1. Active despite pain: the role of pain models in chronic musculoskeletal pain Stephen Morley Leeds Institute of Health Sciences

2. 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

3. 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

4. Naïve model for Rest vs Be active

5. Disrupt ongoing behaviour – Reduce activity Attend to ameliorating pain – Rest/recuperate Except when other tasks have greater imperative

6. 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

7. Chronic pain S D the presence of others From Lousberg et al Pain 1992; 51: 75–9

8. 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

9. 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

10. 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’

11. Evidence from empirical studies

12. Mood as input model for pain

13. 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

14. Approach goals discrepancy reducing Elation / joy Depression Neutral Relief Anxiety Neutral Hope Tension Avoidance goals discrepancy increasing Doing poorly Doing well Frustration Eagerness

15. 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

16. INJURY/STRAIN DISABILITY DISUSE PASSIVE AVOIDANCE PAIN Vlaeyen & Morley, Pain 2004 Catastrophic misinterpretations Enjoy ? INJURY/STRAIN PAIN OVERUSE ACTIVE AVOIDANCE Inflated Responsibility Enough ?

17. 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

18. GOAL 2: passive avoidance GOAL 1: active avoidance Pacing Exposure

19. Thanks to … David Griffith (UK) Johan Vlaeyen (B)