Graded In Vivo Exposure Treatment for Fear-Avoidant Pain Patients with Functional Disability: A Case Study
Abstract
This single-subject study attempts to replicate the effects of in vivo exposure for pain patients with functional difficulties. Fear-avoidance is a clear risk factor related to dysfunction associated with back pain. Nevertheless, until recently treatment had not dealt specifically with the avoidance behaviour. The treatment of other phobias suggests that in vivo exposure might be an efficient means of treatment. As patients do not normally conceptualize their problem as a phobia, there have been numerous problems in developing exposure techniques. Recently, however, an in vivo exposure technique for pain-related functional problems has been described. The study described here replicates the method: 2 male chronic back pain patients with functional problems and high scores on the Tampa Scale for Kinesiophobia volunteered to participate. Hierarchies were established with the help of a "fear thermometer" and the patients were subsequently provided with 8 sessions of in vivo exposure. The results replicated the original study and showed substantial improvements for both patients as they increased their function and decreased their fear. Thus, the findings are extended to another setting: patients and therapists. It is concluded that these results warrant further investigation in larger, controlled trials. Key words: back pain, activity training exposure, fear-avoidance.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Similar effects have been reported in 2 case studies each involving 2 patients with chronic musculoskeletal pain.
“Similar effects have been reported in 2 case studies each involving 2 patients with chronic musculoskeletal pain.”
From Psychological aspects of persistent pain: Current state of the science (2004) · cites this paper as [63]
Cites
Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art.
Vlaeyen, J. W. S., & Linton, S. J. (2000) · Pain · doi:10.1016/s0304-3959(99)00242-0 · Cited by 4,931 · see citing works
Self-citationFear of movement/(re)injury in chronic low back pain and its relation to behavioral performance
Vlaeyen, J. W. S., Kole-Snijders, A. M. J., Boeren, R. G. B., & van Eek, H. (1995) · Pain · doi:10.1016/0304-3959(94)00279-n · Cited by 2,446 · see citing works
Self-citationCrombez, G., Vlaeyen, J. W. S., Heuts, P. H. T. G., & Lysens, R. (1999) · Pain · doi:10.1016/s0304-3959(98)00229-2 · Cited by 1,662 · see citing works
Self-citationBehavioral methods for chronic pain and illness
Fordyce, W. E. (1977) · Pain · doi:10.1016/0304-3959(77)90029-x · Cited by 1,630 · see citing works
Waddell, G. (2004) · Cited by 1,262 · see citing works
Kinesiophobia : a new view of chronic pain behavior
Kori, S. (1990) · Medical Entomology and Zoology · Cited by 1,040 · see citing works
Behavioral Methods for Chronic Pain and Illness
Quimby, C. W. (1976) · Anesthesiology · doi:10.1097/00000542-197610000-00030 · Cited by 866 · see citing works
Miller, R. P., Kori, S. H., & Todd, D. D. (1991) · Clinical Journal of Pain · doi:10.1097/00002508-199103000-00053 · Cited by 670 · see citing works
Linton, S. J., & HALLDÉN, K. (1998) · Clinical Journal of Pain · doi:10.1097/00002508-199809000-00007 · Cited by 627 · see citing works
Self-citationVlaeyen, J. W. S., de Jong, J., Geilen, M., Heuts, P. H. T. G., & van Breukelen, G. (2001) · Behaviour Research and Therapy · doi:10.1016/s0005-7967(99)00174-6 · Cited by 469 · see citing works
Self-citationAsmundson, G. J. G., Norton, P. J., & Norton, G. R. (1999) · Clinical Psychology Review · doi:10.1016/s0272-7358(98)00034-8 · Cited by 461 · see citing works
Neck and back pain : the scientific evidence of causes, diagnosis, and treatment
Jonsson, E., & NACHEMSON, A. L. (2000) · Medical Entomology and Zoology · Cited by 342 · see citing works
Pain management : an interdisciplinary approach
Main, C. J., & Spanswick, C. C. (2000) · Churchill Livingstone eBooks · Cited by 242 · see citing works
Neck and Back Pain: The Scientific Evidence of Causes, Diagnosis, and Treatment
Newcomer, K. L. (2001) · Mayo Clinic Proceedings · doi:10.4065/76.11.1182-a · Cited by 230 · see citing works
Economic evaluation of back pain interventions
Goossens, M. E. J. B., & Evers, S. (1997) · Journal of Occupational Rehabilitation · doi:10.1007/bf02765873 · Cited by 53 · see citing works
Waddell (1998). The back pain revolution. Churchill Livingstone.
