Transcript Document

Fear of Movement:
Relationship to Function and Pain
Mary Christenson, PT, PhD
DPT 781 O
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“…Fear-avoidance may initiate
and/or maintain disability in patients
with chronic pain”1
Fear: Perceived that movement may delay healing or
cause (re) injury and result in continued pain
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Defined & Why Is This Important??
Hypokinesia – “Little Movement”
Kinesiophobia
Fear of falling
A type of kinesiophobia that can result in
hypokinesia
Activity avoidance2
Chronic LBP
Interaction of fear of movement with fear
of pain
Fear of falls, pain, or movement
Avoid physical activity?
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What About Catastrophizing?
Gracely RH, et al. Pain catastrophizing
and neural responses to pain among
persons with fibromyalgia. Brain.
2004;127(4):835-843.
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What types of constructs are measured?
 Fear
Tampa Scale for Kinesiophobia
Fear Avoidance Belief Questionnaire
Pain Catastrophizing Scale
 Falls
Falls Efficacy Scale
10 ADLs commonly performed by older adults
Activities-specific Balance Confidence (ABC) scale
Survey of Activities and Fear of Falling in the
Elderly (SAFFE) – includes exercise and social
activity
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Is There a Relationship??
Fear of Falling and Fear of Pain
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Longitudinal Study – Is There a Cause
and Effect Relationship? 2
 Cause
Fear of Falling
 Effect
Activity Avoidance
 Predictor of future
falls?
Fear of Pain
 Predictor of future
activity avoidance?
Activity Avoidance
What is the role of activity avoidance in pain and falls over
time?
Do measures of activity avoidance predict falls and pain
over and above measures of fear of falling and fear of
pain?
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Activity Avoidance:
System Consequences
Cardiovascular
Musculoskeletal
Neurologic
Other?
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Longitudinal Investigation (continued)
571 participants
Average age 76.6 years
Interviews/questionnaires (pain, pain
anxiety, FES, ABC, SAFFE, MMSE, etc.)
Recorded falls/injuries
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Longitudinal Investigation (continued)
Results
Fear of falling predicts
Distinct Constructs: Fear
of Falls & Fear of Pain
future falls
• Evidence suggests anxiety impacts balance2
• Is the fear an accurate reflection of the patient’s balance?
Activity level
Avoidance is NOT a predictor of future falls
Fear of pain and pain-related avoidance not a
predictor of future pain
Fear of pain not a predictor of falls
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Reflection
What is the role of fear in pain and
movement dysfunction?
What strategies can PTs use to address
fear of movement, whether it’s related to
pain and or movement/function?
What are the potential outcomes of
immobility?
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Falls
Focus on seniors
¼ of community living adults between 65-74
y.o. report 1+ falls per year2
Increases to 1/3 at 75+ y.o.
Significant injuries in ~20% of those who fall
Mortality rate from falls increases with age
Fear of falling
FALLS
Thought
Fear of pain
DISABILITY to be related
Vigilance to reduce falls may put at risk for more falls
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Public
Perceptions of consequences of falls by
public?
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Research
Predictors for falls and fear of falling
similar4
Anxiety
May not be a history of falling
Demonstrate anxiety with walking or
standing and or can describe gait
disturbances/lack of confidence in balance
with gait/movement
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Individual and Public Impact
Change in function, CV status
Quality of Life
Fear of falling – lower Quality of Life5
Avoidance behaviors6
Loss of productivity
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Pain
Roaldsen KS, Elfving B, Stanghelle JK,
Talme T, Mattsson E. Fear-avoidance
beliefs and pain as predictors for low
physical activity in patients with leg ulcer.
Physiother. Res. Int. 2009;14(3):167-180.
A case example
Effects of PA on patients with leg ulcer
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Designing a Plan
 Roaldsen et al.7 article – questions
 What % of patients had fear-avoidance beliefs in this
subpopulation?
 What was the relationship between activity level and fearavoidance?
 What are the consequences of inactivity in this
subpopulation?
 What was the influence of pain?
 Discuss an appropriate treatment plan, including strategies
discussed in class
 This case is relevant to multiple diagnoses and can
serve as a model
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Additional strategies?
Using a behavioral health model?
TTM
TRA/TPB
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General Evaluation Hints
 Subjective and cognition evaluation
General History
Determine if level of activity has changed and timeframe
for this change
“Are you aware of thinking before moving/walking?” “Do
you think seriously before getting up and moving
around?” [Harding]
 In general, use terms that won’t alarm patient
• “concerned about” or “uneasy” walking rather than “fear”
Baseline cognitive function
Anxiety/depression screen
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Objective Evaluation
List – Develop with a partner
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References
 1Vlaeyen JW, Linton SJ. Fear-avoidance and its
consequences in chronic musculoskeletal pain: A state
of the art. Pain. 2000;85:317-332.
 2Hadjistavropoulos T, Martin RR, et al. A longitudinal
investigation of fear of falling, fear of pain, and activity
avoidance in community-dwelling older adults. J Aging
Health. 2007;19:965.
 3Gracely RH, et al. Pain catastrophizing and neural
responses to pain among persons with fibromyalgia.
Brain. 2004;127(4):835-843.
 4Friedman s, et al. Falls and fear of falling: which comes
first?A longitudinal prediction model sggests strategies
for primary and secondary prevention. JAGS.
2002;50(8):1329-1335.
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 5Lachman ME, et al. Fear of falling and activity
restriction: The survey of activities and fear of
falling in the elderly (SAFFE). Jour of
Gerontology. 1998;53:P43-P50.
 6Harding S, Gardner A. Fear of Falling.
Australian Journal of Advanced Nursing SepNov2009;27(1):94-100.
 7Roaldsen KS, Elfving B, et al. Fear-avoidance
beliefs and pain as predictors for low physical
activity in patients with leg lcer. Physiother Res.
Int. 2009;14(3):167-180.
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