Movement With Pain Framework

Overview The Movement with Pain Framework (MWPF) is a biopsychosocial process-based framework for helping clinicians work with individuals struggling with movement and pain problems. It is designed to assist movement and physical rehabilitation professionals to engage in evidence-based psychological informed practice and to fully embrace the biopsychosocial model. It incorporates both identification and engagement of empirically researched processes associated with psychosocial flexibility and a prognostic ladder based on relative psychological flexibility for developing clinical decision-making skills. This prognostic ladder is designed to be expanded to other biopsychosocial flexibility processes with future advances in research on these processes. The MWPF has an appreciation for the qualitative representation of motor behavior (with emphasis on movement variability) and load capacity to comprehensively address the needs of movement and pain in physical rehabilitation. The MWPF is an ongoing work in progress with the possibility of significant change across the course of its development. Background The MWPF was an attempt to address the gap in the working framework for training rehabilitation professionals to engage in the biopsychosocial model. In an attempt to minimize the redevelopment of research that is readily available, significant effort was to draw on available models, theories, and processes to build the MWPF. The vast research work is done relative to pain science, motor behavior, and tissue capacity, RFT, Acceptance and Commitment Therapy (ACT), psychological flexibility, cognitive network psychology, and process-based therapy have been instrumental to the development of the MWPF. The six core psychological flexibility processes of ACT, and the inflexibility processes they target, have been extensively studied in empirical research. The evidence for ACT in comparison to Cognitive Behavioral Therapy (CBT) for chronic pain is equivalent, but the transdiagnostic benefit, such as concurrent improvement in depression and anxiety, is greater in ACT (see here). Psychological flexibility changes account for the majority of improvements in patient functioning with ACT interventions (see here). Initial efforts to integrate physical therapy with ACT (PACT) demonstrated feasibility for physical therapists to implement ACT into practice. PACT when compared to usual physical therapy care showed short term superiority but not long term superiority (see here). We hypothesize that some of the limitations of the PACT approach for long term effectiveness may in part be associated with coherence difficulties between standard physical therapy and ACT. As previously described here, inconsistencies of the worldviews in which an intervention was developed may present with problems of coherence for both the client and the clinician. We propose that a comprehensive re-evaluation of the movement strategies in combination with psychosocial strategies may result in more sustainable benefits and enhance transdiagnostic benefits for improving quality of life. The Movement with Pain Framework (MWPF) is built on a philosophic worldview of contextualism with the pragmatic scientific philosophy of functional contextualism. It is transdisciplinary and rooted in the biopsychosocial model for health. Relational Frame Theory both in the context of language and cognition and as unofficially proposed representation of motor behavior relationships relative to sensory, cognitive, and emotional stimuli. Its interventional approach is process-based and it draws upon the psychological flexibility and inflexibility processes developed for Acceptance and Commitment Therapy (ACT). Finally, efforts to ease the difficulty merging mechanistic views of traditional physical rehabilitation into the contextual aspects of pain and movement, the MWPF was designed to provide a prognostic ladder as a technology to assist with clinical decision-making pathways to help guide treatment planning. Notes

• The biopsychosocial model has had a number of complaints that included philosophical coherence and the confusion of categorization along with biological, psychological, or sociology domains. These complaints highlight the limitations of format, mechanistic, and organicism philosophical viewpoints, as these views are challenged by context and historical reference. Within the viewpoint of contextualism, the biopsychosocial model can be fully appreciated, including the ability to develop contexts and constructs which could be defined for a specific intent to delve into detailed aspects of one domain, such biology, or commonly in physical rehabilitation, neuroscience and biomechanics, but concurrently recognizing the complex overlay of numerous other factors and the context in which these constructs exist. To do so in any of the other lenses could result in unyielding complexity that could not be acted upon.

