Table Of Content3/7/2016
Department of Physical Therapy
Psychologically Informed
Physical Therapy (PIPT):
Pragmatic Application for Low Back Pain
Jason Beneciuk, PT, PhD
Assistant Professor
Department of Physical Therapy
University of Florida
Brooks – PHHP Research Collaboration
Carol M. Greco, PhD
Assistant Professor of Psychiatry
Licensed Psychologist
University of Pittsburgh School of Medicine
Steven George PT, PhD
Associate Professor
Department of Physical Therapy
University of Florida
Brooks – PHHP Research Collaboration
Department of Physical Therapy
Learning Objectives
Upon completion of this course, you will be able to:
1. Summarize relationships between pain science, pain
models, and the development and maintenance of
chronic LBP
2. Implement psychologically informed physical
therapy practice principles for patients with LBP
3. Identify patients at high risk for transitioning from
acute to chronic LBP
4. Apply targeted treatment for patients at high risk for
transitioning from acute to chronic LBP
1
3/7/2016
Department of Physical Therapy
http://www.rstce.pitt.edu/pipt/
Department of Physical Therapy
Pain Science Update: Need for
Psychologically Informed Interventions
Steven George, PT, PhD
2
3/7/2016
Department of Physical Therapy
Pain Science Update Objectives
1. Understand that variability is an inherent feature of the
pain experience
2. Describe how psychological factors can be used to explain
pain related patient differences
3. Understand that identification of pain associated
psychological distress and use of targeted treatment
approaches are key tenets of psychologically informed
physical therapy
4. Identify that preventing transition to chronic back pain is
a primary outcome goal for psychologically informed
physical therapy
Department of Physical Therapy
High Variability in Pain Experience
O’Neill et al, Pain. 2009
3
3/7/2016
Department of Physical Therapy
High Variability in Pain Experience
Stimulus Temperature = 49ºC
Pain Intensity Rating (0-100)
Department of Physical Therapy
High Variability in Pain Experience
1. Pain location with standard stimulus
2. High variability in pain intensity ratings with
standard stimulus
4
3/7/2016
Department of Physical Therapy
Clinical Implications
• High variation in pain experience
– Is evident, even with same peripheral
generator
– Search for “the source” of pain may not be all
that important
– Shifts need from tissue identification to focus
on factors that influence variation
Department of Physical Therapy
Variability in Pain Experience
• Influences on reporting pain (non-exhaustive list)
– Sex
– Age
– Genetics
– Psychological or psychosocial factors
– Nervous system processing
5
3/7/2016
Department of Physical Therapy
Variability in Pain Experience
• Influences on reporting pain (non-exhaustive list)
– Sex
– Age
– Genetics
– Psychological or psychosocial factors
– Nervous system processing
Department of Physical Therapy
General Psychological Model of Pain Perception
Linton & Shaw, Phys Ther. 2011
6
3/7/2016
Department of Physical Therapy
Specific Psychological Models
• Fear-Avoidance Model
– Activity avoidance leads to physical degeneration and social isolation
• Acceptance and Commitment Model
– Repeated (futile) attempts to alleviate pain lead to frustration
• Misdirected Problem-Solving Model
– Normal worrying; more worrying; less likely to solve problem
• Self-Efficacy Model
– Fluctuating pain reduces perceptions of control
• Stress-Diathesis Model
– Psychological stress & limited coping resources predispose one to pain
Linton & Shaw, Phys Ther. 2011
Department of Physical Therapy
Specific Psychological Models
• Fear-Avoidance Model
– Activity avoidance leads to physical degeneration and social isolation
• Acceptance and Commitment Model
– Repeated (futile) attempts to alleviate pain lead to frustration
• Misdirected Problem-Solving Model
– Normal worrying; more worrying; less likely to solve problem
• Self-Efficacy Model
– Fluctuating pain reduces perceptions of control
• Stress-Diathesis Model
– Psychological stress & limited coping resources predispose one to pain
7
3/7/2016
Department of Physical Therapy
Fear-Avoidance Model of Musculoskeletal Pain
Leeuw et al, J Behav Med. 2007
Department of Physical Therapy
Fear-Avoidance Model of Musculoskeletal Pain
• Catastrophizing
– Pain is interpreted as being extremely threatening
• Fear of Pain
– Present threat; defensive behavior
• Pain Anxiety
– Future-oriented; preventative behavior
• Negative Affect
• Threatening Illness Information
8
3/7/2016
Department of Physical Therapy
High Variability in Pain Experience
Stimulus Temperature = 49ºC
Pain Intensity Rating (0-100)
Department of Physical Therapy
Psychological Factors Account for Variability
Stimulus Temperature = 49ºC
Fear of Pain (30-150)
9
Pain Intensity Rating (0-100)
3/7/2016
Department of Physical Therapy
Psychological Factors
• Consistent influence on elevated pain
experiences
• Risk factors for poor patient outcomes
(Nicholas, et al. 2011; Chou & Shekelle, 2010)
Department of Physical Therapy
Clinical Implications
• Opportunity for patient segmentation
– Risk stratification based on pain associated
psychological distress subgroups
– Provide matched treatment based on subgroup
assignment
10
