Therapeutic approach to pain-related fear and avoidance in adults with chronic musculoskeletal pain: an integrative review and a roadmap for clinicians

Hotta, Gisele Harumi; Oliveira, Anamaria Siriani de; Alaiti, Rafael Krasic; Reis, Felipe José Jandre dos

doi:10.5935/2595-0118.20220015

Acessibilidade / Reportar erro

Brasil

Español English

sumário « anterior atual seguinte »

Sumário

REVIEW ARTICLE • BrJP 5 (1) • Jan-Mar 2022 • https://doi.org/10.5935/2595-0118.20220015 copy

Therapeutic approach to pain-related fear and avoidance in adults with chronic musculoskeletal pain: an integrative review and a roadmap for clinicians

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

BACKGROUND AND OBJECTIVES:

Cognitive-behavioral approaches have been applied in patients with chronic pain as a treatment strategy to reduce symptoms and disability, since fear related to pain, kinesiophobia and catastrophizing may be important psychosocial barriers for recovery. The relevance of fear and avoidance behaviors in the development and maintenance of processes of disabling chronic pain is already well established in the scientific literature.

The cognitive-behavioral approach defines the relationship of pain with defense behaviors and the contribution to functional disability, assisting clinicians to recognize signs of these defensive behaviors during practice, as well as providing strategies for clinical practice, highlighting approaches that can be used, such as pain neuroscience education and exposure therapy. Therefore, it is possible to provide a guide to facilitate the implementation of these concepts in clinical practice for the management of chronic musculoskeletal pain, helping clinicians to ground the theories of fear learning and avoidance in the context of pain and to address the psychosocial factors of patients who present an association between pain and movement.

CONCLUSION:

Pain-related fear and catastrophic thoughts influence pain intensity and functional disability. Recognizing pain within a multidimensional context assists in establishing targeted approaches. Cognitive-behavioral approaches based on exposure therapy focus on the view beyond body structures.

Keywords:
Adaptation psychological; Chronic pain; Exercise therapy; Fear; Musculoskeletal pain; Pain

Characteristics	Description
Overestimation	The patient exaggerates the probability of a negative outcome and the severity of that outcome (overestimation of cost).
Intolerance to uncertainty	The patient is uncomfortable with the uncertainty of the outcome when exposing themselves to activities and movements, even if the possibility of the negative event occurring is remote.
Low coping capacity	The patient believes he or she would not be able to tolerate or cope with threatening stimuli.
Beliefs about pain	Exaggerating the significance of pain and the need to control it before exposure to any activity.
Selective attention	The patient’s focus is directed only to the pain.
Selective memory and confirmation bias	The patient has a tendency to selectively recall events that reinforce their beliefs regarding pain, movement, and activity.
Safety behaviors (Avoidance)	The patient seeks to adopt behaviors designed to prevent unfavorable outcomes that somehow prevent them from being confronted with their maladaptive threat beliefs.

Exposure Therapy	Definition and grading
In vivo exposure	Directly confronting the threatening situation (feared movement or activity in reality). Example: the person who considers climbing a ladder to be a threatening activity can be instructed to climb a ladder.
Exposure through imagination	Vividly imagining the threatening situation or activity. Example: a person who has been injured in a sports activity, and is now afraid to do the same activity, can be asked to recall/imagine the activity in a safe situation.
Exposure through virtual reality	Virtual reality technology can be used as a form of immersion, but also when in vivo exposure is not the best option.
Graded activity or operant therapy	The clinician establishes feasible goals and specific behaviors with the patient, seeking a gradual return to activity. It consists of three phases: measuring functional capacity, education, and providing a submaximal exercise program that is gradually increased.
Graded exposure	The clinician helps the patient to identify a hierarchy of threatening movements/activities according to difficulty. Exposure begins with the mildest activities and progresses to moderately difficult, and finally the most difficult.
Cognition-targeted	The principles of this therapy include: (1) all exercises should be performed on a time contingent (“perform this exercise 10 times, regardless of pain”) rather than pain-related contingent (“stop or adjust the exercise when you feel pain”); (2) goal setting is done with the patient, focusing on functionality rather than pain relief; (3) the clinician should continually evaluate and challenge the patient’s beliefs and perceptions about pain and the predicted outcome of each exercise to change negative beliefs into positive ones; (4) exercises should be individually tailored and progressed gradually from least threatening to most threatening or complex.
Flooding	Use the threat hierarchy of activities to start exposure with the most difficult tasks.
Systematic desensitization	The exposure can be combined with relaxation exercises to make patients apprehend the possibility of control over the activities that are considered threatening.

