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Pain exposure therapy – what is it?

Thanks to an enquiry on my About page, I’ve been prompted to read a little about pain exposure therapy. This is a little-known approach to helping people with CRPS type I (the type that is NOT associated with a peripheral nerve injury. Type II is the same phenomenon but IS associated with an injury to the nerve.)

Graded exposure is an approach commonly adopted to help those people who are afraid of, or phobic about, a “thing”. Most of us will know about spider phobia treatment where people are progressively encouraged to stay with feelings of anxiety and distress while being shown and eventually handling a spider. Graded exposure has also been used to help people who are fearful of experiencing painful flare-ups and therefore avoid doing things – it’s been a successful approach especially for people who report high levels of pain catastrophising (or, as I like to put it, “freaking out” at fluctuations in pain). I’ve reported on graded exposure several times in my blog over the years, and use the approach myself with great success. BUT this approach requires some foundation skills for both the clinician AND the person living with pain.

Before I delve into the skills I think clinicians and people living with pain need, let me outline the treatment and it’s rationale.

The basis for this treatment is the idea that if pain is going to be present, and it no longer represents an indication of the state of the tissues, then avoiding movements is no longer necessary for tissue healing. At the same time, people generally don’t want to do things that flare pain up, and so they tend to avoid those movements. The issue is then much more about how to gradually get used to the fluctuations in pain (ie freak out less) while at the same time beginning to do things with the painful limb. Supporting this approach is some basic science that suggests the less we use an area of our body, the more distorted our brain’s representation of that area becomes.

So, after discussing basic information about pain and tissues, in pain exposure therapy, clinicians work together with the person living with pain to:

  • begin doing movements that are usually avoided
  • avoid responding to any behaviour that is usually associated with experiencing pain – things like grimacing, groaning, saying ouch, and rubbing the area
  • provide progressively more demanding input to the painful area despite changes in reported pain
  • encourage increased normal use of the area within daily life – eg holding onto bottles, cups, utensils, putting shoes and sox on, walking normally

In addition, clinicians use this type of therapy also prescribe many exercises to be carried out frequently through the day despite painful flareups. Sometimes clinicians will restrain the other unaffected limb so that the painful limb HAS to be used just to get things done.

Some of you reading this blog will be reminded of the work by Doidge in which a very similar approach is used during rehabilitation from stroke or traumatic brain injury – by using the limbs in a normal way, new neuronal pathways are developed, allowing the limb to eventually return to pretty much normal function.

Others of you will probably be saying “how cruel!” and “but Moseley and Butler say don’t do things that increase pain because – neurotags!”

Here’s my take on it.

Currently there exist very few, if any, randomised controlled trials of this approach for CRPS I. Actually, there are few RCTs for ANY form of CRPS and ANY treatment for CRPS.

This means we don’t have a great deal of evidence to go on when trying to decide the best approach for managing the functional problems experienced by people living with CRPS. We know that for some people mirror therapy is helpful, while there is less support for graded motor imagery (Bowering, O’Connel, Tabor, Catley et al, 2013).  We know there are very few pharmaceuticals that provide any pain reduction for people living with CRPS. There is “low quality evidence that bisphosphonates, calcitonin or a daily course of intravenous ketamine may be effective for pain when compared with placebo” (O’Connell, Benedict, McAuley, Marston et al, 2013), but otherwise very little else has been shown to have any effect at all either on pain intensity or function.

We do know that physiotherapy and occupational therapy focusing on function rather than pain reduction may have some longterm positive effects (O’Connell, Benedict, McAuley, Marston et al, 2013), and we also know that graded exposure treatments for other types of pain problem, especially low back pain, have been effective (studied since 2001).

BUT here’s the thing. Unless the person living with chronic pain is comfortable with the idea that this approach directly confronts their fear of painful flare-ups, it’s just not going to float. Both the clinician and the person living with pain need to understand the underlying principles of this approach – and have some skills to deal with the very likely distress that will emerge when pain inevitably flares up.

What we should also know is that this approach does not try to reduce pain – although for many people, according to one study (Barnhoorn, Oostendorp, van Dongen et al, 2012) pain does reduce. Yet for others, pain increases – but people can do more.

Where do I stand on this?

I think it’s worth a try but only if the person conducting the therapy is VERY comfortable with the underlying principles of graded exposure as it’s used for phobia. AND has skills to manage their own discomfort at seeing someone else experiencing high levels of distress. To me this means having had some additional training in graded exposure for phobia, and lots of practice at using mindfulness and other forms of maintaining empathy despite seeing another person being distressed. It’s not easy to be empathic without either losing your own cool – or “giving in” to the distress of the person – and that just undoes the therapy.