van vanBurken (2000) · FysioPraxis · Cited by 50 · see citing works
Chronic Back Pain: Integrating Psychological and Physical Therapy—An Overview
Linton, S. J. (1994) · Behavioral Medicine · doi:10.1080/08964289.1994.9934623 · Cited by 41 · see citing works
Self-citation(2006) · Springer eBooks · doi:10.1007/978-3-540-29805-2_4377 · Cited by 15 · see citing works
Flagged first, then by citations
Cited by
Sorted by citations
Persistent postsurgical pain: risk factors and prevention
Kehlet, H., Jensen, T. S., & Woolf, C. J. (2006) · The Lancet · doi:10.1016/s0140-6736(06)68700-x · Cited by 4,086 · see citing works
The fear-avoidance model of musculoskeletal pain: Current state of scientific evidence
Leeuw, M., Goossens, M. E. J. B., Linton, S. J., Crombez, G., Boersma, K., & Vlaeyen, J. W. S. (2007) · Journal of Behavioral Medicine · doi:10.1007/s10865-006-9085-0 · Cited by 2,261 · see citing works
Self-citationPsychological aspects of persistent pain: Current state of the science
Keefe, F. J., Rumble, M. E., Scipio, C. D., Giordano, L. A., & Perri, L. M. (2004) · The Journal of Pain · doi:10.1016/j.jpain.2004.02.576 · Cited by 897 · see citing works
Complex Regional Pain Syndrome: Practical Diagnostic and Treatment Guidelines, 4th Edition
Harden, R. N., Oaklander, A. L., Burton, A. W., Perez, R. S. G. M., Richardson, K., Swan, M., Barthel, J., Costa, B., Graciosa, J. R., & Bruehl, S. (2013) · Pain Medicine · doi:10.1111/pme.12033 · Cited by 534 · see citing works
Leeuw, M., Goossens, M. E. J. B., van Breukelen, G. J. P., de Jong, J. R., Heuts, P. H. T. G., Smeets, R. J. E. M., Köke, A. J. A., & Vlaeyen, J. W. S. (2008) · Pain · doi:10.1016/j.pain.2007.12.009 · Cited by 393 · see citing works
Self-citationFrench, D. J., France, C. R., Vigneau, F., French, J. A., & Evans, T. R. (2006) · Pain · doi:10.1016/j.pain.2006.07.016 · Cited by 342 · see citing works
Woods, M. P., & Asmundson, G. J. G. (2008) · Pain · doi:10.1016/j.pain.2007.06.037 · Cited by 280 · see citing works
Screening to Identify Patients at Risk
Boersma, K., & Linton, S. J. (2004) · Clinical Journal of Pain · doi:10.1097/00002508-200501000-00005 · Cited by 237 · see citing works
Self-citationBoersma, K., Linton, S., Overmeer, T., Jansson, M., Vlaeyen, J., & de Jong, J. (2004) · Pain · doi:10.1016/j.pain.2003.03.001 · Cited by 228 · see citing works
Self-citationPain-Related Fear: A Critical Review of the Related Measures
Lundberg, M., Grimby‐Ekman, A., Verbunt, J., & Simmonds, M. J. (2011) · Pain Research and Treatment · doi:10.1155/2011/494196 · Cited by 205 · see citing works
Graded Activity and Graded Exposure for Persistent Nonspecific Low Back Pain: A Systematic Review
Macedo, L. G., Smeets, R., Maher, C. G., Latimer, J., & McAuley, J. H. (2010) · Physical Therapy · doi:10.2522/ptj.20090303 · Cited by 190 · see citing works
Leeuw, M., Goossens, M. E. J. B., van Breukelen, G., Boersma, K., & Vlaeyen, J. W. S. (2007) · Journal of Pain · doi:10.1016/j.jpain.2007.05.013 · Cited by 174 · see citing works
Self-citationSwinkels-Meewisse, I., Roelofs, J., Schouten, E. G. W., Verbeek, A. L. M., Oostendorp, R. A. B., & Vlaeyen, J. W. S. (2006) · Spine · doi:10.1097/01.brs.0000203709.65384.9d · Cited by 170 · see citing works
Self-citationLinton, S. J., Boersma, K., Jansson, M., Overmeer, T., Lindblom, K., & Vlaeyen, J. W. S. (2008) · European Journal of Pain · doi:10.1016/j.ejpain.2007.11.001 · Cited by 156 · see citing works
Self-citationMcWilliams, L. A., & Asmundson, G. J. G. (2007) · Pain · doi:10.1016/j.pain.2006.07.020 · Cited by 135 · see citing works
Fear reduction in patients with chronic pain: a learning theory perspective
den Hollander, M., de Jong, J. D., Volders, S., Goossens, M., Smeets, R., & Vlaeyen, J. (2010) · Expert Review of Neurotherapeutics · doi:10.1586/ern.10.115 · Cited by 102 · see citing works
Self-citationWicksell, R. K., Dahl, J., Magnusson, B., & Olsson, G. L. (2005) · Cognitive and Behavioral Practice · doi:10.1016/s1077-7229(05)80069-0 · Cited by 95 · see citing works
Basler, H.-D., Luckmann, J., Wolf, U., & Quint, S. (2008) · Clinical Journal of Pain · doi:10.1097/ajp.0b013e31816b54f6 · Cited by 79 · see citing works
Trost, Z., France, C. R., & Thomas, J. S. (2009) · Pain · doi:10.1016/j.pain.2008.11.016 · Cited by 76 · see citing works
On what patients does the Tampa Scale for Kinesiophobia fit?
