Thread by @CraigLiebenson

1) A non-linear BPS approach for persistent MSP consists of an enactive reconceptualization designed to expand affordances & ⬇️ FABs associated w/ embodied past experiences. Such behavioral experimentation aims to support an ecologically valid positive experience w/ movement.

2) Here is an example of such a behavioral experiment w/ an AT I had never met before at a workshop in Winnipeg @MeganPomarensky This models what I learned from K Lewit, S Linton, G Waddell, Fordyce & others. Today it is best taught by @PeteOSullivanPT

3) @bunzli_s @jpcaneiro & Pete O have written w/ great clarity about the steps of “Guided behavioural experiments” here - much of this is about identifying & coaching clients to alter over-protective behavior like guarded movements or breath holding.

rbf-bjpt.org.br//en-beliefs-ab…

4) “an interactive learning process using the person’s own narrative & experience during the movement exploration to help them make sense of their pain through a BPS lens, w/ the aim to gain self-efficacy (“facilitate mindset & behavioural change, & reduce emotional distress”)”

5) “Identification of protective responses (people's implicit beliefs and fears linked to specific daily tasks)”

6) “Coach people with pain to relax their body posture and breathing pattern to ensure they feel safe and calm.”

7) “Beliefs about the body and musculoskeletal pain influence a person's behavioural and emotional response to pain. Beliefs are modifiable and should be considered an important target for the management of musculoskeletal pain.”

8) “Guided behavioural experiments can be used to assess the patient's pain, behavioural and emotional response during the performance of these tasks...

Repeat exposures of tasks to build confidence, and gradually progress them towards their goals”

9) “During these guided behavioral experiments, attention is brought to discrepancies between pain expectations & actual pain experiences in order to disconfirm the individual's belief that movement is threatening & should be avoided. academic.oup.com/ptj/article/98…

10) “This approach powerfully demonstrates to the individual that moving and loading the spine without protection and avoidance is safe and that pain responses are controllable.” @MaryOKeeffe007 @kieranosull

11) “Exposure with control is a process of behavioral change through experiential learning, in which sympathetic responses and safety behaviors that manifest during painful, feared, or avoided functional tasks are explicitly targeted and controlled.”

12) “This approach enables individuals to gradually return to their valued functional activities without pain escalation and associated distress.”

13) “A common aspect of all these biopsychosocial interventions is the use of active listening, reflection, and empathy as a strategy to allow patients to communicate their feelings and beliefs.” rbf-bjpt.org.br/en-biopsychoso…

14) “Graded exposure is based on the identification and ranking a hierarchy of movements eliciting fear and avoidance, as well as the recognition of dysfunctional beliefs related to fear of reinjury or pain aggravation.”

15) “This is followed by patient education to clarify misconceptions and a program of systematic gradual exposure to feared movements until the patients feel confident in performing the movements without any support.”

16) “the process of exposure w/control happens through experiential learning & behavioral changes w/ the goal to improve self-efficacy…

17) “The aim is to allow patients to return to their valued functional activities w/out pain escalation, pain vigilance, or associated emotional distress.”

18) “Beliefs about the body and pain play a powerful role in behavioural and emotional responses to musculoskeletal pain. What a person believes and how they respond to their musculoskeletal pain can influence how disabled they will be by pain.” doi.org/10.1016/j.bjpt…

19) “Importantly, beliefs are modifiable and are therefore considered an important target for the treatment of pain-related disability.”

20) “Participatory Discourse is alternate
What a person can do to participate in valued life activities. Instead of focusing on fixing the degeneration they focus on what they can do to maintain health & participation” @ProfDavidHunterjointaction.info/podcast/episod…

21) “with persistent MSK pain a permanent ‘fix’ is unlikely and being coached towards effective self-management has long term benefits for both their physical and mental health.” @JeremyLewisPT bjsm.bmj.com/content/52/24/…

22) “The first stage of behaviour change intervention is to collaboratively identify a behaviour that aligns with the person’s goals and contributes to improving health” doi.org/10.1016/j.phys…

23) “Re-engaging in valued activities may involve exposure to movements and activities that have been avoided. Here, graded exposure ensuring that progression feels safe or to gradually increase physical performance can be helpful.” sciencedirect.com/science/articl…

24) “This exposure is an opportunity to provide a positive experience and increase the patient's beliefs in their ability to move and be active.” @JanHartvigsen @AliceKongsted

25) “A traditional biomedical paradigm would focus on structural and degenerative changes in the spine that presumably explain the patient's symptoms. However, these do not correlate well with an individuals’ pain or activity limitations,”

26) “A structural diagnosis does therefore not help patients make sense of their symptoms, and it may, in fact, add to their fear and worry, and even drive the use of ineffective treatments.”

27) “Chronic pain represents an enticing paradox: it persists with no apparent benefit to the individual. Responses to pain that at 1 time point and context are helpful, appear to have the opposite effect at a later time and context.” doi.org/10.1093/ptj/pz…

28) “Recent evidence shows that certain movements are avoided, not because they are harmful, but rather because they are generalized into a category of believed “dangerous” movements.Problem solving may assist in challenging “rigid” responses & beliefs & to increase flexibility.”

29) “This is fueled by the emergence of beliefs based on generalizations from actual associations (eg, “it is dangerous to sit too long” or “each repetitive movement deteriorates my back”)…

30) …These beliefs increase negative affect and muscle tension, which in turn can increase the pain intensity and enhance the other co-occurring problems.”

