Fear Avoidance Beliefs Are a Learned Behavior

• "You shouldn't bend you back when you lift things".
• "Don't work too hard".
• "Don't go back to the gym until I tell you its safe".
• And (drum roll please), the most egregious commission of all - "Consult with your physician BEFORE you begin an exercise program".

Are conventional physical therapists in danger of creating what MovNat founder Ewan Corwin calls "zoo humans"?

Watch this 1:32 video and leave a comment. Its pretty impressive.

Maybe physical therapists and their patients could learn from two-year old Steven in the video below some tips for confronting their movement limitations.

How to Use Fear Avoidance Beliefs in your Physical Therapy Plan of Care

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?

What are Fear Avoidance Beliefs?

Fear Avoidance Beliefs are one type of psychosocial factors that include:

• depression,
• anxiety and
• job dissatisfaction,

...among other factors.

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?

1. Cognitive Behavioral Therapy (CBT)

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:

• 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.

George et al distinguished between the 'typical' educational approach of biomedical education and a fear-avoidance model of self-management.




2. Use FAB to screen for modalities

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.


3. 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.
   


4. 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.

Why Can't Connor Ride His Bike?

My eight-year old son has a friend named Connor. Connor is a normal eight-year old boy except in one respect.

Connor can't ride his bike.

Connor is in physical therapy at school working on gross motor control, lower extremity strengthening, jumping, hopping and climbing activities. I've seen Connor run - he's a bit slow but otherwise normal. Jumping is a bit awkward but he makes it. Hopping is status quo.

So, why can't Connor ride his bike? Why does he walk when all the other neighborhood kids ride by - leaving him pushing his bike?

It turns out that Connor is scared of falling off of his bike.

Connor fell of a smaller bike when he was two years old and broke his arm. He has been scared to ride his bike ever since. His mom has asked many of the neighborhood dads (even Connor's karate instructor) to help Connor get over his fear. I've tried to work with him a few times.

Connor seems to demonstrate what Hart et al describe as...

"Evidence (of the) possible existence of fear avoidance beliefs or pain-related fear in people who have other impairments or who may not have pain, perhaps because of learned behavior after previous painful episodes or misconceptions about pain."

In Screening for Elevated Levels of Fear-Avoidance Beliefs Regarding Work or Physical Activities in People Receiving Outpatient Therapy in the August Physical Therapy Journal Hart et al found that fear avoidance beliefs can be described as High or Low (rather than a score) and that one screening question can measure the level (rather than 21 questions in the Fear-Avoidance Beliefs Questionnaire - FABQ).

What Can You Do?

Physical therapists can find out if musculoskeletal pain patients have elevated fear-avoidance beliefs early in the course of care so that reducing the level of fear-avoidance becomes a goal of therapy.

The fancy term for reducing fear-avoidance beliefs is Cognitive Behavioral Therapy (CBT) which is a distinct psychological specialty but one from which physical therapists might be able to learn some management strategies for chronic pain patients.

Hart et al recommend the first step is to screen your patients for high levels of fear-avoidance with these two, simple statements:

1. "I should not do physical activities which (might) make my pain worse."
2. "I should not do my normal work with my present pain."

Statement #1 predicts the response (high/low) on the Physical Activity sub-scale. Statement #2 predicts the response on the Work sub-scale.

We've used the FABQ (21-item) but now I'm making these statements a part of my intake patient (self-report) forms that will be indicated with checkboxes indicating agreement or dis-agreement.

Co-morbid factors like fear-avoidance, age, depression and self-reports of function turn out to be bigger drivers of chronicity, cost and resource utilization (eg: PT visits) than traditional impairment measures like strength, ROM and swelling.

Physical therapists may be able to improve overall patient management and increase reimbursement by screening for fear-avoidance at the first and last visit.

Just as important, we may be able to more accurately detect those at risk - those people like Connor.

Mo' money

Treating fear-avoidance early in the course of care may allow physical therapists to 'risk adjust' an episode fee capped at, for instance, ten visits for uncomplicated lower back pain.

Today, all of your Medicare visits are reimbursed fee-for-service (FFS) but nobody expects Medicare FFS to last much longer in its present state - nor is Medicare FFS sustainable if it does last past this current legislative session.

Al Amato, PT wrote an article in IMPACT (PPS log-in required) called Value Purchasing in Physical Therapy in March 2006 that described the effect of risk adjustment on an alternative payment system. Mr. Amato wrote...

"Risk adjustment allows the comparison of a patient with a specific profile to a similar risk-adjusted group of patients in a large database.

This allows the ability to predict the efficiency and effectiveness of an individual treatment because of the profile of the similar risk-adjusted group of patients from the national database."

In the future, you will need to identify which patients are likely to have poorer outcomes (based of elevated fear-avoidance beliefs) but you will be able to request more treatment sessions. Or, you can treat the elevated fear-avoidance beliefs from baseline, get the patient better in fewer visits - and get paid a bonus.

Who Could get Better by Learning About Fear?

In 2007, there were 97,900 outpatient therapy providers billing the Medicare program in the United States: about 19% of these are Occupational Therapists and 7% are Speech Language Pathologists (table 7 & 10).

The intent is to transition all of these providers to a 'value based' payment program that allows providers to succeed and patients to get better.

Hart's study is a big step in the direction of value-based payment (Hart and Amato work for the same company) because this study shows clinicians how to quickly and accurately screen people like Connor for elevated fear-avoidance beliefs.

Improved screening for this, and other, psychosocial factors that influence chronicity can improve the effectiveness and efficiency of our physical therapy treatments.