Fear/Anxiety/Avoidance – treatments review!

For years, clinicians working in pain management have mixed together a rich assortment of strategies to help people function better.  But to identify the ‘active ingredients’ of multidisciplinary pain management using a cognitive behavioural approach, it’s been important to tease each element apart.  One size does not fit all – and just as a physician chooses the most effective medication for a disorder, in time I hope we will be able to choose the most effective strategy for the problems each individual experiences rather than applying our current ‘scatter-gun’ approach.

Yesterday I gave a brief overview of the three main treatments to helping people who are fearful/anxious of their pain (or harm) and avoid activities as a result. They are:

  1. Graded exposure in vivo
  2. Graded activation or reactivation
  3. Acceptance and Commitment Therapy

…and the combined or mixed sort of multi-modality approach used in most settings.

Bailey and colleagues have conducted one of the first reviews to summarise the effectiveness of these treatments.  It’s too soon to carry out a full meta-analysis because so few of the published papers are RCT’s.  After searching the various databases, and personally approaching researchers known to the authors, 17 studies were identified, made up of eight randomized clinical trials (RCTs), eight replicated single-case studies, and one case study.  Over 1200 patients have been involved in these studies, but there was a fairly high drop-out rate in both case studies and RCT’s, and while reasons for drop-out were not given in many cases, in those that were it was found participants thought the treatment was ‘too psychological’ (didn’t give enough of a biomedical explanation for their pain) or weren’t sufficiently motivated to complete.  Of course, I’d suggest that motivation is a case of readiness to engage – and that motivation can be enhanced, but nonetheless, this is what was stated in two of the papers.

The type of patients in terms of age, gender and pain duration were fairly similar in all of these studies (and very similar to the type of patient I see each day).  The participants were attending research-oriented pain management centres, so possibly look a little different from the people seen in community settings, or in primary care.  Their pain was mainly lower back, with a subset having pain from whiplash or similar.

The main treatment outcome measures used were the Tampa Kinesiophobia Scale for most of the studies with the PHODA, or photographs of daily activities being used alongside this for most of the graded exposure studies.  The Roland Disability Questionnaire was the most commonly used disability measure, Beck Depression Inventory the most common depression measure, and Pain Catastrophising Scale and Pain Anxiety Symptoms Scale used for pain-related anxiety.  Only one study used physical performance measures as part of the outcome measurement, and none used individualised or patient-specific goal achievement as a measure.

So, what did they find?

From this set of studies, graded exposure and ACT appear to have the greatest positive effect on disability and reducing fear of pain compared with waitlist groups or graded activation.  Graded exposure was also superior to graded activation for reducing fear of movement, catastrophising and perceived harm, while ACT was demonstrated as effective for reducing pain and disability in all of the studies in which it was used.  Both graded exposure and ACT appear to be effective in addition to ‘treatment as usual’ (participants weren’t asked to refrain from using other treatments), but this finding doesn’t always occur.

Unfortunately, the mixed CBT approaches don’t demonstrate such clear-cut results on catastrophising, fear of movement/reinjury, and disability.  The authors suggest that the mixed protocols probably don’t provide greater effectiveness than waiting list or a combination of cognitive therapy and ‘physical therapy’ (what ever that looks like!).

Graded exposure does seem to offer some advantages over ACT in terms of reducing pain-related catastrophising, and overall require fewer sessions than ACT (at least in these studies) – but there does appear to be a greater chance for people to drop out.

Our problems with this summary are that these are not direct RCT comparisons of different treatments, and because of differences in context, and size of the study groups and different methodology.  And an interesting feature is that most of the graded exposure studies were carried out in Netherlands, Sweden, and the United Kingdom, and only one study was conducted in North America.  This is quite at odds with the majority of studies looking at chronic pain management.  There are considerable differences between these countries and the US in terms of litigation and access to various treatment modalities (particularly psychological treatments).  As the authors say “Potentially more important is that these same countries do not rely on insurance models for psychology-augmented multidisciplinary health care.”

What can we learn from this review?

Rather than suggesting that graded activation shouldn’t be used as widely as it is, I think this review shows that there are at least two other treatment protocols that can be successfully applied to this sub-group of people who are fearful/anxious and avoid activities because of their pain.

There were no generally-applied cut-off scores on, say, TSK or PCS to help clinicians in other settings decide who would best benefit from graded exposure vs a broader approach, which makes it a little difficult to select patients – but my initial thinking is that if you have a person reporting that they avoid activities, particularly if they have specific movements they avoid (like bending or reaching), these people may be candidates for graded exposure.  For people who are basically deactivated and are not avoiding any specific movements, maybe ACT or graded activation could be a better bet.

The question to ask too is, can physiotherapists, occupational therapists and other ‘non-psychologists’ apply these treatments successfully?  My thoughts are that yes, of course – provided that clinicians take the time to learn about the approaches and theoretical basis for conducting them.

My worry is that some of the subtleties of graded exposure especially may not always be picked up by people unfamiliar with the idea of eliciting specific thoughts, beliefs or concerns about a movement – this can lead to inadvertently failing to expose the person to their fear, and potentially incorporating ‘safety behaviours’ into the treatment.  This prevents the patient from learning to manage what they are actually afraid of, and can replace complete avoidance with a set of almost ‘magical’ beliefs – such as using a specific lifting technique to ‘prevent’ damage. More about this aspect tomorrow!

Bailey, K., Carleton, R., Vlaeyen, J., & Asmundson, G. (2010). Treatments Addressing Pain-Related Fear and Anxiety in Patients with Chronic Musculoskeletal Pain: A Preliminary Review Cognitive Behaviour Therapy, 39 (1), 46-63 DOI: 10.1080/16506070902980711


  1. Nice, and rather theatrical in stringing us along a day at a time. I’ll be back!

    I agree that it is necessary to actually understand the theoretical underpinnings to the approaches used, and very important to address the context of the person as well as the specific activity – trading fearful avoidance of lifting for “I can only lift within this specific set of circumstances” or other superstitious practice- that is not good enough for a positive outcome, and likely to perpetuate the problem.

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