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Department of Physical Therapy

Psychologically Informed Physical Therapy (PIPT)

Targeted Treatment: Pain Coping Skills Pre-Course Module

Carol M. Greco, PhD Assistant Professor, Licensed Psychologist Department of Psychiatry University of Pittsburgh School of Medicine

Department of Physical Therapy

Psychologically Informed Physical Therapy (PIPT)

Psychologically Informed Physical Therapy Practice: Pragmatic Application for Low Back Pain

Jason Beneciuk, PT, PhD Research Assistant Professor Department of Physical Therapy, University of Florida; Brooks Rehabilitation – PHHP Research Collaboration

Steven George, PT, PhD Associate Professor DPT Program Director Department of Physical Therapy, University of Florida; Brooks Rehabilitation – PHHP Research Collaboration

Carol M. Greco, PhD Assistant Professor of Psychiatry Licensed Psychologist University of Pittsburgh School of Medicine

Department of Physical Therapy

Psychologically Informed Physical Therapy (PIPT)

We will address: •  Physiologic relaxation / breathing methods •  Pleasant place imagery •  Replacing cognitive distortions / unhelpful

thinking

Pre-Course Module: Pain Coping Skills

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Department of Physical Therapy

Psychologically Informed Physical Therapy (PIPT)

Pain Coping Skills: Physiologic Relaxation / Breathing methods

Department of Physical Therapy

Psychologically Informed Physical Therapy (PIPT)

Physiologic Relaxation What it is… •  Muscle tension reduced •  Heartbeat may slow •  Increased temperature

in hands/feet •  Feeling of calm

What it is not… •  Reading a book •  Watching the game •  Socializing

Department of Physical Therapy

Psychologically Informed Physical Therapy (PIPT)

•  Pain often leads to bracing or tensing the muscles •  Stress of pain heightens physiologic arousal

–  heart rate, BP, stress hormones

All this can Increase Pain •  Physiologic Relaxation counteracts the stress

reaction to pain

Why use Physiologic Relaxation for Coping with Pain?

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Department of Physical Therapy

Psychologically Informed Physical Therapy (PIPT)

Simple methods: •  Deep breathing •  Diaphragmatic (Belly) breathing •  Progressive Muscle Relaxation (tense, then let go,

various body regions)

Physiologic Relaxation

Davis M, Eshelman ER, McKay M (1995) The Relaxation and Stress Reduction Workbook. New Harbinger Publications, Inc. Oakland, CA

Department of Physical Therapy

Psychologically Informed Physical Therapy (PIPT)

Pain Coping Skills: Pleasant Place Imagery

Department of Physical Therapy

Psychologically Informed Physical Therapy (PIPT)

Pleasant place imagery •  Human attention is limited •  Pleasant memory, visualization of pleasant place

can distract from pain, worry

Pain Coping Skills

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Department of Physical Therapy

Psychologically Informed Physical Therapy (PIPT)

•  Often associated with physiologic relaxation, and with reduced sensations of pain

•  Image or memory from the Patient, ideally

•  Uses can range from simple distraction to hypnotherapy

Pleasant place imagery

Gatchel RJ, Turk DC (1996) Psyhological Approaches to Pain Management. New York: Guilford Press

Department of Physical Therapy

Psychologically Informed Physical Therapy (PIPT)

Pain Coping Skills: Replacing cognitive distortions / unhelpful thinking with balanced thinking

Department of Physical Therapy

Psychologically Informed Physical Therapy (PIPT)

Replacing unhelpful thinking / cognitive distortions •  Identify the unhelpful pattern(s) •  Acknowledge importance of thinking styles •  Develop ‘balanced’ alternatives (with patient)

Pain Coping Skills

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Department of Physical Therapy

Psychologically Informed Physical Therapy (PIPT)

Identify: STarT Back Tool clues •  “I feel my back pain is terrible and it’s never going

to get any better” – Tendency to ‘awful-ize’ (catastrophize) and ‘predict the

future’ •  “I have not enjoyed all the things I used to enjoy”

– Possible clue to depression – feeling helpless

•  “…not really safe to be physically active… “Worrying thoughts going through my mind” – Rumination, distortion

Replacing Unhelpful Thinking

Department of Physical Therapy

Psychologically Informed Physical Therapy (PIPT)

Example: the Role of Thoughts and Beliefs

Behaviors

Thoughts

Emotions / Moods

Sensations

This Will NEVER get Better!!!

