Exposure in vivo as a treatment approach to target pain-related fear: theory and new insights from research and clinical practice
Open accessAbstract
Pain-related fear (PRF) can be a significant factor contributing to the development and maintenance of pain-related disability in individuals with persistent pain. One treatment approach to target PRF and related avoidance behavior is exposure in vivo (EXP). EXP has a long history in the field of anxiety, a field that is constantly evolving. This Perspective outlines recent theoretical advancements and how they apply to EXP for PRF, including suggestions for how to optimize inhibitory learning during EXP; reviews mechanistic work from neuroimaging supporting the targeting of PRF in people with chronic pain; and focuses on clinical applications of EXP for PRF, as EXP is moving into new directions regarding who is receiving EXP (eg, EXP in chronic secondary pain) and how treatment is provided (EXP in primary care with a crucial role for physical therapists). Considerations are provided regarding challenges, remaining questions, and promising future perspectives. IMPACT: For patients with chronic pain who have elevated pain-related fear (PRF), exposure is the treatment of choice. This Perspective highlights the inhibitory learning approach, summarizes mechanistic work from experimental psychology and neuroimaging regarding PRF in chronic pain, and describes possible clinical applications of EXP in chronic secondary pain as well as in primary care.
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In a feasibility pilot study, participants living with chronic pain rated EPIO as useful, with excellent system usability.
“In accordance with the Medical Research Council framework for complex intervention evaluation,16,57 the EPIO program was tested in a feasibility pilot study, with participants living with chronic pain rating the program as useful, with excellent system usability.10”
From Living well with chronic pain: a 12-month randomized controlled trial revealing impact from the digital pain self-management program EPIO (2024) · cites this paper as [16]
The Clinical Applications and Considerations and Future Directions sections discuss exposure treatment for pain-related fear, including some digital approaches, but do not report an EPIO feasibility pilot. Searches for EPIO, usefulness, and system usability found no passage about participants’ ratings of the program. (LLM, conf=0.75)
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Illusion-enhanced Virtual Reality Exercise for Neck Pain
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Imaging vs quantitative sensory testing to predict chronic pain treatment outcomes
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Brain signatures of threat–safety discrimination in adolescent chronic pain
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Living with painful diabetic neuropathy: insights from focus groups into fears and coping strategies
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Verbunt, J., Nijhuis, A., Vikström, M., Stevens, A., Haga, N., de Jong, J. R., & Goossens, M. E. J. B. (2014) · European Journal of Pain · doi:10.1002/ejp.592 · Cited by 22 · see citing works
Holzapfel, S., Riecke, J., Rief, W., Schneider, J., & Glombiewski, J. A. (2016) · The Clinical Journal of Pain · doi:10.1097/ajp.0000000000000349 · Cited by 21 · see citing works
Timmers, I., de Jong, J. R., Goossens, M. E. J. B., Verbunt, J., Smeets, R., & Kaas, A. L. (2019) · Frontiers in Neuroscience · doi:10.3389/fnins.2019.00970 · Cited by 21 · see citing works
Generalization of exposure in vivo in Complex Regional Pain Syndrome type I
den Hollander, M., de Jong, J. R., Onghena, P., & Vlaeyen, J. W. S. (2019) · Behaviour Research and Therapy · doi:10.1016/j.brat.2019.103511 · Cited by 18 · see citing works
Understanding fear of pain in chronic pain: Interoceptive fear conditioning as a novel approach
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Simons, L. E., Pielech, M., McAvoy, S., Conroy, C., Hogan, M., Verbunt, J. A., & Goossens, M. E. (2017) · Pain · doi:10.1097/j.pain.0000000000000855 · Cited by 14 · see citing works
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Dekker, C., van Haastregt, J. C. M., Verbunt, J., de Jong, J. R., van Meulenbroek, T., Pernot, H., van Velzen, A. D., Bastiaenen, C. H. G., & Goossens, M. E. J. B. (2020) · BMC Health Services Research · doi:10.1186/s12913-020-5053-6 · Cited by 11 · see citing works