• Emphasis on movement vs. exercise prescription
  • Our emphasis on improving functional understanding, awareness, and meaningful action during movements and positions such as sitting, standing, walking, lifting, pushing, pulling are that these are movement behaviors present in most ADL. We know clients/patients have very low adherence to HEP after discharge, let alone during the POC itself. Most of the benefits of clinical treatment are occurring along with broad biopsychosocial processes that are more important than strength and flexibility, despite so many clinicians emphasizing these elements exclusively. Most successful outcomes can be predicted by early increases in psychological flexibility, such as what may be noted after expectation violation. We are double-dipping into researched processes for movement as well as psychosocial processes emphasized formally in ACT work. With this process-based approach we are working on weaving skill developments into ADL for a long term sustainable improvement. The behavioral skills we are attempting to emphasize are often self-reinforcing. “If I am present and pay attention, I make better decisions and often I feel better” “When I forget or am distracted, I start to have problems”, this also overlaps with the literature on work injury, distraction and moving awkwardly are the primary biomechanical mechanisms driving injury secondary to work satisfaction and depression. No exercise prescription will accomplish improvement in attentional ability, only practicing attention will do so. Our working hypothesis is that diverse biopsychosocial attentional efforts combined with developing of skills to promote true ownership for the setting the stage for building further biopsychosocial capacity and ultimately thriving in these practices will maximize the opportunity of a lifetime of improvement beyond the clinical space and redirect trajectories of disability and
• “You can skip steps, function on one step, fall down the steps, and then climb back up”
  • The MWPF is NOT intended to serve as a mechanistic linear progression
  • The psychological flexibility processes of ACT as described in the hexaflex are designed for constant pivoting in which the clinician first is flexible to determine where change is possible for a client. While the prognostic ladder we propose contains key biopsychosocial processes it is expected that that engagement in processes outside of the “step” on the MWPF will and should be engaged to meet the needs of the client in front of you.
• Self as defined by RFT
  • In RFT, the experience of self is divided into an umbrella of two parts, self-as-perspective (observing mind, transcendent mind, among many other names) and “content of self”. The content of self is further divided into self-as-process and self-as-story. Self-as-process is the “ongoing, observable process of ourselves”, such as memories, emotions, bodily sensations, and thoughts. It only exists here and now and as a result, is open for change. This dynamic nature of self-as-process is important because this means memories are not always thought of or remembered in the same way, nor does sensation always feel the same, and our emotional state and how we interpret emotions is also variable. Self-as-story is the “who I am”, identity part built on our history, and it is important that this story is coherent and a connected whole. The self-as-perspective, or observing self, is difficult to describe. As Hayes describes it, “it’s borders are fuzzy”, we cannot observe it and it is devoid of content, it is the lens through which we look that is not influenced by what it sees. The observing self is also a powerful process to engage in from a therapeutic perspective, classically emphasized in mindfulness strategies but explicitly engaged with Acceptance and Commitment Therapy. While there are numerous directions (in particular “I/you”, “here/there”, “now/then” relationships!) for which I could take this and future posts, I will for now leave these for specific courses on these approaches and end on the note that the experience of self, as defined by RFT, provides a clinical framework for understanding the difficulty of addressing beliefs, memories, relationships with emotions and sensations, and sustainable behavior change.

• Psychological flexibility as the basis of the prognostic ladder function
  • We recognize the fragmented nature of research on psychological flexibility, for the purpose of creating a construct for which the MWPF could operate with, we utilize the definition recommended by Kashdan:
    • “Psychological flexibility actually refers to a number of dynamic processes that unfold over time. This could be reflected by how a person:
      1. adapts to fluctuating situational demands
      2. reconfigures mental resources
      3. shifts perspective
      4. balances competing for desires, needs, and life domains Thus, rather than focusing on specific content (within a person), definitions of psychological flexibility have to incorporate repeated transactions between people and their environmental contexts.” – Kashdan,
    • A metaphor that may be helpful for clinical purposes is to look at psychological flexibility as the availability of space in a defined area of land for tending vegetation, with vegetation representing relational frames and networks. Larger amounts of land yield greater space for opportunities to change arrangements of vegetation growth. Conversely, less availability of space limits options and opportunities for variability and change.
    • The role of psychosocial processes in chronic pain has been well established. While some evidence for the prognostic representation of psychological flexibility in physical rehabilitation exists (here), the principal limitation of the MWPF is the lack of research related to the prognostic ability of psychological flexibility in physical rehabilitation for pain. We have drawn extensively the prognostic ability of psychological flexibility in multiple aspects of human health (here, here, here) and some research on psychological flexibility prediction and mediation role in chronic pain (here, here, here). Our hope is the open-source nature of MWPF will draw on the community of researchers who resonate with the proposed framework.

 

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Functional Understanding

ACT Psychological Inflexibility Processes Identified: Cognitive Fusion,Conceptual Past/Future, Attachment to conceptualize self ACT Psychological Flexibility Processes Engaged: Cognitive Defusion, Presence, self Prognostic Ladder Representation of Psychological Flexibility: Low In adherence to a contextual philosophic viewpoint, the static content of knowledge or understanding is not inherently functional, but if this knowledge is used toward a pragmatic end, function is obtained. Providing “education” and expecting behavior change without consideration for an individualized relational framework will not yield functional goals. Biopsychosocial processes other than cognitive content are responsible for behavior change but knowledge for the purpose of change is functional. The most important element for providing knowledge which meaningful improves a client’s functional capacity is clinician understanding. The clinician’s assessment for the additional knowledge that would actually improve the functional outcome for the patient is key to this process. Recall here again, in understanding RFT, we learned we cannot argue or replace thoughts or understanding, we can only add new knowledge which the client then must determine whether it is meaningful enough to act on. Therapeutic neuroscience education (TNE), general biopsychosocial concepts, simple analogies can be helpful added content that opens up opportunities for new relationships and networks when the client is able to view both old and new content through a state of observing them. Tools drawn from motivational   interviewing and ACT provide strategies for engaging in the process of experience of self, specific for functional understanding, engaging in the self-as-perspective toward the function of engaging in content-of-self provides opportunity for recognition of cognitive fusion and the opportunity for cognitive defusion. By engaging in the self-as-perspective, the process presents options and the client now has a choice to be made with the available information. In order to act on these options, behavioral tools, such as values and goals, can allow the knowledge to become functional. For clinicians who have seen significant client behavior shifts via “fire hydrant education”, this may explain some of the underlying processes that we unintentionally engaged in and resulted in cognitive defusion. We propose therefore that it would be advantageous that cognitive fusion inflexibility processes be targeted deliberately with an effort to pivot towards flexibility processes as necessary.  

