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Cited by 280Musculoskeletal pain and rehabilitationPain Management and TreatmentAnxiety, Depression, Psychometrics, Treatment, Cognitive Processes

Evaluating the efficacy of graded in vivo exposure for the treatment of fear in patients with chronic back pain: A randomized controlled clinical trial

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Woods, Marc P., Asmundson, Gordon J.G.·2008·Pain
DOI 10.1016/j.pain.2007.06.037
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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.

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  • EXP was not superior to graded activity in terms of pain-related impairment.

    “While EXP was not superior to graded activity in terms of pain-related impairment [17, 18]”

    From EFFects of Exposure and Cognitive behavioral Therapy for chronic BACK pain (“EFFECT-BACK”): study protocol for a randomized controlled trial (2024) · cites this paper as [17]

    The Results (§3.3.2; page unavailable) report that graded in vivo exposure produced greater improvement than graded activity on the Pain Disability Index, a measure of pain-related impairment, from pretreatment to follow-up (p = .005). The claim does not limit itself to post-treatment outcomes, so its blanket statement of no superiority conflicts with that finding. (LLM, conf=0.86)

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  • Four RCTs found no between-groups differences on the primary outcome, pain-related disability.

    “but found no between-groups differences on the primary outcome, pain-related disability.”

    From Exposure and CBT for chronic back pain: An RCT on differential efficacy and optimal length of treatment (2018) · cites this paper as Woods & Asmundson, 2008

    In §3.3.2 (page unavailable), the paper reports a significant between-group difference in Pain Disability Index improvement from pretreatment to follow-up: graded in vivo exposure outperformed graded activity (p = .005). It also classifies disability as a secondary, not primary, outcome. This paper is one trial, so it cannot establish the finding for all four RCTs. (LLM, conf=0.88)

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    Experimental — accuracy not yet measured

  • Four RCTs found some benefits of Exposure, including greater reduction in pain-related fear and perceived harmfulness of physical activity.

    “These studies found some benefits of Exposure, including greater reduction in painrelated fear and perceived harmfulness of physical activity”

    From Exposure and CBT for chronic back pain: An RCT on differential efficacy and optimal length of treatment (2018) · cites this paper as Woods & Asmundson, 2008

    Section 3.6.2 reports a greater post-treatment improvement in fear-related scores with graded in vivo exposure than with graded activity, and a 65% pre-to-post reduction in PHODA scores, a measure of fear and avoidance of activities. It does not establish a greater reduction in perceived harmfulness of physical activity relative to another group. This paper is one RCT, so it cannot by itself substantiate the statement about four RCTs. (LLM, conf=0.85)

    Experimental — accuracy not yet measured

  • The existing literature on exposure for high fear of pain indicates that psychology-only interventions may be sufficient to achieve significant reductions in problematic fear avoidance.

    “The extant literature on exposure for high fear of pain indicates that psychology only interventions may be sufficient to achieve significant reductions in problematic levels of fear avoidance.46,47,58”

    From A Comparative Meta-Analysis of Unidisciplinary Psychology and Interdisciplinary Treatment Outcomes Following Acceptance and Commitment Therapy for Adults with Chronic Pain. (2020) · cites this paper as [58]

  • Three RCTs on EXP in CBP show positive effects on pain-related impairment, kinesiophobia, depressive mood, pain catastrophizing, and perceived harmfulness of activity.

    “Three randomized controlled trials (RCTs) on EXP in CBP show positive effects on pain-related impairment, kinesiophobia, depressive mood, pain catastrophizing, and perceived harmfulness of activity [16–18].”

    From EFFects of Exposure and Cognitive behavioral Therapy for chronic BACK pain (“EFFECT-BACK”): study protocol for a randomized controlled trial (2024) · cites this paper as [17]

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Authors
Woods, M. P., & Asmundson, G. J. G.
Affiliations
University of Regina (CA)
Corresponding author
Woods, Marc P.
ORCID
Asmundson, Gordon J.G.
Venue
Pain
Publisher
Ovid Technologies (Wolters Kluwer Health)
Published
2008-06
Volume
136
Issue
3
Pages
271-280
ISSN
0304-3959 (ISSN-L)
DOI
10.1016/j.pain.2007.06.037
OpenAlex
W2080816720
Cited by
280
References
57
Citations by year
2026: 9 · 2025: 9 · 2024: 13 · 2023: 14 · 2022: 13 · 2021: 16 · 2020: 19 · 2019: 21 · 2018: 11 · 2017: 15 · 2016: 13 · 2015: 17 · 2014: 16 · 2013: 15 · 2012: 14
FWCI
11.52
Type
journal article
Language
en
Open access
Locations
  • Pain (publishedVersion)
  • PubMed (publishedVersion)
  • oURspace (University of Regina) (submittedVersion)
  • UREG-DEV
Funders
  • University of Regina
  • Royal Bank of Canada
  • Canadian Institutes of Health Research
Topics
  • Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
  • Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Treatment
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
Keywords
chronic low back pain, fear-avoidance beliefs, fear of pain, kinesiophobia, graded activity, pain catastrophizing, pain self-efficacy, pain-related anxiety, pain-related disability, cognitive behavioral therapy, musculoskeletal pain, treatment efficacy
MeSH terms
Back Pain, Chronic Disease, Desensitization, Psychologic, Fear, Humans, Middle Aged, Stress, Psychological, Cognitive Behavioral Therapy, Treatment Outcome

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