31) “The prevailing impairment discourse may potentially discourage people from using knees that have passed their ′use-by-date′ and increase reliance on doctors to repair joint damage…. @bunzli_sdoi.org/10.1093/pm/pna…

32) ..Consistent w/ recommendations in clinical practice guidelines, a participatory discourse may provide an alternative way of communicating, which may encourage people w/ knee OA to continue to engage in PA by focusing on what they can do, rather than what they cannot do.”

33) “Predictive processing - illusions. The same perception is seen through lense of expectations” @Peter_Stilwell Perception & action are coupled which is why beliefs influence behavior.

open.spotify.com/episode/6T1ZPv…

34) This is the Ecological approach from Gibson & includes a person’s affordances

“Affordances - action possibilities. Between a person & what their social environment/context
affords them.” Our goal is to expand what a person feels safe doing. @Peter_Stilwell

35) Discussions w/ Daniela Vaz
❇️ The enactive approach brings context forward so we avoid dichotomization
❇️ Enactive model recognizes perception is not just a reaction to stimuli
❇️ Pain is an emergent process w/ Perception bring embodied

36) “affordances emerge based on what the environment offers & the capabilities of the person” D Vaz

37) “People are dynamic systems. Pain is not in the body or brain.” D Vaz

38) “we should explore new possibilities for action not tied to narrow structural narratives.” D Vaz

39) “enactive framework enables us to emphasize the lived embodied experience of concerned subjects & the centrality of their perceived possibility to act, two aspects which have been largely ignored in more traditional approaches.” @sconinxphillink.springer.com/article/10.100…

40) “we need to acknowledge that the initiating factors of pain may not be the same as the maintaining factors and the effectiveness of a specific treatment cannot simply be reverse engineered to conclude what caused the pain.” @Peter_Stilwell

41) “Often reductionist approaches are taken where the clinician looks for the underlying ‘root cause’ of pain and ways to ‘fix it’.”

42) “Ultimately, the aim is to shift patients towards improved pain-related self-efficacy, believing that they can successfully (re)engage in valued activities now and in the future.”

43) “With an enactive approach, clinicians can work to create a context where positively valenced actions are more salient rather than relying primarily on passive strategies.”

44) “subjects can begin to predict pain in relation to various simple and complex behaviors that are often harmless, and this expectation can enforce the actual experience of pain”

45) “chronic pain is more often related to the development of expectations of a salient & negatively valenced outcome, rather than a reflection of sensory evidence indicating threat to bodily tissues…

46) .. It is possible that such negative predictions may be partly generated & reinforced through unhelpful social feed-back loops.”

47) “Pain’ is a broad term, a word for a sensation or experience with a periodicity that is individually and culturally constructed through communication into meaning, subject to a wide range of influences, and linked in time and space to a body….

discovery.ucl.ac.uk/id/eprint/1012…

48) …Its meanings are also powerful communications that can themselves be taken on, embodied, even affecting sensations.”

Acute pain is sexy and chronic pain is not. Language, communication and transformation - Jennifer Patterson

49) “Tensions in the shift from a singular biomedical worldview to pluralist biopsychosocial models of care align with patient demands and economics.”

50) “Aiming to improve the close listening skills of HCP & medical professionals, narrative-based analyses highlight language & narrative patterns; turning points, changes in structure, shape, metre & direction…facilitate difficult practitioner conversations in a safe setting.”

51) “‘Close listening’ educates the clinician or practitioner-listener to hear better. In so doing they gain a more nuanced understanding of a case, find out what matters to a patient and are better able to support what they are experiencing.”

52) “Consider for the moment that the sensory experience of pain is a communication from the body. Just as there is an aspect of communication, there also is one of translation, and of form, in the voicing of pain.” @MyCuppaJo @MattLowPT

53) “This is even more pertinent when it comes to detailing what this sensation is or ‘feels like’. The ‘is’ of pain is therefore an embodied communication, an individual’s conscious recognition of the sensation, indivisible from an existential process.”

54) “So, in a pain metaphor, the meaning that is carried across is contextually mediated as linguistic or visual within an embodied experience. Language often functions as a signpost indicating something that cannot be fully expressed..,,

55) …Becoming a knowledgeable listener requires compassionate listening, practice, patience & observation…

56) ..Words embedded in the content of a story hold clues for something that needs to be decoded. Decoding the relevance of this for the teller is critical, as critical as sitting face to face & sharing breath as human beings during the consultation.”

57) “If we are aiming for a patient or athlete-centered model we are not treating an (ACL) injury we are treating person… @LKTphysiom.soundcloud.com/bmjpodcasts/ta…

58) “.. A person consists of psychological & social contextual factors. If we are moving towards this patient-centered model we have to acknowledge it. By acknowledging it we start to directly or indirectly treating it.”

59) “While an athletes’ ability to return-to-sport is influenced by their physical & psychological readiness, this is superseded by the systemic social forces that shape an athlete’s reality & determines their access to sport development, funding & medical resources.” @LKTphysio

60) “psychological factors are only the tip of the iceberg. Social & contextual factors, which have largely been ignored…directly impact health outcomes, well-being & sport injury recovery by facilitating or impeding health & health behaviour change” bjsm.bmj.com/content/55/9/4…

61) “Informing all relevant stakeholders is very important, but for real change more than simply informing relevant stakeholders is needed. @OsteloR

twin.sci-hub.tw/7095/dab45ffd2…

62) “In and vested interests are dominant, the challenge now is to transform this ‘call for action’ into ‘real change’. “ @OsteloR

63) We all must fight “The tyranny of the mainstream”
David Bowie
@CGMMaher @MaryOKeeffe007 @RachelleBuchbin

@CGMMaher @MaryOKeeffe007 @RachelleBuchbin @threadreaderapp unroll