title: Evaluating the efficacy of graded in vivo exposure for the treatment of fear in patients with chronic back pain: a randomized controlled clinical trial.
abstract: Psychological treatments for chronic pain, particularly those based upon cognitive behavioural principles, have generally been shown to be efficacious. Recently, a treatment has been developed based upon the fear-avoidance model of chronic musculoskeletal pain, which suggests chronic pain can be relieved by exposing the individual to movements and tasks that have been avoided due to fear of (re)injury. This graded in vivo exposure treatment has been found to be beneficial in case studies. The present investigation utilized a randomized controlled trial method to assess the effectiveness of graded in vivo exposure relative to other conditions. Forty-four chronic low back pain patients were randomly assigned to graded in vivo exposure, graded activity, or a wait-list condition. While only trend differences were observed for pain-related disability, patients in the graded in vivo exposure condition demonstrated (a) significantly greater improvements on measures of fear of pain/movement, fear avoidance beliefs, pain-related anxiety, and pain self-efficacy when compared to those in the graded activity condition, and (b) significantly greater improvements on measures of fear-avoidance beliefs, fear of pain/movement, pain-related anxiety, pain catastrophising, pain experience, and anxiety and depression when compared to those in the wait-list control condition. Additionally, patients in the graded in vivo exposure condition maintained improvements in these areas at one month follow-up. Implications of these findings for the treatment of individuals with chronic low back and other pain conditions are discussed.
authors: Department of Psychology, University of Regina, Regina, SK, S4S 0A2, Canada Faculty of Kinesiology and Health Studies, Department of Psychology, University of Regina, Regina, SK, S4S 0A2, Canada.
authors: Marc P
authors: MP
authors: Woods
authors: Gordon J G
authors: GJG
authors: Asmundson
mesh_terms: D001416:Back Pain / Q000150:complications* / Q000517:prevention & control*; D002908:Chronic Disease; D015928:Cognitive Behavioral Therapy / Q000379:methods*; D003887:Desensitization, Psychologic / Q000379:methods*; D005239:Fear; D006801:Humans; D008875:Middle Aged; D013315:Stress, Psychological / Q000150:complications* / Q000517:prevention & control*; D016896:Treatment Outcome
references: Bjelland I, Dahl AA, Haug TT, Neekelmann D. The validity of the Hospital Anxiety and Depression Scale: an updated literature review. J Psychosom Res. 2002;52:69-77.
references: Boersma K, Linton S, Overmeer T, Jannsen M, Vlaeyen J, de Jong J. Lowering fear-avoidance and enhancing function through exposure in vivo: a multiple baseline study across six patients with back pain. Pain. 2004;108:8-16.
references: Borkovec TD, Nau SD. Credibility of analogue therapy rationales. J Behav Ther Exp Psychiatry. 1972;3:257-260.
references: Coons MJ, Hadjistavropoulos HD, Asmundson GJG. Factor structure and psychometric properties of the Pain Anxiety Symptoms Scale – 20 in a community physiotherapy clinic sample. Eur J Pain. 2004;8:511-516.
references: Crombez G, Vervaet L, Lysens R, Baeyens F, Eelen P. Avoidance and confrontation of painful, back straining movements in chronic back pain patients. Behav Modif. 1998;22:62-77.
references: de Jong JR, Vlaeyen JWS, Onghena P, Goosens M, Geilen M, Mulder H. Fear of movement/(re)injury in chronic low back pain. Clin J Pain. 2005;21:9-17.
references: de Jong JR, Vlaeyen JWS, Onghena P, Cuypers C, den Hollander M, Ruijgrok J. Reduction of pain-related fear in complex regional pain syndrome type I: the application of graded exposure in vivo. Pain. 2005b;116:264-275.
references: Frymoyer JW, Cats-Baril WL. An overview of the incidences and costs of low back pain. Orthop Clin North America. 1991;2:263-271.
references: Hart LG, Deyo RA, Cherkin DC. Physician office visits for low back pain: frequency, clinical evaluation, and treatment pattern from a U.S. national survey. Spine. 1995;20:11-19.
references: Horvath AO, Greenberg LS. Development and validation of the Working Alliance Inventory. J Couns Psychol. 1989;36:223.
references: Huge V, Schloderer U, Steinberger M, Wuenschmann B, Schops P, Beyer A, et al. Impact of a functional restoration program on pain and health-related quality of life in patients with chronic low back pain. Pain Med. 2006;7:501-508.
