Positive Psychology: The role of pain-related fear and avoidance in chronic pain

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The role of pain-related fear and avoidance in chronic pain

09FridayJan 2015

Posted by michaeljmcdermott in Chronic Pain

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(Image directly copied from Vlaeyen & Linton, 2012)

Key Points
• Long-term avoidance of pain-related behaviors due to fear of pain may increase sensitization to pain and pain-related stimuli, decrease self-efficacy, increase expectation of pain, and increase pain perception, ultimately perpetuating pain-related disability and functional impairment.
• Increased willingness to experience pain and graded exposure to situations or behaviors perceived to be threatening is effective in reducing pain-related fears and subsequent pain-related avoidance and disability among individuals with chronic pain.

Fear and Avoidance in the Development and Maintenance of Chronic Pain
Traditional biomedical models of pain suggest that an individual’s pain experience should directly match the physical damage incurred and that similar injuries should result in similar pain. However, pain isn’t that simple. Rarely will two individuals with identical physical injuries report the exact same pain. For that matter, two individuals with the same injury will likely demonstrate differences in impairment and suffering. These observed discrepancies between expected and reported pain and disability suggest a more complex relationship; one that has led researchers to examine the role of psychological and behavioral factors in the development and maintenance of chronic pain conditions.

The fear-avoidance model (Vlaeyen & Linton, 2000; 2012) details a potential pathway for the development of pain disability, affective distress, and physical disuse resulting from anxiety- and fear-related avoidance behaviors and provides a platform for understanding the dynamic relationship between psychological factors and chronic pain. The fear-avoidance model suggests that pain-related avoidance behaviors and withdrawal, as well as increased vigilance toward internal bodily sensations and external threats of pain, play an adaptive and functional role in protecting the body. It’s healthy to avoid behaviors that cause pain – at least in the short-term. For example, bending or lifting heavy objects may be avoided in order to limit lower back pain from a previous injury. Although adaptive in promoting recovery in acute phases of pain, prolonged avoidance and hypervigilance behaviors may serve to maintain or even exacerbate pain symptoms in the long term by inadvertently increasing pain disability and affective distress. That is, long-term avoidance of pain-related behaviors is maladaptive and ultimately increases pain and pain-related disability.

Pain-related fear and negative affective states play an integral role in escape and avoidance behaviors, suggesting that the meaning of pain may be just as important as the actual experience of pain. When pain is feared and viewed as dangerous, an individual may act in anticipation of pain, rather than in direct response to pain. Avoiding movements due to pain-related fears may contribute to physical deconditioning, negative affect or affective comorbidities, and preoccupation with physical and somatic symptoms associated with pain. These effects in turn may increase sensitization to pain and pain-related stimuli, decrease self-efficacy, increase expectation of pain, and increase pain perception, ultimately perpetuating pain-related disability and functional impairment.

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The Good News

You don’t need to change a patient’s beliefs or fear of pain to reduce their avoidance of pain-related behaviors. Graded exposure to situations or behaviors perceived to be threatening is effective in reducing pain-related fears and subsequent pain-related avoidance and disability among individuals with trauma-related neck pain (de Jong et al., 2008), upper extremity pain (de Jong et al., 2012), complex regional pain syndrome (de Jong et al., 2005) and chronic low back pain (Vlaeyen et al., 2001; 2002). Exposure-based treatments are some of the most effective and widely-used psychological interventions for anxiety and trauma-related disorders and have gained continuing support in the treatment of chronic pain conditions. By providing education about the role of avoidance behaviors in the maintenance and development of pain and systematically increasing engagement in feared or pain-related behaviors, psychological and physical therapists can effectively reduce pain-related fear and anxiety and enhance effective recovery through confrontation and increased self-efficacy.

