Graded exposure in the real world

Well, not exactly the real world – yet – just the clinic.

A man I’m working with is very worried about his back.  Some years ago he had a discectomy and his surgeon told him he needed to be ‘very careful’ with his back – and so he has.  No bending, twisting, lifting for this man!  He’s given up some of his favourite things like fishing and whitebaiting and even golf because of this worry, although when I talk things through with him he’s not exactly sure what might happen if he ‘disobeyed’.

Let’s call him Matt for wont of a better name (and yes, as usual, details have been changed to ensure confidentiality), and he’s a fairly ‘blokey’ man who loved his fishing, diving, and taking off for days in his converted bus with his partner.  He’s just recently hurt his knee in a fall, and although the knee has been slow to recover, he’s now on the mend – but his back pain has become much worse.

Matt’s previous back problem involved a large disc prolapse, compression of the nerve root, and radicular pain radiating down his left leg.  After his surgery, the leg pain completely went but as often happens, he was left with slight low back pain.  Matt told me he could usually manage this and it didn’t bother him because he was ‘very careful’ with his back.  When he said ‘very careful’ what he meant was he’d stopped all those things he’d enjoyed and when he got pain he immediately thought of what his surgeon had said, and worried that maybe his back was ‘under stress’ and he might have a recurrence of that pain that he had experienced before.

While his knee is settling down, Matt’s back pain has increased – and to cap it off, he’s now got pain in all his joints.  Matt’s not one to visit the doctor unless he ‘has’ to, and he hasn’t mentioned this widespread pain to his doctor – and his fear was that this pain ‘must be’ rheumatoid arthritis.  He doesn’t have any RA in his family, but his understanding was that RA is something that affects every joint, it’s progressive and certain to mean he will be crippled (his words).

I guess we could say that Matt is a man with health anxiety, and more specifically, pain anxiety – and kinesiophobia.

Matt’s worry about his back pain has lead him to see his GP to get an MRI to ‘find the cause’ of his increased pain, and to ‘get it fixed’.  Unfortunately, even though he hasn’t any specific signs to suggest the need for an MRI, he’s been referred for one (see my previous posts on ‘is reassurance reassuring’!).

I spent a while discussing the possible outcomes of the MRI with Matt.  Maybe there will be a clear anatomical change that will account for his back pain and a clear surgical solution.  Maybe there will be a slight anatomical change but no surgical solution.  Maybe there will be no anatomical change at all.  What will he do?

I should add at this stage that Matt and I spent quite a while with one of our doctors looking at his previous surgery and the possible explanations for his increased back pain.  Even though he had a clear explanation, his questions were answered and he has had a good response to medication suggesting that the pain is most likely due to central sensitisation, Matt is not convinced he should change his practice of avoiding movements involving his back.

At our session, Matt and I discussed the effect of his avoidance strategy.  He’s aware that it’s not working for him, and that it means he has given up many of the things he really enjoys – but at the same time, to him the risk of ‘doing damage’ is far too high. So I suggested to him that we go through a set of photographs (the PHODA) to look at exactly which movements and activities he felt he shouldn’t do – and would avoid.

Together we sorted through the 100 photographs of people doing everyday activities.  He sorted them into two piles – one that he would do reasonably happily, and the other of things he wouldn’t do.  Sixty seven of the photographs were sorted into the pile of things he wouldn’t do. Things like carrying a load of washing, picking up a planter pot, pushing a wheelbarrow, twisting to reach for a book, reaching above his head to retrieve a box from the top shelf…

Things he would do included some activities that looked very similar to the ones he wouldn’t do. For example, he wouldn’t bend over to pick up a pair of shoes from the floor – but he would reach across a bed to pull the duvet up.  He wouldn’t reach across a table to pick up a book, but he would reach forward to prune a rosebush.  In both of these cases the postures he adopted were the same but for Matt, there were clear ‘reasons’ one movement was fine, and another was not.

He and I have agreed to develop a hierarchy of these avoided activities. We’ll put the photographs in order from least bothersome to most avoided.  And we’ve agreed to work through each activity and firstly identify what it is about the activity that concerns Matt.  Then I’ll show him how I’d do the movement, and he will attempt to do it the same way.  I’ll ask him to rate his level of concern out of 10, and to rate the likelihood that what he fears will happen out of 10.  Then he’ll do the movement, and repeat the measures.

What we’re trying to do is test his hypothesis that these movements are going to do what he fears. It seems that although he’s concerned that he might ‘damage’ his back, the cue that he uses is his pain level – and he is not happy about fluctuations in his pain, both because it might mean his back is ‘getting worse’, but also because he is fearful that he won’t be able to ‘handle’ the pain (remember he’s usually a pretty staunch and blokey man).  He’s got a few theories about how his back works, but readily acknowledges that he doesn’t really know all that much about his spine, just what his surgeon has told him.

I’ll keep you updated on Matt’s progress as we work through this exposure activity.  I think this is a great opportunity to help Matt learn both about his body, and that he can cope with fluctuations of pain.  I’ll be listening carefully to what he thinks is going on, so I can set up ‘experiments’ that we can do together (at least initially) to test out whether his hypothesis is correct.  Matt seems satisfied that I’ll be ‘doing the worrying’ for him, and that he’ll be doing the activities in our environment.  My plan is that once we’ve managed it in the clinic, he will feel confident enough to practice the same activity at home.

For some more details on the graded exposure process and the theory behind it, here are several papers:

Wicksell, Rikard K; Ahlqvist, Josefin; Bring, Annika; Melin, Lennart; Olsson, Gunnar L. Can exposure and acceptance strategies improve functioning and life satisfaction in people with chronic pain and whiplash-associated disorders (WAD)? A randomized controlled trial. Cognitive Behaviour Therapy. Vol.37(3), Sep 2008, pp. 1-14.

Linton, Steven J; Boersma, Katja; Jansson, Markus; Overmeer, Thomas; Lindblom, Karin; Vlaeyen, Johan W. S. A randomized controlled trial of exposure in vivo for patients with spinal pain reporting fear of work-related activities. European Journal of Pain. Vol.12(6), Aug 2008, pp. 722-730.
Vlaeyen, Johan W. S; de Jong, Jeroen; Sieben, Judith; Crombez, Geert. Graded exposure in vivo for pain-related fear. Turk, Dennis C [Ed]; Gatchel, Robert J [Ed]. (2002). Psychological approaches to pain management: A practitioner’s handbook (2nd ed.). (pp. 210-233). xviii, 590 pp. New York, NY, US: Guilford Press; US.


  1. Were you lying on the sand or ground on your back to take the photo? The triangle composition works wonderfully.
    And the framing of the feathery elements of the grasses with the sunlight shining through…..aaaah.

    Oh and btw your description with the use of words like “blokey” really had me looking over your shoulder with you and “Matt” at those activity photographs….I look forward to hearing (reading) more.

    1. Hi Bernadette
      Thank you!
      The toitoi are really tall – about 8 – 10 feet tall, so I was looking while standing on my own two feet! They’re gorgeous plants, but probably better in a natural environment than in a home garden IMHO. Luckily these are planted on the golf course nearby and NOT in my garden, my garden being a typical suburban one with not quite enough room. I used to grab the fronds and play spears with them as a kid!
      Yes, Matt’s quite a character in a typical male Kiwi manner – I’ll keep you posted!

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