Awareness

ACT Psychological Inflexibility Processes Identified: Experiential Avoidance, Conceptual Past/Future, Cognitive Fusion, Attachment to conceptualize self ACT Psychological Flexibility Processes Engaged: Cognitive Defusion, Acceptance, Presence, self-as-context Prognostic Ladder Representation of Psychological Flexibility: Low The scope of awareness is deliberately broad as many biopsychosocial processes are engaged in intentional attention allowing for an arising awareness. Attention is defined by the APA as a state in which cognitive resources are focused on certain aspects of the environment rather than on others and the central nervous system is in a state of readiness to respond to stimuli. Awareness is defined by the APA as perception or knowledge of something. Accurate reportability of something perceived or known is widely used as a behavioral index of conscious awareness. However, it is possible to be aware of something without being explicitly conscious of it. As these definitions clearly define, attention is independent of awareness and awareness is o nly relative to consciousness. However, from a pragmatic sense, there is not much functional benefit from defining the two separately in the ladder, conscious deliberate attention is engaging in awareness. Exploration of the RFT experience of self forms the basis for awareness in MWPF (I/You, Here/There, Now/Then). Utilizing the RFT definitions of self previously described in the notes section, explicitly bringing attention to the self-as-perspective and exploring the content of self are the relationships and networks is the process we are engaged in. As physical rehabilitation professionals, we may have to emphasize sensorimotor experiences, rather than cognitions and emotions, as our entry point for developing basic levels of awareness despite the often arbitrary and futile nature of the effort. This, in part, is an attempt to meet the expectations of the client attending physical rehabilitation. We attempt to guide individuals to recognize resting muscular activity, the uniqueness of their own structural anatomy, and the ability to influence it. In sensorimotor awareness, there are many realms of exploration of sensorimotor options and experiments which could lead to meaningful action if so desired. Depending on the flexibility and openness of the client to engaging in deliberate psychosocial processes, cognitive awareness, such as knowing we have and observing thoughts, beliefs, memories, judgements, and predictions which influence our sensorimotor behavior and relate to our emotions are guided experiences which could be gradually introduced as the client shows openness to the concepts. Emotional awareness entails knowledge of emotions as experienced in the physical body that there is relationships with thoughts and sensations but also unique physical experience qualities to be noticed. Awareness of values that have been lost or never identified are often vital for individuals to develop true ownership but are more explicitly explored in meaningful action. When we engage in awareness processes we explore options. What do we mean by options? We mean to explore variability across biopsychosocial domains: movement variability through exploring ways of moving, ways of holding positions, ways of doing actions; psychological flexibility in noticing what we think we’re doing and respecting emotional and mental cues for our internal congruence; and respecting the needs of the whole person for functional capacity through relationships of extrinsic factors in preparation for meaningful action. In this awareness we will also recognize the things that matter to us, that are valuable and use these as compasses toward a better life and the ability to thrive no matter what.   Awareness Engagement Process (EAP or Exploring options) - added 5/22/2020 For the purpose of the MWPF, the “options” revealed to the client and/or the clinician during engagement with Awareness Processes will be label Awareness Engagement Processes (EAP). A client may be prognostically in the awareness phase of the MWPF but the action they are engaging in, relative to that phase, will be defined as EAP. Symptom Modification The forefront of rehabilitation has been symptom modification (eg: modulation/”calming”), whether exercises such as specific exercise, directional preference, manual therapy, dry needling, taping/strapping, any number of modalities, and referral related to pharmacology, and procedures. However, the value of symptom modification in long term outcomes and addressing disability is questionable. In some contexts, symptom modification when combined with functional understanding may have the potential for cognitive defusion, committed action, contacting values, and potentially address thoughts about the conceptualized past and future through expectation violation. However, it also has strong potential to reinforce experiential avoidance, attachment to conceptualized self, decrease presence in the now and in the physical body. It is potentially a risky behavioral path to focus on and has the potential for decreasing likelihood for true ownership, building, or thriving. Symptom modification may overlap with behavior change and processing, but more than likely, it may result in an indirect effect of these two processes. As defined above, the opportunity for cognitive defusion may still present an indirect effect on either, or both, EAP.     Behavior Change The scope and scale of biopsychosocial behavioral change available to humans is broad. The EAP of Behavior change is a client lead process in which a clinician presents activities which are selected in their ability to overlap with multiple psychological flexibility processes. An example of a common first-generation activity found in the early phase of MWPF development is the acts of sitting, standing, or walking. The act of sitting, standing, or walking provides the client an open opportunity to increase sensory, cognitive, and emotional awareness and to explore options within the experiences that arise in the process. Case review of the breadth of behavior change from these guided awareness practices yielded behavior changes across physical, personnel, professional, and social life domains with clients reporting the experience of these 3 awareness acts being their most influential moment in their POC when questioned greater than 6 months after the guided process. Again the individual acts are likely not as important as the EAP, and the transition of simple awareness acts toward multiple life domains is another proposed example to support the theoretical transdiagnostic ability of the MWPF. Behavior change strategies presented in context have the long term potential for increasing true ownership, building, and ultimately thriving prognostic trajectories. Behavior change may include overlap with symptom modification and processing, but this is not the intent, but rather the indirect (“fuzzy”) effect of EAP.    