van Laake‐Geelen, C. C. M., Smeets, R., Goossens, M. E. J. B., & Verbunt, J. (2021) · Journal of Rehabilitation Medicine – Clinical Communications · doi:10.2340/20030711-1000046 · Cited by 11 · see citing works
Corticolimbic Circuitry in Chronic Pain Tracks Pain Intensity Relief Following Exposure In Vivo
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Matheve, T., Hodges, P. W., & Danneels, L. A. (2023) · Journal of Clinical Medicine · doi:10.3390/jcm12175510 · Cited by 78 · see citing works
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Role of Immersive Virtual Reality in Motor Behaviour Decision-Making in Chronic Pain Patients
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Task-Specific Perceived Harmfulness Predicts Protective Movement Behaviour in Chronic Low Back Pain
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Fear of Movement: Past, Present, and Future for Rehabilitation and Health
Lundberg, M., & Archer, K. R. (2022) · Physical Therapy · doi:10.1093/ptj/pzac007 · Cited by 11 · see citing works
Çalışkan, E., & Gökkaya, F. (2025) · Current Pain and Headache Reports · doi:10.1007/s11916-025-01373-4 · Cited by 10 · see citing works
Key aspects concerning the role of emotion in the chronic pain experience
Boersma, K., & Flink, I. K. (2025) · Current Opinion in Psychology · doi:10.1016/j.copsyc.2025.102000 · Cited by 11 · see citing works
Solberg Nes, L., Børøsund, E., Varsi, C., Eide, H., Waxenberg, L. B., Weiss, K. E., Morrison, E. J., Støle, H. S., Kristjansdottir, Ó. B., Bostrøm, K., et al. (2024) · Pain Reports · doi:10.1097/pr9.0000000000001174 · Cited by 7 · see citing works
“17,18,68 Pain is a subjective phenomenon that can only be assessed through self-report, and a combination of quantitative and qualitative measures might therefore enable more in-depth explorations, as seen through the EPIO feasibility pilot.”
BackgroundGraded-Modelle – eine Einführung
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Maunder, L., Marriott, E. C. S., Katz, J. D., & Salomons, T. V. (2022) · Journal of Military Veteran and Family Health · doi:10.3138/jmvfh-2022-0011 · Cited by 4 · see citing works
Exposure-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
Ummels, D., Cnockaert, E., Timmers, I., den Hollander, M., & Smeets, R. (2023) · JMIR Rehabilitation and Assistive Technologies · doi:10.2196/47541 · Cited by 3 · see citing works
Diemer, F., & Zebisch, J. (2023) · Sportphysio · doi:10.1055/a-2160-8737 · Cited by 3 · see citing works
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Approaching persistent pain and emotion dysregulation
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Bewegungsängste lösen – Expositionstherapie nach VKB-Ruptur
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De patiënt met een vermijdende coping
den Hollander, M., & van Meulenbroek, T. (2026) · doi:10.1007/978-90-368-3246-5_27
De patiënt met secundaire aanhoudende pijn
van Laake‐Geelen, C. C. M., & Hoeijmakers, J. G. J. (2026) · doi:10.1007/978-90-368-3246-5_24
- Authors
- den Hollander, M., Smeets, R. J. E. M., van Meulenbroek, T., van Laake-Geelen, C. C. M., Baadjou, V. A., & Timmers, I.
- Affiliations
- Adelante Centre of Expertise in Rehabilitation and Audiology, Maastricht, the Netherlands
- Maastricht University (NL)
- Venue
- Physical Therapy
- Publisher
- Oxford University Press (OUP)
- Published
- 2022-01-27
- Volume
- 102
- Issue
- 2
- ISSN
- 0031-9023 (ISSN-L)
- 1538-6724
- OpenAlex
- W4206648618
- Cited by
- 30
- References
- 122
- Citations by year
- 2026: 5 · 2025: 6 · 2024: 9 · 2023: 7 · 2022: 3
- FWCI
- 3.74
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model (vor)
- Locations
- Physical Therapy (publishedVersion)
- PubMed (publishedVersion)
- Research Publications (Maastricht University) (publishedVersion, other-oa)
- Research Publications (Maastricht University) (submittedVersion, other-oa)
- Funders
- European Union's Horizon 2020 (841426)
- 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
- fear of pain, chronic pain, inhibitory learning, avoidance behavior, pain-related disability, primary care
- MeSH terms
- Fear, Humans, Implosive Therapy, Phobic Disorders, Psychological Theory, Chronic Pain
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