References

de Jong, J. R., Vangronsveld, K., Peters, M. L., Goossens, M. E. J. B., Onghena, P., Bulté, I., & Vlaeyen, J. W. S. (2008). Reduction of pain-related fear and disability in post-traumatic neck pain: A replicated single-case experimental study of exposure in vivo. The Journal of Pain, 9, 1123-1134.
de Jong, J. R., Vlaeyen, J. W. S., van Eijsken, M., Loo, C., & Onghena, P. (2012a). Reduction of pain-related fear and increased function and participants in work-related upper extremity pain (WRUEP): Effects of exposure in vivo. Pain, 153, 2109-2118.
de Jong, J. R., Vlaeyen, J. W. S., Onghena, P., Cuypers, C., den Hollander, M., & Ruijgrok, J. (2005). Reduction of pain-related fear in complex regional pain syndrome type I: The application of graded exposure in vivo. Pain, 116, 264-275.
Vlaeyen, J. W. S., de Jong, J. R. Geilen, M., Heuts, P. H., & van Breukelen, G. (2001). Graded exposure in vivo in the treatment of pain-related fear: A replicated single-case experimental design in four patients with chronic low back pain. Behavior Research and Therapy, 39, 151-166.
Vlaeyen, J. W. S., de Jong, J. R. Geilen, M., Heuts, P. H., & van Breukelen, G. (2002). The treatment of fear of movement/(re)injury in chronic low back pain: Further evidence on the effectiveness of exposure in vivo. The Clinical Journal of Pain, 18, 251-261
Vlaeyen, J. W. S., & Linton, S. J. (2000). Fear-avoidance and its consequences in chronic musculoskeletal pain: A state of the art. Pain, 85, 317-332.
Vlaeyen, J. W. S., & Linton, S. J. (2012). Fear-avoidance model of chronic musculoskeletal pain: 12 years on. Pain, 153, 1144-1147.
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Chronic Pain: Breaking the Cycle

16TuesdaySep 2014

Posted by firstascentpt in Chronic Pain

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Chronic Pain is a difficult issue to deal with and treat. Sometimes people experiencing it do not know they have it. Individuals tend to be consumed by their pain and feel helpless. It is hard to think that you can get back to your life prior to pain when healthcare professionals are having trouble finding the root cause and when any activity causes you pain. Chronic low back pain is shown to be as prevalent at 23% of the population.

It is important to not only treat the physical aspect but also the cognitive aspect for individuals with chronic pain. Leventhal provided a self-regulation model that showed maladaptive illness perceptions can lead to maladaptive behavior; such as activity limitations.

I came across an article that developed and studied the effectiveness of a cognitive treatment of illness perceptions (CTIP). The goal of this treatment method is to challenge and change perceptions of patients dealing with chronic pain by going through a 4 phase process.

Cognitive Treatment of Illness Perceptions (CTIP)

Phase 1: Mapping of Existing Illness Perceptions
Approximately 2 sessions to complete
The use of subjective information that focused on activity limitations as a starting point.
Then elaborating on thoughts about low back pain in relation to their limitation activity.
Example: I need to rest in bed in order to allow the pain to fade away.

Phase 2: Challenge Maladaptive Illness Perceptions
Approximately 2 sessions to complete
Create doubt about the most maladaptive illness perceptions
Example: Questioning the patient’s perception that resting in bed would decrease the pain.

Phase 3: Alternative Illness Perceptions are Formulated
Approximately 1 session to complete
Convert maladaptive perceptions to alternative perceptions that will help to increase physical activity
The physical therapist and patient both agree and conclude on plausible perceptions
Example: Doing light jobs is a suitable replacement for bedrest, as it allows the body to recuperate and it distracts away from the pain.

Phase 4: Alternative Perceptions are Tested and Strengthened by Confirming Their Utility in Daily Practice
On going once alternative perception is created
Example: The continuation of completing light jobs instead of bed rest.

This treatment protocol for perception modification gives recommendations for treatment time frame per phase. It is recommended to use professional clinical judgement when using this for patients with chronic pain.

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(Click the link below for access to the article)

Cognitive Treatment of Illness Perceptions in Patients with Chronic Low Back Pain: A Randomized Controlled Trial

Purpose: To compare the effectiveness of treatment of illness perceptions against a waiting list for patients with chronic low back pain.

Methods: They classified chronic pain as greater than 3 months of lower back pain. They studied 156 subjects with an 18% withdrawl rate from treatment. The subjects were randomized into a chronic low back pain group (experimental) and a waitlist group (control). The researchers had an intention to treat. The subjects were treated one time a week for 1 hour each session over a period of 10-14 weeks. They completed the Cognitive Treatment of Illness Perception protocol for the first 5 weeks and then followed the subjects for the remainder of the treatment sessions. The subjects were also expected to keep a diary on medical costs for their back such as doctor visits, physical therapy, and alternative methods. They researchers measured change using the Patient-Specific Complaints Questionnaire (PSC), the Illness Perception Questionnaire (IPQ-R), and the Quebec Back Pain Disability Scale (QBPDS).

Results: They found significant improvement in reported reductions in back pain symptoms in the PSC questionnaire (1 out of 4 will benefit from this treatment and 49% in the experimental group showed clinically relevant change compared to 26% for the control group). There were significantly different changes found in the IPQ-R for baseline and follow-up measurements between the control and experimental groups for 4 of the subscales: time line cyclical, consequences, personal control, and coherence. There were no significant differences found for QBPDS (for general physical activities) which was expected since the focus was on specific tasks.

Limitations: The researchers only concluded on one limitation which was that they did not measure the long-term effectiveness of the treatment.

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