Lundberg, M., STYF, J. R., & Jansson, B. (2009) · Physiotherapy Theory and Practice · doi:10.1080/09593980802662160 · Cited by 71 · see citing works
Craig, K. D. (2006) · Elsevier eBooks · doi:10.1016/b0-443-07287-6/50019-9 · Cited by 69 · see citing works
Trost, Z., France, C. R., & Thomas, J. S. (2007) · Pain · doi:10.1016/j.pain.2007.08.005 · Cited by 63 · see citing works
The relationship between the Tampa Scale of Kinesiophobia and low back pain rehabilitation outcomes
Gregg, C. D., McIntosh, G., Hall, H., Watson, H., Williams, D., & Hoffman, C. (2015) · The Spine Journal · doi:10.1016/j.spinee.2015.08.018 · Cited by 62 · see citing works
Meulders, A., & Vlaeyen, J. W. S. (2012) · Pain · doi:10.1016/j.pain.2012.04.013 · Cited by 59 · see citing works
Self-citationAlbaret, M., Sastre, M. T. M., Cottencin, A., & Mullet, É. (2003) · European Journal of Pain · doi:10.1016/j.ejpain.2003.09.005 · Cited by 58 · see citing works
Flink, I. K., Nicholas, M. K., Boersma, K., & Linton, S. J. (2009) · Behaviour Research and Therapy · doi:10.1016/j.brat.2009.05.003 · Cited by 52 · see citing works
Self-citationMeulders, A., Meulders, M., & Vlaeyen, J. W. S. (2014) · The Journal of Pain · doi:10.1016/j.jpain.2014.02.009 · Cited by 48 · see citing works
Self-citationLohnberg, J. A. (2007) · Journal of Clinical Psychology in Medical Settings · doi:10.1007/s10880-007-9062-y · Cited by 46 · see citing works
Flink, I. K., Boersma, K., & Linton, S. J. (2010) · European Journal of Pain · doi:10.1016/j.ejpain.2010.02.003 · Cited by 39 · see citing works
Self-citationMultidimensional Prognostic Modelling in People With Chronic Axial Low Back Pain
Rabey, M. I., Smith, A. J., Beales, D. J., Slater, H., & O’Sullivan, P. (2017) · Clinical Journal of Pain · doi:10.1097/ajp.0000000000000478 · Cited by 31 · see citing works
Ryum, T., & Stiles, T. C. (2023) · PAIN Reports · doi:10.1097/pr9.0000000000001092 · Cited by 28 · see citing works
Pain psychology in the 21st century: lessons learned and moving forward
Flink, I. K., Rème, S. E., Jacobsen, H. B., Glombiewski, J. A., Vlaeyen, J. W. S., Nicholas, M. K., Main, C. J., Peters, M. L., Williams, A. C. D. C., Schrooten, M. G. S., et al. (2020) · Scandinavian Journal of Pain · doi:10.1515/sjpain-2019-0180 · Cited by 26 · see citing works
Self-citationFear of pain associated with medical procedures and illnesses
Sastre, M. T. M., Albaret, M., Raich, R. M., & Mullet, É. (2005) · European Journal of Pain · doi:10.1016/j.ejpain.2005.01.009 · Cited by 20 · see citing works
Post-trauma and postoperative painful neuropathy
da Fonseca, P. R. B., Gatto, B. E. O., & Tondato, V. A. (2016) · Revista Dor · doi:10.5935/1806-0013.20160050 · Cited by 18 · see citing works
AMIKA: Ältere Menschen in körperlicher Aktion
Quint, S., Luckmann, J., Wolf, U., & Basler, H.-D. (2007) · Der Schmerz · doi:10.1007/s00482-007-0531-x · Cited by 13 · see citing works
Meulders, A., Rousseau, A., & Vlaeyen, J. W. S. (2015) · Journal of Experimental Psychopathology · doi:10.5127/jep.043614 · Cited by 12 · see citing works
Self-citationFear Avoidance Beliefs und Funktion bei älteren Personen mit chronischem Rückenschmerz
Basler, H. ‐., Quint, S., & Wolf, U. (2005) · Der Schmerz · doi:10.1007/s00482-005-0418-7 · Cited by 8 · see citing works
Successful Self-Treatment of a Case of Writer's Block
Carlbring, P., & Andersson, G. (2011) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2010.549791 · Cited by 6 · see citing works
Fear of movement in patients after anterior cruciate ligament reconstruction