references: Jacobson NS, Truax P. Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. J Consult Clin Psychol. 1991;59:12-19.
references: Jensen MP, Turner JA, Romano JM. Chronic pain coping measures: individual vs. composite scores. Pain. 1992;51:273-280.
references: Kuch K, Cox BJ, Evans RJ. Posttraumatic stress disorder and motor vehicle accidents: a multidisciplinary overview. Can J Psychiatry. 1996;41:429-434.
references: Lethem J, Slade PD, Troup JD, Bentley G. Outline of a fear-avoidance model of exaggerated pain perception – I. Behav Res Ther. 1983;21:401-408.
references: Linton SJ, Overmeer T, Janson M, Vlaeyen JW, de Jong JR. Graded in vivo exposure treatment for fear-avoidant pain patients with functional disability: A case study. Cognitive Behaviour Therapy. 2002;31:49-58.
references: McCracken LM, Dhingra L. A short version of the Pain Anxiety Symptoms Scale (PASS-20): Preliminary development and validity. Pain Res Manag. 2002;7:45-50.
references: McCracken LM, Zayfert C, Gross RT. The Pain Anxiety Symptom Scale: Development and validation of a scale to measure fear of pain. Pain. 1992;50:67-73.
references: Melzack R. The short-form McGill Pain Questionnaire. Pain. 1987;30:191-197.
references: Nicholas MK. The pain self-efficacy questionnaire: taking pain into account. Eur J Pain. 2007;11:153-163.
references: Norton PJ, Asmundson GJ. Amending the fear-avoidance model of chronic pain: what is the role of physiological arousal? Behav Ther. 2003;34:17-30.
references: Openshaw C, Waller G, Sperlinger D. Group cognitive-behaviour therapy for bulimia nervosa: statistical versus clinically significant change in symptoms across treatment. Int J Eat Disord. 2004;36:363-375.
references: Osman A, Barrios F, Gutierrez P, Kopper B, Merrifield T, Grittmann L. The Pain Catastrophising Scale: further psychometric evaluation with adult samples. J Behav Med. 2000;23:351-365.
references: Pollard CA. Preliminary validity study for the Pain Disability Index. Percept Mot Skills. 1984;59:974.
references: Rizzo JA, Abbott TA, Berger ML. The labour productivity effects of chronic backache in the Unite States. Med Care. 1998;36:1471-1488.
references: Roelofs J, Peters ML, Vlaeyen JW. The modified Stroop paradigm as a measure of selective attention towards pain-related information in patients with chronic low back pain. Psychol Rep. 2003;92:707-715.
references: Sullivan MJ, Bishop SR, Pivik J. The Pain Catastrophising Scale: development and validation. Psychol Assess. 1995;7:524-532.
references: Tait RC, Chibnall JT, Krause S. The Pain Disability Index: psychometric properties. Pain. 1990;40:171-182.
references: Tracey TJ, Kokotovic AM. Factor structure of the Working Alliance Inventory. Psychological Assessment. 1989;1:207-210.
references: Turk DC, Okifuji A. Psychological factors in chronic pain: evolution and revolution. J Couns Clin Psychol. 2002;70:678-690.
references: van Breukelen GJP. ANCOVA versus change from baseline had more power in randomized studies and more bias in nonrandomized studies. J Clin Epidemiol. 2006;59:920-925.
references: Vickers AJ. Statistical reanalysis of four recent randomized trials of acupuncture for pain using analysis of covariance. Clin J Pain. 2004;20:319-323.
references: Vlaeyen JW, de Jong JR, Geilen M, Heuts P, van Breukelen G. Graded exposure in vivo in the treatment of pain-related fear: a replicated single-case experimental design in four patients with low back pain. Behav Res Ther. 2001;39:151-166.
references: Vlaeyen JW, Kole-Snijders A, Boeren R, van Eek H. Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance. Pain. 1995;62:363-372.
references: Vlaeyen JW, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: A state of the art. Pain. 2000;85:317-332.
references: Waddell G, Newton M, Henderson I, Somerville D, Main CJ. A fear-avoidance beliefs questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain. 1993;52:157-168.
references: Wright KD, Asmundson GJ, McCreary DR. Factorial validity of the short form McGill Pain Questionnaire. Eur J Pain. 2001;5:279-284.