AJ – You succinctly laid out a really nice set of 5 questions we can ask to get the discussion rolling on pain, and whether we need to administer a specific fear avoidance scale. Did you get this from a specific framework/paper, or just through your experience? (1. Do you avoid movement 2. What their perception of pain is (ie all pain is bad), 3. Are they hypervigilant about it 4. how is that impacting their lives both physically and emotionally 5. whether they think this can improve or not.)

Justin – I love the wrist example. I’m stealing that immediately.

Katie – Great point about getting a good read on your patient before delving into biopsychosocial aspects of pain. Even when I feel like I have done a decent job of educating my patient, I have still gotten a response of “So, you’re saying it’s all in my head?”, which can be frustrating and decrease therapeutic alliance with the patient

Aaron – I like the idea of asking the patient “Why do you do that?”, as this makes them generate a hypothesis that you can work towards deconstructing. I think this is a better strategy than what most new grads do, which is that when we see something abnormal we immediately say “Oh, do you see that? you are shifted/asymmetrical with weight-bearing, etc” And then we put our own assumption as to why the person is actually doing that versus just asking them. Sometimes just saying something like “you are shifted” can make someone more fearful

For answers to your questions, Austin:

1) What measures of FA have you used most frequently in your clinic now or in the past? What do you like or not like about particular PROs? What are your thoughts on this metric for use in the clinic? Possible positives and negatives of its use?

Most often it’s the FABQ. I have used the Pain Catastrophizing Scale (PCS) and Tampa Scale of Kinesiophobia in the past. I actually hate using the PCS because of the name. I feel like sometimes a patient reads the name of the scale and thinks “Is he saying i’m being dramatic?”. I’d use it more if I could just black out the name. The FABQ is included in FOTO so the patient never sees the words “fear avoidance”.

2) When you do have a patient, potentially one who is trying to return to work, that responds with a high score on one of these outcome measures, to what extent do you address their fear avoidance? Has anyone utilized true graded exposure or graded activity training to address fear avoidance? Or has your approach been more informal and education based?.

I’m currently using graded activity with a chronic LBP and hip pain patient. It started with a lot of education (over at least 3-4 sessions) before she agreed to try it. She has been slowly decreasing her activity level and social activities for 15 years due to pain and avoidance. Allowing her to choose exercises where she can have initial success has been key in her buying into the treatment plan. In addition, when we perform treadmill training, giving her full control over when we stop the exercise really decreases her fear and is a useful strategy

3) Similarly, when you do have a patient with high FA, what sorts of resources have you used to refer patients to other providers?

During clinicals I had one or two patients where a psych referral was warranted and initiated. I have yet to initiate a psych referral while working at Progress. I currently have been co-treating a patient with body image issues that are starting to affect her function where one is warranted, but it hasn’t happened yet.

What other types of resources/referrals are you thinking about here, August?