Active despite pain: the role of pain models in chronic musculoskeletal pain

Stephen MorleyLeeds Institute of Health Sciences

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

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 valuePerson characteristics

Fear of pain

CatastrophisingTask effects

Competitive value of primary task

Experimentally difficult

Naïve modelfor Rest vs Be active

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Low intensity High intensity

Pain intensity

Probability(rest)

Probability(active)

• Disrupt ongoing behaviour – Reduce activity• Attend to ameliorating pain –

Rest/recuperate

Except when other tasks have greater imperative

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

Chronic pain SD the presence of others

660

680

700

720

740

760

780

Non-Solicit Solicit

Tim

e to

to

lera

nce

- s

(st

op

)

Alone

Partnerpresent

0

5

10

15

20

25

Non-Solicit Solicit

Pai

n Alone

Partnerpresent

From Lousberg et al Pain 1992; 51: 75–9

Pain and increased behavioural activity

Two issues

1. Aetiologicala) 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

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

Mood as input

Interaction between mood as information and characteristics of the task

Task characteristics = rules about when to StopAs many as can (AMAC) – ‘when you’re

satisfied’Feel like discontinuing (FLDC) – ‘not enjoying’

Schematic Stop Rule X Mood Interaction

0

20

40

60

80

100

AMAC FLDC

Stop rule

Per

form

ance

Negative Mood

Positive Mood

Evidence from empirical studies

Mood as input model for pain

Pain

NEG. Mood

Persistence

Avoidance

Overuse

Disuse

Disability

AMAC

FLDC

Stop-rule Performance Physical risk

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

Approach goals discrepancy reducing

Elation / joy

Depression

Neutral

Relief

Anxiety

Neutral

Hope

Tension

Avoidance goals discrepancy increasing

Doing poorly

Doing well

Frustration

Eagerness

Passive and Active avoidance

Passive‘don’t act and be safe

Fear-avoidance

DO NOTHING

BE ACTIVE

Doing poorly

Doing well

ActiveDo act or else ….

Persistence

BE ACTIVE

DO NOTHING

INJURY/STRAIN

DISABILITY

DISUSEPASSIVE AVOIDANCEPAIN

Vlaeyen & Morley, Pain 2004

Catastrophic misinterpretations

Enjoy ?

INJURY/STRAIN

PAIN OVERUSE ACTIVE

AVOIDANCE

Inflated Responsibility

Enough ?

Avoiding, pacing and ‘doing’

From McCracken & Samuel Pain2007; 130:119-125

Avoid Pace Conf

Pace .51

Conf -.13 .07

Uptime -.35 -.14 .10

Disab .43 .23 -.01

GOAL 2: passive avoidance

GOAL 1: active avoidance

Pacing

Exposure

Thanks to …

David Griffith (UK)

Johan Vlaeyen (B)