Clifford, A. M., Buckley, E., O’Farrell, D., Louw, Q. A., & Moloney, C. (2017) · Physiotherapy Practice and Research · doi:10.3233/ppr-170098 · Cited by 5 · see citing works
Ryum, T., Hartmann, H., Borchgrevink, P. C., Ridder, K. D., & Stiles, T. C. (2020) · European Journal of Pain · doi:10.1002/ejp.1659 · Cited by 5 · see citing works
Early Interventions for “At Risk” Patients with Spinal Pain
Linton, S. J. (2006) · Springer eBooks · doi:10.1007/0-387-28919-4_25 · Cited by 4 · see citing works
Self-citationExposure-based Interventions for Chronic Pain and Bodily Symptoms: A Special Interest Meeting Report
Schemer, L., Glogan, E., Sjouwerman, R., Ahm, R., Ashar, Y. K., Boddez, Y., Boersma, K., Cañeiro, J. P., Cima, R. F. F., den Hollander, M., et al. (2026) · Behaviour Research and Therapy · doi:10.1016/j.brat.2026.104998 · Cited by 3 · see citing works
Self-citationMendis, V. (2009) · Sri Lankan Journal of Anaesthesiology · doi:10.4038/slja.v16i2.360 · Cited by 3 · see citing works
Psychological Co-morbidities in Patients with Pain
Dorsten, B. V., & Weisberg, J. N. (2011) · Springer eBooks · doi:10.1007/978-1-4419-0029-6_7 · Cited by 3 · see citing works
Pain Syndromes Associated with Cancer Therapy
Cascella, M., Cuomo, A., & Viscardi, D. (2016) · Springer eBooks · doi:10.1007/978-3-319-33587-2_3 · Cited by 2 · see citing works
Interdisciplinary Management/Functional Restoration
Harden, R. N. (2006) · Journal of Neuropathic Pain & Symptom Palliation · doi:10.1300/j426v02n03_12 · Cited by 1 · see citing works
INTERDISCIPLINARY MANAGEMENT FOR COMPLEX REGIONAL PAIN SYNDROME
Harden, R. N. (2009) · Elsevier eBooks · doi:10.1016/b978-1-4160-4836-7.00041-9 · Cited by 1 · see citing works
Volders, S., Leeuw, M., Vlaeyen, J. W. S., & Crombez, G. (2013) · Springer eBooks · doi:10.1007/978-3-642-28753-4_1126 · Cited by 1 · see citing works
Self-citationRitter, N. W. (2014) · Unitec Research Bank (Unitec Institute of Technology) · Cited by 1 · see citing works
Exploring exposure in vivo in chronic pain
de Jong, J. R. (2010) · doi:10.26481/dis.20101125jj
SJUKGYMNASTIK SOM BEHANDLING VID LÄNDRYGGSDISKBRÅCK
Yusuf, A. (2013)
A novel multidisciplinary approach to the treatment of chronic pain
Shertzer, E. L. (2004) · The Mathematics Enthusiast
Hartzell, M. M. (2015) · UTA ResearchCommons (University of Texas Arlington)
Craig, K. D. (2007) · Elsevier eBooks · doi:10.1016/b978-84-8174-949-6.50014-9
(2013) · Wiley eBooks · doi:10.1002/9781118783009.refs
Stubbs, C., Auliffe, S. M., Walsh, C. B., Chimenti, R. L., Mest, J., O'Sullivan, K., van den Akker‐Scheek, I., & Malliaras, P. (2026) · Musculoskeletal Science and Practice · doi:10.1016/j.msksp.2026.103564
Applications of exposure techniques in behavioral medicine
Hoodin, F., & Gillis, M. A. (2007) · Elsevier eBooks · doi:10.1016/b978-012587421-2/50013-2
- Authors
- Linton, S. J., Overmeer, T., Janson, M., Vlaeyen, J. W. S., & de Jong, J. R.
- Venue
- Cognitive Behaviour Therapy
- Publisher
- Informa UK Limited
- Published
- 2002-01
- Volume
- 31
- Issue
- 2
- Pages
- 49-58
- ISSN
- 1650-6073 (ISSN-L)
- 1651-2316
- OpenAlex
- W2076930563
- Cited by
- 59
- References
- 18
- Citations by year
- 2026: 2 · 2023: 1 · 2020: 2 · 2017: 2 · 2016: 2 · 2015: 3 · 2014: 2 · 2013: 4 · 2012: 1
- FWCI
- 1.61
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Cognitive Behaviour Therapy (publishedVersion)
- Topics
- Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Treatment
- Keywords
- fear avoidance, chronic back pain, functional disability, kinesiophobia, avoidance behavior
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
