Fear of Movement: Relationship to Function and Pain

1. Fear of Movement: Relationship to Function and Pain Mary Christenson, PT, PhD DPT 781 O

2. “…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

3. 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 movementAvoid physical activity?

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

5. 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

6. Is There a Relationship?? • Fear of Falling and Fear of Pain

7. Cause 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?

8. Activity Avoidance:System Consequences • Cardiovascular • Musculoskeletal • Neurologic • Other?

9. Longitudinal Investigation (continued) • 571 participants • Average age 76.6 years • Interviews/questionnaires (pain, pain anxiety, FES, ABC, SAFFE, MMSE, etc.) • Recorded falls/injuries

10. Longitudinal Investigation (continued) • 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

11. 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?

12. 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 • Fear of pain DISABILITY Thought to be related Vigilance to reduce falls may put at risk for more falls

13. Public • Perceptions of consequences of falls by public?

14. 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

15. Individual and Public Impact • Change in function, CV status • Quality of Life • Fear of falling – lower Quality of Life5 • Avoidance behaviors6 • Loss of productivity

16. 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

17. 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 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

18. Additional strategies? • Using a behavioral health model? • TTM • TRA/TPB

19. 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

20. Objective Evaluation • List – Develop with a partner

21. 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.

22. 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. 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.