Assessment
Clinical history	Qualified listening. Use verbal and non-verbal communication strategies. Consider pain as a multidimensional experience.
Identification and hierarchization of activities and movements	Identify activities/movements perceived to cause injury. Use open-ended questions. “Are there any activities/movements that you believe may worsen your condition”? “Are there any activities/movements that you believe may cause some injury to your body”? “Are there any activities/movements that you avoid doing because you consider them to be too dangerous for your body”? Use standardized scales. Photograph Series of Daily Activities (PHODA) Pictorial Fear of Activity Scale-Cervical (PFActS-C) Avoidance Daily Activities Photo Scale (ADAP-Shoulder) Hierarchization Threat perception: Use a scale from zero (perceived as mildly threatening) to 10 (perceived as extremely threatening) Avoidance: Use a scale of 0 (I do not avoid) to 10 (I completely avoid)
Exposure to activities or movements considered threatening	Expose patient to feared activities and movements. Observe physiological defense responses such as increased sweating and respiratory rate. Observe motor defense responses such as quality of movement.
Setting goals	Establish achievable goals. Identify the activities or movements which the patient considers most important and are limited by fear.
Therapeutic approach
Pain education	Reduce maladaptive beliefs that increase the pain threat value and defense behaviors. Introduce concepts about the neuroscience of pain: neurons, nociception and pain, pathways, pain processing in the brain, central and peripheral sensitization. Introduce how other factors influence pain: sleep, diet, inactivity.
Define the activity or movement that will be the target of the exposure	Therapist and patient select a movement or activity from the hierarchy considering scores from zero to 4 (mildly threatening), 5 to 7 (moderately threatening), and above 7 (highly threatening).
Choose the method and grading of exposure	Described in table 2 The choice of method and grading depends on the patient and there are different recommendations for progression.
Evaluate how the patient is feeling during the exposure and challenge maladaptive beliefs	“Are you feeling safe to exercise”? “What do you think will happen when you do this exercise”? “Do you think your fear regarding this activity was really necessary”?
Provide safety cues	“Your body may be feeling pain because you are no longer used to performing these movements” “Feeling pain does not mean that your lesion is getting worse” “Exercise is important to activate circuits that inhibit pain in our body “We are doing a safe activity. Realize that if your pain increases during exercise, you may be able to manage it
Evaluate the experience	“Have your fears come true”? “Were the feelings toward the activity/movement tolerable”? “What surprised you about going through the exposure”?
Provide information about adverse events	“It is common for some people who do not exercise to feel pain the next day. This does not mean that your pain has gotten worse” “If your pain increases the next day, do lighter exercises in order to allow recovery”
Value the gains	Recognize, highlight, and value the patient’s gains.

Sociedade Brasileira para o Estudo da Dor Av. Conselheiro Rodrigues Alves, 937 Cj2 - Vila Mariana, CEP: 04014-012, São Paulo, SP - Brasil, Telefones: , (55) 11 5904-2881/3959 - São Paulo - SP - Brazil
E-mail: dor@dor.org.br

Acompanhe os números deste periódico no seu leitor de RSS

[1] Correspondence to: Felipe José Jandre dos Reis E-mail: felipe.reis@ifrj.edu.br

Brasil

Brasil

Therapeutic approach to pain-related fear and avoidance in adults with chronic musculoskeletal pain: an integrative review and a roadmap for clinicians

ABSTRACT

BACKGROUND AND OBJECTIVES:

CONTENTS:

CONCLUSION: