Linton, Watson & Main, 2011

58 Results of the Review 11 studies show Significant improvements compared to Usual Treatment assess risk and target it with psychological methods. Assessing and targeting psychological factors results in significantly better 7 studies showed little or no effect care! as compared to Usual Treatment B*U*T did not identify risk or specifically target it Nicholas, Linton, Watson & Main, Phy Therapy, 2011

59 Conclusions Activity is complex including biopsychosocial aspects Psych factors impact on the experience of pain & function Psych factors are central drivers in the development of chronic dysfunction

60 Implications Engagement communication, goals, values Comorbidity central Psych for early identification Address relevant psych aspects Including psychological perspective PAYS OFF

61 Thank You for Your Attention!