A randomized controlled trial of exposure in vivo for patients with spinal pain reporting fear of work-related activities


The complex question of whether to integrate experimental therapeutic interventions into daily clinical practice is one that has caught many therapists out. A case in point is the use of laterality and visualised movements for CRPS where, in one clinic, it was found that of the 10 participants recruited, only 4 had actually adhered to the treatment protocol, none of these demonstrated changes to their function or reported pain.

A treatment with more experimental support than laterality training for CRPS is graded exposure for pain-related anxiety and fear in people with low back pain.

This study by Linton, et al. (2008), is an excellent example of how careful description of process and equally careful monitoring and measurement can provide insights into how to transfer promising experimental findings into clinical practice. As the authors state: “Pain-related fear is a key factor in the perpetuation of back pain disability for a subgroup of patients with work-related pain problems (Asmundson et al., 2004; Leeuw et al., in press; Vlaeyen and Linton, 2000).” Previous studies by Vlaeyen and others have demonstrated the effectiveness of an exposure-based approach to reduce the fear and disability experienced by people scoring above >35 on the TSK (Boersma et al., 2004; de Jong et al., 2005a,b; Linton et al., 2002; Vlaeyen et al., 2001). The process involves assessing specific activities that the individual identifies as causing concern using the PHODA Photograph Series of Daily Activities (PHODA) (Kugler et al., 1999), developing a graded hierarchy of activities, then working through this hierarchy until the individual no longer experiences concern at these activities.

This study extends the research by employing a randomised controlled trial, with waitlist control group, and treatment as usual carried out at the same time as the graded exposure. Treatment as usual consisted of medication, contact with the GP and physiotherapy (the content of physiotherapy was not specified). Quite stringent criteria were used for inclusion, leading to a small treatment group (46 out of 223 potential participants), and a high drop-out rate also influenced results although this was controlled for using intention to treat methodology. The drop-out rate is similar to that found in other exposure-based treatments for other disorders (eg OCD), and probably reflects the difficulty of the task – facing very real fears is never easy!

Something that this study included that other exposure-based studies have not, is attention to work-specific concerns. The basis for this is that many people with ongoing disability report their fear of being able to sustain activities at work, while they may continue to participate in home-based activities. The study does not specify the type of work these participants were engaged in, which is a short-coming, and the authors say ‘Because this study was not specifically designed to assess fear of work movements, future studies will be needed to ascertain whether fear may be specific to work movements as well as whether the addition of exposure for work movements/situations is of real value.’ The PHODA does not identify work-specific activities, but instead uses a range of daily home and community-based activities, and I can envisage some challenges in developing a research appropriate work task assessment tool similar to the PHODA simply because of the wide range of work activities. Phobia’s are incredibly personal, unique and specific fears, and stimuli for eliciting fear need to be just as unique, which will be a challenge for research. In my practice, photographs or video of the actual workplace has been used, which provides some degree of authenticity to the initial stimulus.

The results? Overall, it was found that exposure therapy did have an effect, but given both the limitations of a waitlist design, and the relatively high threshold for inclusion, it may be difficult to justify exposure therapy as a standalone treatment. It seems to have effect when included with treatments addressing family, employer, cognitive beliefs and other work rehabilitation barriers, alongside functional activity.

Perhaps, when occupational therapists and psychologists start to talk to each other, and trust each others clinical skills, both they and physiotherapists may be able to develop treatment protocols to help transfer exposure therapy into settings such as work – although I value the work of therapy in clinic, it seems that with treatment of phobia, it’s not enough to do this only in a clinic setting and the ‘real life’ setting of work, home and the community needs to be used as an integral part of therapy.

Asmundson GJ, Vlaeyen JWS, Crombez G. Understanding and treating fear of pain. Oxford, England: Oxford University Press; 2004.

Boersma K, Linton SJ, Overmeer T, Janson M, Vlaeyen JWS, de Jong. 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.

de Jong JR, Vlaeyen JW, Onghena P, Cuypers C, den Hollander M, uijgrok J. Reduction of pain-related fear in complex regional pain syndrome type I: the application of graded exposure in vivo. Pain 2005a;116:264–75.

de Jong JR, Vlaeyen JW, Onghena P, Goossens ME, Geilen M, Tulder H. Fear of movement/(re)injury in chronic low back pain:education or exposure in vivo as mediator to fear reduction? Clin J Pain 2005b;21:9–17.

Kugler K, Wijn J, Geilen M, de Jong J, Vlaeyen JWS. The photograph series of daily activities (PHODA). The Netherlands: Heerlen; 1999.

Vlaeyen JWS, de Jong J, Geilen M, Heuts PHTG, van Breukelen G.Graded exposure in vivo in the treatment of pain-related fear: a replicated single-case experimental design in four patients with chronic low back pain. Behav Res Ther 2001;39:151–66.

Vlaeyen JWS, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain


LINTON, S. (2007). A randomized controlled trial of exposure in vivo for patients with spinal pain reporting fear of work-related activities. European Journal of Pain DOI: 10.1016/j.ejpain.2007.11.001


  1. Hi there, I’ll post on this in a day or so – CRPS is a complex condition and the treatments need to be tailored for each person.
    The graded exposure approach follows a very similar approach to that for low back pain – start with activities that the individual is only slightly fearful of, develop active coping strategies to enable approaching the stimulus activity, engage with the stimulus, then monitor the level of distress. Essentially you’re working to disprove the person’s hypothesis that encountering the activity will harm them, while not increasing their distress to a point where they can’t engage with the activity at all.
    The study by Vlaeyen et al followed this approach, and monitored both fearfulness and pain intensity – and both ratings reduced after exposure therapy, even though pain intensity was never directly addressed.
    But – more on this another day! Keep tuned!

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