We recently held a Treatment Based Classification Seminar (TBC) at our physical therapy clinic in Palmetto, Florida.
Most of the physical therapists attending (14) had a fairly good awareness of TBC but one item stood out - Fear Avoidance Beliefs (FAB).
None of the attending therapists used even the FAB 'clinical shortcut' in their evaluation:
“I should not do physical activities which (might) make my pain worse.”The clinical shortcut identifies elevated fear-avoidance beliefs early, so you could treat them. A number of seminar participants expressed interest in how physical therapists could screen for and treat patients' Fear Avoidance Beliefs in their plan of care.
- What are Fear Avoidance Beliefs and Behaviors?
- What techniques should physical therapists use when these findings are present?
- How can we help these people or should they be referred to medical providers?
Fear Avoidance Beliefs are one type of psychosocial factors that include:
- depression,
- anxiety and
- job dissatisfaction,
Persons experiencing an episode of acute pain are believed to manage the episode by 'confronting' the pain or by 'avoiding' the pain.
Persons who exhibit these 'avoidance' beliefs and behaviors are significantly more likely to experience disablement as a result of their acute pain.
How to Use Fear-Avoidance Beliefs in the Plan of Care?
- Cognitive Behavioral Therapy (CBT)
- keeping a diary of significant events and associated feelings, thoughts and behaviors;
- questioning and testing cognitions, assumptions, evaluations and beliefs that might be unhelpful and unrealistic;
- gradually facing activities which may have been avoided; and
- trying out new ways of behaving and reacting.
- Relaxation,
- mindfulness and
- distraction techniques are also commonly included.
- Use FAB to screen for modalities
- Predictor variable in TBC
- Flynn's lumbar manipulation
- Child's thoracic manipulation and
- Hicks' lumbar stabilization rules
...all use the Fear Avoidance Beliefs Questionnaire as a predictor variable - lower levels of fear avoidance behavior generally predict successful outcomes. Hicks' stabilization rule is the exception - higher levels of fear-avoidance beliefs predicts success in this group. - Risk factor under a Medicare alternative payment system.
Between 12-15% of the variation in the outcome of industrial workers' injuries was due to psychosocial factors, like FAB, not the physical or personal factors that physical therapists typically measure - like straight leg raise and Manual Muscle Testing (ugh).
Since the payment by Medicare under an alternative payment system is likely to be a 'case rate' - say, $800 for 10 visits - anybody over the 10th visit is a financial risk to the provider.Physical therapists will need better measurement tools to identify these people, these outliers, early and perhaps apply for extra dollars.
Screening for 'outliers' under an alternative payment system to Medicare Fee for Service will require sensitive tests to predict who is likely to need 20 visits for LBP, not 10 visits.
Cognitive Behavioral Therapy (CBT) is a cool new tool that already fits the physical therapist skill set - although many of us may need additional training.
Some physical therapists may feel unprepared to render CBT but I would argue that the physical therapist is already well-suited to learn about CBT - it should complement our current 'toolbox'.
Cognitive behavioral therapy, within the context of our current practice, could be described as follows:
"Effective patient education by physical therapists appears to depend on the use of effective brief psycho-educational strategies that can address the cognitive and affective processes that motivate pain-related activity avoidance."In other words, some of the same persuasive, coaxing, gentle, positive encouragement that most of us have used our entire careers to get patients more active.
Specific examples of some CBT techniques are as follows:
George et al distinguished between the 'typical' educational approach of biomedical education and a fear-avoidance model of self-management.
Childs et al found that use of electrotherapeutic or ultrasound modalities may encourage patients with elevated FAB to focus on their pain, avoid active 'confrontation' behaviors and lead to decreased outcomes.
Studies in America, Israel and the Netherlands tend to support the findings of poorer functional outcomes when modalities are used in the plan of care.
There is a significant chance that Medicare will decrease the relative value of modalities such as ultrasound or e-stim - even 'bundling' these modalities with other Common Procedural Terminology (CPT) codes, such as exercise, based on a lack of efficacy or effectiveness of modalities.
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