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Active despite pain: the role of pain models in chronic musculoskeletal pain Stephen Morley Leeds Institute of Health Sciences
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Aims 1.Review the relationship between pain and behaviour 2.Focus on seemingly counter intuitive relationship between pain and increased (over) activity 3.Implications –aetiological accounts –maintenance of disorder –developing rational treatment model
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Pain – perception for action Attention : efficient engagement in current task Vs awareness of higher priority demands A dynamic process Response Pain stimulus Pain signal Task (signal) Pain characteristics Novelty & unpredictability Intensity Threat value Person characteristics Fear of pain Catastrophising Task effects Competitive value of primary task Experimentally difficult
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Naïve model for Rest vs Be active
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Disrupt ongoing behaviour – Reduce activity Attend to ameliorating pain – Rest/recuperate Except when other tasks have greater imperative
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Chronic pain Behaviour as a public event –Influence of reinforcers –Establishment of discriminative stimuli – context effects Examples –Pain report –Facial display –Use of aids –Walking speed –Medication consumption
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Chronic pain S D the presence of others From Lousberg et al Pain 1992; 51: 75–9
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Pain and increased behavioural activity Two issues 1.Aetiological a)Persistence ► injury b)Maintenance injury ►continuation despite pain vs rest recuperation 2.Fluctuations in pain ◄►behaviour e.g. rest- activity cycling / pacing NB Transdiagnostic nature of these accounts
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Two aetiological accounts Ergomania (pre morbid) (van Houdenhove) –Based in psychodynamic terminology –Not easy to operationalize –Relative context independent Avoidance-endurance (Hasenbring) –Catastrophising ► fear avoidance –Suppression ► switching attention: irritable & depressed –Minimizing ► ignore pain: positive mood & overexertion
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Mood as input Interaction between mood as information and characteristics of the task Task characteristics = rules about when to Stop As many as can (AMAC) – ‘when you’re satisfied’ Feel like discontinuing (FLDC) – ‘not enjoying’
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Evidence from empirical studies
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Mood as input model for pain
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Some issues The relationship between behaviour and mood: the possible role of goals The development of goal preferences –Prevention vs promotion focus –State vs action preferences Multiple goals / tasks – the dynamics of pacing Association of stop rules and tasks –Doing the dishes vs. writing a novel
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Approach goals discrepancy reducing Elation / joy Depression Neutral Relief Anxiety Neutral Hope Tension Avoidance goals discrepancy increasing Doing poorly Doing well Frustration Eagerness
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Passive and Active avoidance Passive ‘don’t act and be safe Fear-avoidance DO NOTHING BE ACTIVE Doing poorly Doing well Active Do act or else …. Persistence BE ACTIVE DO NOTHING
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INJURY/STRAIN DISABILITY DISUSE PASSIVE AVOIDANCE PAIN Vlaeyen & Morley, Pain 2004 Catastrophic misinterpretations Enjoy ? INJURY/STRAIN PAIN OVERUSE ACTIVE AVOIDANCE Inflated Responsibility Enough ?
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Avoiding, pacing and ‘doing’ From McCracken & Samuel Pain2007; 130:119-125 AvoidPaceConf Pace.51 Conf -.13.07 Uptime -.35-.14.10 Disab.43.23-.01
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GOAL 2: passive avoidance GOAL 1: active avoidance Pacing Exposure
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Thanks to … David Griffith (UK) Johan Vlaeyen (B)
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