Pain More Pain

Department of Physical Therapy

Psychologically Informed Physical Therapy (PIPT)

Acknowledge the importance of thinking styles •  Clarify – ask patient to elaborate if needed •  Acknowledge that thoughts and beliefs may seem

‘true’ but they may slow progress to recovery – Thoughts influence mood, behavior

•  Keeping an open mind / being willing to consider alternative beliefs may improve mood, energy, and enhance progress toward PT goals

Replacing Unhelpful Thinking

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Department of Physical Therapy

Psychologically Informed Physical Therapy (PIPT)

Communication: •  Having good rapport / trust is important •  Reassure – appropriate Activity is Safe •  Brainstorm with patient – more realistic, balanced

ways of thinking –  use the patient’s own words if possible

Replacing Unhelpful Thinking

Department of Physical Therapy

Psychologically Informed Physical Therapy (PIPT)

Replacing Unhelpful Thinking

Unhelpful / distorted •  I have no control over

this! •  This shouldn’t have

happened to me! It’s not fair!

•  This pain makes me so anxious that I can’t stand it!

Balanced / realistic •  I can cope. I’m

learning new skills. •  Back pain is really

common – and so is recovery.

•  Relax. I’ve managed difficulties before and will do so again.

Department of Physical Therapy

Psychologically Informed Physical Therapy (PIPT)

Replacing unhelpful thinking with more balanced thinking

Behaviors

Thoughts

Emotions / Moods

Sensations

Pain

Things take time. My PT and I are working on it…

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Department of Physical Therapy

Psychologically Informed Physical Therapy (PIPT)

Challenges for the PT: •  Adding and using a new skill set •  Limited about of time with each patient

Opportunity: •  Greater success with patients at high risk for

chronicity… – You may have more energy and a better mood

yourself!

Pain Coping Skills

Department of Physical Therapy

Psychologically Informed Physical Therapy (PIPT)

How to implement Pain Coping Skills training: •  While assessing symptoms / monitoring progress •  As part of teaching an exercise •  As you observe pain behaviors

– Grimacing, bracing, hunched shoulders •  As a response to patient’s fear, anxiety

But I don’t have time…

Department of Physical Therapy

Psychologically Informed Physical Therapy (PIPT)

Practice pain coping skills in day-long training •  Breath training / physiologic relaxation

– Focus attention – body sensations of breathing

•  Pleasant imagery / pleasant memory – Needs to come from the patient (though you can give

them an example from your life)

•  Replace unhelpful with adaptive attitudes –  ‘together we will move forward’ ‘stay in the here-and-

now,’ etc.

Teaching Pain Coping Skills

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Department of Physical Therapy

Psychologically Informed Physical Therapy (PIPT)

Acknowledgement: •  There is no cook-book! •  It’s OK to be uncertain •  Adding these skill sets to your repertoire is not

trivial, but may be worth it! •  “Don’t let Perfect be the enemy of Good”

Pain Coping Skills

Department of Physical Therapy

Psychologically Informed Physical Therapy (PIPT)

Psychologically Informed Physical Therapy Practice: Pragmatic Application for Low Back Pain

Jason Beneciuk, PT, PhD Research Assistant Professor Department of Physical Therapy, University of Florida; Brooks Rehabilitation – PHHP Research Collaboration

Steven George, PT, PhD Associate Professor DPT Program Director Department of Physical Therapy, University of Florida; Brooks Rehabilitation – PHHP Research Collaboration

Carol M. Greco, PhD Assistant Professor of Psychiatry Licensed Psychologist University of Pittsburgh School of Medicine

Department of Physical Therapy

Psychologically Informed Physical Therapy (PIPT)

Thank you for your attention – Carol M. Greco, Ph.D. greco@pitt.edu