The treatment of fear of movement/(re) injury in chronic low back pain: further evidence on the effectiveness of exposure in vivo
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BACKGROUND AND OBJECTIVE: Several cognitive-behavioral factors contribute to the persistence of pain disability in patients with chronic back pain. Fear-avoidance beliefs and fear of movement/(re)injury in particular have been shown to be strong predictors of physical performance and pain disability. Patients reporting substantial pain-related fear might benefit from exposure in vivo to a set of individually tailored, fear-eliciting, and hierarchically ordered physical movements rather than more general graded activity. PATIENTS AND INTERVENTIONS: Six consecutive patients with chronic low back pain who reported substantial fear of movement/(re)injury were included in the study. After a no-treatment baseline measurement period, the patients were randomly assigned to one of two interventions. In the first intervention, patients received exposure in vivo first, followed by graded activity. In the second intervention, the sequence of treatment modules was reversed. Before each treatment module, treatment credibility was assessed. Daily measures of pain-related fear, pain catastrophizing, and pain intensity were completed using visual analog scales. In addition, standardized measures of pain disability, pain-related fear, and pain vigilance were taken before and after each treatment module and at the 1-year follow-up. To obtain more objective data on actual activity levels, an ambulatory activity monitor was carried by the patients during 1 week before and after each treatment module. RESULTS: Time series analysis of the daily measures showed that improvements in pain-related fear and pain catastrophizing occurred only during the exposure in vivo and not during the graded activity, irrespective of the treatment order. Analysis of the pretreatment to post-treatment differences also revealed that decreases in pain-related fear also concurred with decreases in pain disability and pain vigilance and an increase in physical activity levels. All improvements remained at the 1-year follow-up.
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In studies of graded in vivo exposure for chronic low back pain, all 10 patients exhibited very high levels of fear of movement and reinjury before intervention.
“All 10 patients with chronic low back pain who participated in these studies exhibited very high levels of fear of movement and reinjury before intervention.”
From Psychological aspects of persistent pain: Current state of the science (2004) · cites this paper as [141]
The Participants section reports that six patients with chronic low back pain entered this study with substantial fear of movement or reinjury. The Discussion also says the study included only six patients. Our copy therefore supports the pretreatment fear finding for those six, but does not establish that all 10 patients across the studies had very high fear levels. (LLM, conf=0.86)
Experimental — accuracy not yet measuredResults indicated that whenever graded exposure was introduced, patients exhibited substantial improvements in pain-related fear, disability, and activity level.
“Results indicated that whenever graded exposure was introduced, patients exhibited substantial improvements in pain-related fear, disability, and activity level.”
From Psychological aspects of persistent pain: Current state of the science (2004) · cites this paper as [141]
These improvements were maintained during the activation intervention.
“These results were maintained during the activation intervention.”
From Psychological aspects of persistent pain: Current state of the science (2004) · cites this paper as [141]
Kinesiophobia is a strong predictor for long-term pain disability and pain chronicity, and is associated with higher rates of sick leave, pain vigilance, disability, and decreased physical activity.
“It has been demonstrated that kinesiophobia has shown to be a strong predictor for pain disability and pain chronicity in the longer term [73] associated with higher rates of sick-leaves [74], pain vigilance and disability as well as decreased physical activity levels [75–77].”
From Chronic pain and sex-differences; women accept and move, while men feel blue (2017) · cites this paper as [77]
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- Authors
- Vlaeyen, J. W. S., de Jong, J., Geilen, M., Heuts, P. H. T. G., & van Breukelen, G.
- Affiliations
- Maastricht University (NL)
- Corresponding author
- Vlaeyen, Johan W. S.
- ORCID
- Vlaeyen, Johan W. S.
- Venue
- The Clinical Journal of Pain
- Published
- 2002-07
- Volume
- 18
- Issue
- 4
- Pages
- 251-261
- ISSN
- 0749-8047 (ISSN-L)
- OpenAlex
- W2048514270
- Cited by
- 499
- References
- 53
- Citations by year
- 2026: 8 · 2025: 7 · 2024: 12 · 2023: 9 · 2022: 16 · 2021: 13 · 2020: 18 · 2019: 18 · 2018: 17 · 2017: 27 · 2016: 18 · 2015: 28 · 2014: 18 · 2013: 18 · 2012: 23
- FWCI
- 13.31
- Type
- journal article
- Language
- en
- Open access
- green
- lirias.kuleuven.be
- Licence
- other-oa
- Locations
- Clinical Journal of Pain (publishedVersion)
- PubMed (publishedVersion)
- Lirias (KU Leuven) (submittedVersion, other-oa)
- Funders
- Nederlandse Organisatie voor Wetenschappelijk Onderzoek
- 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, kinesiophobia, fear of reinjury, graded activity, fear-avoidance beliefs, pain catastrophizing, fear of pain, pain-related disability, pain vigilance, physical activity, ambulatory activity monitoring, treatment order
- MeSH terms
- Activities of Daily Living, Adult, Avoidance Learning, Chronic Disease, Desensitization, Psychologic, Disability Evaluation, Fear, Female, Follow-Up Studies, Humans, Male, Middle Aged, Movement, Pain Measurement, Cognitive Behavioral Therapy, Treatment Outcome, Low Back Pain, Cross-Over Studies, Secondary Prevention
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