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Fear of Movement: Relationship to Function and Pain. Mary Christenson, PT, PhD DPT 781 O. “…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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Fear of movement relationship to function and pain

Fear of Movement: Relationship to Function and Pain

Mary Christenson, PT, PhD

DPT 781 O


“…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


Defined why is this important
Defined & Why Is This Important?? in patients with chronic pain”

  • 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 movementAvoid physical activity?


What about catastrophizing
What About Catastrophizing? in patients with chronic pain”

  • Gracely RH, et al. Pain catastrophizing and neural responses to pain among persons with fibromyalgia. Brain. 2004;127(4):835-843.


What types of constructs are measured
What types of constructs are measured? in patients with chronic pain”

  • 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


Is there a relationship
Is There a Relationship?? in patients with chronic pain”

  • Fear of Falling and Fear of Pain


Longitudinal study is there a cause and effect relationship 2

Cause in patients with chronic pain”

Fear of Falling

Predictor of future falls?

Fear of Pain

Predictor of future activity avoidance?

Effect

Activity Avoidance

Activity Avoidance

Longitudinal Study – Is There a Cause and Effect Relationship? 2

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?


Activity avoidance system consequences
Activity Avoidance: in patients with chronic pain”System Consequences

  • Cardiovascular

  • Musculoskeletal

  • Neurologic

  • Other?


Longitudinal investigation continued
Longitudinal Investigation (continued) in patients with chronic pain”

  • 571 participants

  • Average age 76.6 years

  • Interviews/questionnaires (pain, pain anxiety, FES, ABC, SAFFE, MMSE, etc.)

  • Recorded falls/injuries


Longitudinal investigation continued1
Longitudinal Investigation (continued) in patients with chronic pain”

  • Results

    • Fear of falling predicts

      • 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

Distinct Constructs: Fear of Falls & Fear of Pain


Reflection
Reflection in patients with chronic pain”

  • 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?


Falls
Falls in patients with chronic pain”

  • 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

    • Fear of pain DISABILITY

Thought to be related

Vigilance to reduce falls may put at risk for more falls


Public
Public in patients with chronic pain”

  • Perceptions of consequences of falls by public?


Research
Research in patients with chronic pain”

  • 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


Individual and public impact
Individual and Public Impact in patients with chronic pain”

  • Change in function, CV status

  • Quality of Life

    • Fear of falling – lower Quality of Life5

  • Avoidance behaviors6

  • Loss of productivity


Pain in patients with chronic 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


Designing a plan
Designing a Plan in patients with chronic pain”

  • Roaldsen et al.7 article – questions

    • What % of patients had fear-avoidance beliefs in this subpopulation?

    • What was the relationship between activity level and fear-avoidance?

    • 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


Additional strategies
Additional strategies? in patients with chronic pain”

  • Using a behavioral health model?

    • TTM

    • TRA/TPB


General evaluation hints
General Evaluation Hints in patients with chronic pain”

  • 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


Objective evaluation
Objective Evaluation in patients with chronic pain”

  • List – Develop with a partner


References
References in patients with chronic pain”

  • 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.


  • 5 in patients with chronic pain”Lachman 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. AustralianJournalof Advanced Nursing Sep-Nov2009;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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