EMORY DPT MEDICAL SCREENING: Psychological Yellow Flags

What is Fear-avoidance Model?

- Activity avoidance leads to physical degeneration and social isolation •Acceptance and

What is the Misdirected Problem-Solving Model

- Hypervigilance to pain, more worrying; failed attempts to escape pain •Self-efficacy model

What are three pain coping skills?

1. Physiologic Relaxation 2. Imagery 3. Cognitive Reframing

Patient centered communication should include what 5 things?

1.Patient as a person 2.Biopsych1.Patient as a person 2.Biopsychosocial perspective 3.Sharing power and responsibility 4.Therapeutic alliance 5.Provider as a person

What is the STarT Back Tool?

A risk assessment for low back patients form that guides targeted/specific treatments for individuals with a scale of 0-9

What are treatment moderators?

Baseline characteristics that interact with treatment to affect outcomes - can help stratify treatment

How would you incorporate Cognitive Reframing?

Clarify - ask patient to elaborate Affirm - validate their present emotions as real Acknowledge - thoughts & beliefs are part of vrecovery Alternative Perspective - guide patient, offer perspective if welcome

What is the framework for psychologically informed practice?

Core philosophy is to incorporate patient beliefs, attitudes, and emotional responses into patient management based on biophysical models Primary goal is the secondary prevention of disability

True or False: "Taken as a whole, evidence does not show a clear relationship between psychological yellow flags and future clinical and occupational outcomes."

False "Those who catastrophize frequently, are depressed, have intense pain, hold high fear-avoidance beliefs are more likely to develop persistent pain problems..."

What are the two types of activity based interventions?

Graded Activity and Graded Exposure

What is cognitive reframing?

Identifying unhelpful thought patterns Acknowledge impact of thoughts Present an alternative

Can We Identify Patients More Likely to Have Psychological Distress?

It depends! but really no, our biases affect this Some examples... •Headaches after car accident - he/she at fault •Pain not resolved after elective surgery •Back "thrown out" after loss of husband (married 50 yrs) •Single working mother with flare-up of recurrent LBP •Ankle Sprain in playoff game he/she lost •Ankle Sprain in playoff game he/she won (championship next week)

What are the risk groups of the STarT Back Tool?

Low = (3 or <) few physical and/or psychological factors present Mod = (4 or > with 3 or less in the psych score) Physical and psychological factors present; psychological factors are not high High = (4 or > with > 3 in the psych score) High level of psychological factors present; with or without physical factors

What are the suggestions from the STarT Back Tool when treating each different risk group?

Low = Advise, education & self management Mod = PT to address symptoms and function High = Psychologically informed DPT, consider psychological referral

In motivational interviewing, what does OARS stand for?

O - open ended questioning A - Affirmations R - Reflection S - Summaries + Empathy

What must treatment moderators do?

Precede treatment Not be associated with treatment Ex: pain distal to knee as CPR for lumbar manipulation

True or False: With proper instruction and support, psychological interventions can improve pain management outcomes

True

True or False: Personal acceptance + commitment to self-manage pain problems are associated with better pain outcomes

True •Over-attention to diagnostic details + biomedical explanations may reinforce futile searches for a cure and delay pain self-management

What are treatment mediators?

Variable responsible for all or part of effects of treatment on an outcome

Is there high variability in pain experiences?

Yes

What is required to suggest change in a psychological construct?

baseline measurements - not screening with intuition

What must treatment mediators do?

change during treatment be associated with treatment have effect on outcome Ex. CBT improves fear avoidance which improves treadmill duration

What is the treatment monitoring process for follow up from the STarT Back Tool?

re-administer the tool Uni-dimensional measurements OSPRO-YF Assessment Tool

If you wanting a specific outcome what should you focus on?

treatment monitoring - this should be a constant process

The international Assocation for the study of pain or IASP described pain as...?

•"An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage"

What sets motivational interviewing apart in patient interaction?

•Autonomy vs. Authority - clinician affirming the patient's rights and capacity for self-direction •Collaboration vs. Confrontation - partnership that honors the patient's expertise and perspectives •Evocation vs. Education - recognizing that the motivation resides within the patient and is drawn out by facilitation

What is graded expsoure?

•Based on classic exposure principles: - Gradually expose patient to what they fear - Increase exposure as fear decreases •An exposure based system - Exercise progression based on decreasing fear of activity - Pain does NOT normally figure into progression criteria

What are graded activity interventions?

•Based on operant conditioning: - All behavioral responses are influenced by their consequences and the context - Provide positive reinforcement for beneficial behaviors such as increasing activity - Do NOT provide positive reinforcement for pain behaviors such as inappropriate fear and inactivity

What are some characteristics of chronic pain?

•Chronic pain is both unhelpful and uninformative •Lacks specificity •Lacks precision

What are the principles of graded activity?

•Encourages continued activity, despite pain •Select activity that motivates patient - Increasing therapeutic alliance •Dosage: quota based system - Pain rating not a determinant in establishing a quota •Reinforcement provided for quota achievement - Positive reinforcement examples •Baseline level: perform exercise/activity to pain t •Tolerance (note duration, intensity, frequency) - Subsequent sessions based on "initial quota" •Reinforcement not provided if quota not achieved •Quota will fluctuate; our goal is to keep improving •Important patient understands process

What are the different Psychological Models associated with pain?

•Fear-avoidance Model •Acceptance and Commitment Model - Repeated unsuccessful attempts to alleviate pain lead to frustration •Misdirected Problem-Solving Model - Hypervigilance to pain, more worrying; failed attempts to escape pain •Self-efficacy model - Fluctuating pain reduces perceptions of control over pain •Stress-Diathesis Model - Psychological stress and limited coping resources predispose one to pain

Who is the grade exposure treatment style for?

•Primarily for patients reporting a high level of fear and avoidance behaviors •Feared or avoided activities determining focus of treatment •Dosage: hierarchical exposure approach - Subsequent progression based on fear with specific activities

What is the Optimal Screening for Prediction of Referral and Outcome or OSPRO-YR?

•Provides estimate for individual psychological measure scores (upper/lower quartile) •17, 10, 7 item versions •With 85%, 81%, and 75% accuracy respectively