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
Syfte Grundläggande om aktivitetsträning Smärta Träning vs funktion Har vi kommit så långt vi kan? Engagemang Komorbida problem
Focus on spinal pain: back pain
What is activity? Complex system= many aspects The movement/exercise itself Verbal reports about it BEHAVIORS
Activity behavior influenced by BIO PSYCHO SOCIAL Research -------------------- Clinic
Biopsykosocial modell *Kontext (Miljö) *Kultur *Nociceptiva stimuli *Familj *Kön påverkar SMÄRTPERCEPTION: Emotion Kognition Beteende Fysiologi
Exercise: bioperspective Increase strength of certain muscles Restore balance in muscle system Increase mobility, tone, etc. Increase condition, lung capacity, etc.
Psychological perspective Emotion, thoughts and overt behavior might affect exercise
Exercise: social perspective Effects of society &interpersonal relationships
Pain as a result of injury Pain is a vital warning signal!
The Dilemma Injury=Pain Pain=Disability If it hurts= don t do it! REPORT OF DISABILITY VS ACTUAL BEHAVIOR (ACTIVITY LEVELS) PAIN VS ACTIVITY
Statistics: 2 studies in Sweden 73% reported an episode of back pain/year Activity hindrance: moderate 4.6 28% however >7 Work absenteeism: 31% Health care visits: 3.5/year 6% of sufferers consume >50% of resources
Impact of chronic pain on activities 1,250,000 Swedes Breivik et al, 2006
Reported relationship: Pain and activity 21 79 activity provokes Activity does not provoke Breivik et al 2006
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!
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
Beh. activation/graded activity Results 45 40 35 30 25 20 15 10 5 0 Baseline 1 3 2 4 6 Trials 8 10 12 14 activity target Linton, et al, 1999, Jr Occ Rehab
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
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
Does pain cause disability? How is pain related to disability? Is disability related to actual activity levels?
Relationship: pain & activity % r e l a t i o n 100 90 80 70 60 50 40 30 20 10 0 Self-report Believed Rating Scales Pain = function Monitoring Behavioral observation Actual
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
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
Activity & function How much you can do physically is related not only to BIO Psychosocial factors important as well!
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!
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
What drives disability then? Pain, of course Process over time!! What factors??
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
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
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%
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
Lessons learned Motivation/engagement Comorbidity: When activity training fails WHAT TO DO? Communication Goal setting/values Early id Treatment that includes psych
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
Communication the patient and HCP! anxiety fear vigilance fear-avoidance anxiety fear of mistakes selective listening misinterpretation unclear double messages
The challenge Difficult Patients have different needs : emotions Context may be different Time constraints Need to provide correct info/psychoed
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)
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
NEEDED: Patient focused, empathetic communication Motivational interviewing Dialectical Behavior Therapy Focus on understanding patient s experience Stimulate patient s own problem solving skills
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
Results: Adherence test
Developing personally relevant goals Goal setting Operational definition Small steps
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
The Compass of Life Social, friends citizenship/public service Spirituality Intimate partnership Leisure Health/ well-being Family Parenting Career personal development /education
When treatment fails Despite our knowledge, intentions, and delivery NOT EVERYONE RESPONDS WHY?
Co-morbidity: pain & psych Patients often have other problems including depression, anxiety, fear, & insomnia Co-morbidity might be associated with treatment failure
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
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.
Depression (post) and RTW % 100 75 50 25 91% RTW maximized by early intervention 60% that reduces depression 26% 0 None Mild Mod-severe Sullivan et al, Jr of Occ Rehab, 2006
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
Depression & Catastrophizing Two samples of patients @ primary care Ratings of depression, and catastrophizing Categorized by combinations Low Cat Hi Cat Low Dep 229 46 High Dep 57 37
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
10 Improvements in function by early changes in catastrophizing, depression, and anxiety Function improvement 8 6 4 2 0 EARLY CHANGES MARKERS OF SUCCESS! 0 1 2 3 # of psych. variables changed by session 3 Bergbom et al, 2010
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
Results: pain 10 8 Similar! Different** 6 4 HI CFD LO CFD 2 0 Base 3yrs
Screening: Örebro scores and longterm problem New Zealand ACC claims N= 328 Örebro Screen, obtained @ 2nd visit Followed until claim was closed Outcomes: costs, days off work Grimmer-Somers et al. 2008
AverageCase Cost by Level of Risk
Review of early psychosocial interventions 18 RCTs of early psych intervention Musculoskeletal pain Most in primary care settings Nicholas, Linton, Watson & Main, 2011
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
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
Implications Engagement communication, goals, values Comorbidity central Psych for early identification Address relevant psych aspects Including psychological perspective PAYS OFF
Thank You for Your Attention!