Meaningful Action

ACT Psychological Inflexibility Processes Identified: Absent or confused values, Lack of committed action ACT Psychological Flexibility Processes Engaged: Values, Committed Action Prognostic Ladder Representation of Psychological Flexibility: Moderate Explicit identification or engagement of values are necessary for meaningful action. Values lead us toward a direction while taking our symptoms/internal context with us. After all, we can't just keep pushing in a direction without respecting the needs of our body. For many people, our difficulties with movement and pain are significantly affected by and an effect of our overextended effort. We need to learn how to pace through our values, how to listen to the movement needs in the context of work. As traditional physical rehabilitation has a mechanistic oriented perspective to action, the emphasis is on outcomes and addressing specific impairments and dysfunction. This   mechanistic orientation limits long-term opportunities for autonomy and self guided improvement in workability. Intentional awareness skill development often is advised as an early phase of meaningful action. These skills engage in biopsychosocial processes related to movement and pain. When applied using values, this can be paired with exercise prescription related to improving aerobic capacity or other metabolic pathways specific to meaningful activity in a client's life. Meaningful action may also for some clients meaning realizing via awareness the need to see a counselor or other provider to help with more direct guidance in psychosocial layers and processing. Often meaningful action is also oriented around practices to improve nerve health including neurodynamics and performing movement experiments (or “snacks”) during the day to improve sensorimotor awareness.    

True Ownership

ACT Psychological Inflexibility Processes Identified: All ACT Psychological Flexibility Processes Engaged: All Prognostic Ladder Representation of Psychological Flexibility: Moderate-High True ownership is prognostically representative of a progression in which autonomy, psychological flexibility, and movement variability are both verbally and functionally expressed by the client. It indicates familiarity in engagement with any of the flexibility processes albeit their application may still be limited. The client has a fundamental recognition of values and action and has encountered some symptom flare-ups during the course of care, or verbalizes readiness for the occurrence of symptoms. At this level of function, decreased clinician/client interaction is necessary, decreased session utilization, and increasing spacing between sessions should be initiated.  

Build

ACT Psychological Inflexibility Processes Identified: Absent or confused values, Lack of committed action ACT Psychological Flexibility Processes Engaged: Values, Committed Action Prognostic Ladder Representation of Psychological Flexibility:: Moderate-High Build prognostically does not represent a higher level of psychological flexibility than True Ownership and serves more to support the merging of the physical rehabilitation world concurrent with psychological flexibility processes associated with resilience. Emphasis on developing comprehensive loading capacity across tissues, kinetic chains, psychosocial, the nervous system, and the non-musculoskeletal domains is placed here. Furthermore, ongoing challenges with values and committed action are revisited and expanded on.  

Thrive

ACT Psychological Inflexibility Processes Identified: All ACT Psychological Flexibility Processes Engaged: All Prognostic Ladder Representation of Psychological Flexibility:High Thrive functions more as a prognostic indicator of a client who is autonomous, resilient, and able to work not only with their initial presentation but take on future unknown difficulties with greater grace. Thrive is an ACTION state of living all the processes and steps with acknowledging the ups and downs and still having a sense of fulfillment and direction. The “feeling” of “thriving” is recognized as impermanent, but a desire to maintain the ACTION of thriving is maintained. Engagement in this process will be a fluid ability to identify processes that you need to revisit