It also means the person participating in the therapy, ie the patient, must be completely on board with it, and not just the person but also his/her healthcare team AND family. AND have some skills to deal with distress that comes with exacerbations of pain. This approach is not for the faint-hearted, or for anyone who feels coerced into participating in the treatment without feeling very confident that they can maintain their involvement.


Barnhoorn, K. J., van de Meent, H., van Dongen, R. T. M., Klomp, F. P., Groenewoud, H., Samwel, H., . . . Staal, J. B. (2015). Pain exposure physical therapy (pept) compared to conventional treatment in complex regional pain syndrome type 1: A randomised controlled trial. BMJ Open, 5(12), e008283. doi:10.1136/bmjopen-2015-008283

Barnhoorn, K. J., Oostendorp, R. A., van Dongen, R. T., Klomp, F. P., Samwel, H., van der Wilt, G. J., . . . Frolke, J. P. (2012). The effectiveness and cost evaluation of pain exposure physical therapy and conventional therapy in patients with complex regional pain syndrome type 1. Rationale and design of a randomized controlled trial. BMC Musculoskeletal Disorders, 13, 58.

Barnhoorn, K. J., Staal, J. B., van Dongen, R. T., Frolke, J. P., Klomp, F. P., van de Meent, H., . . . Nijhuis-van der Sanden, M. W. (2014). Are pain-related fears mediators for reducing disability and pain in patients with complex regional pain syndrome type 1? An explorative analysis on pain exposure physical therapy. PLoS ONE [Electronic Resource], 10(4), e0123008

Bowering, K. J., O’Connell, N. E., Tabor, A., Catley, M. J., Leake, H. B., Moseley, G. L., & Stanton, T. R. (2013). The effects of graded motor imagery and its components on chronic pain: A systematic review and meta-analysis. Journal of Pain, 14(1), 3-13

Ek, J. W., van Gijn, J. C., Samwel, H., van Egmond, J., Klomp, F. P., & van Dongen, R. T. (2009). Pain exposure physical therapy may be a safe and effective treatment for longstanding complex regional pain syndrome type 1: A case series. Clinical Rehabilitation, 23(12), 1059-1066.

O’Connell Neil, E., Wand Benedict, M., McAuley, J., Marston, L., & Moseley, G. L. (2013). Interventions for treating pain and disability in adults with complex regional pain syndrome- an overview of systematic reviews. Cochrane Database of Systematic Reviews, (4).

van de Meent, H., Oerlemans, M., Bruggeman, A., Klomp, F., van Dongen, R., Oostendorp, R., & Frolke, J. P. (2011). Safety of “pain exposure” physical therapy in patients with complex regional pain syndrome type 1. Pain, 152(6), 1431-1438.


  1. Firstly, thank you for sharing this. It was a great article, and I don’t see enough pieces like these. You wrote an excellent comprehensive piece which I appreciate during a time that we don’t have enough people considering alternative, controversial approaches to pain management.
    I have mixed feelings about this as a patient.
    It reminds me of those who do CBT/exposure therapy to treat their OCD. Except with chronic pain, as you said, the pain may not subside in time, and may actually flare every time due to the exposures.
    To me, this is an extreme version of something physical therapists already do commonly for CRPS with graded desensitization. Incorporating some level of exposure into physical therapy and behavioral therapy desensitizes over time, and that can help increase functioning. I’ll be sharing this. Thank you very much!

    1. Unfortunately there’s nothing that is really convincing at this stage. Lots of things seem to help some people some of the time with small effects, but nothing stands out as being The Treatment. Sad isn’t it.

  2. I have had RSD/CRPS for over 10 years now. Please don’t take this as critisism at all, it’s not meant to be. First off, you have CRPS I and CRPS II reversed: CRPS I is NOT associated with a nerve injury where as CRPS II IS and vica versa. Secondly, I have been to see one of the TOP RSD Dr’s in the country, Dr. Pradeep Chopra, (you can google his name) he also has people from around the world come to the USA for consultations. He offers many different treatment plans as individual as each person is because we all know that what works for some may not work for others. He has been doing extensive research on CRPS for over 10 years now. I just want to say that I saw dr Chopra, back in 2005, when I was first diagnosed with RSD. At that time he used blocks and believed in desentization. Now, after all of his research, which is ongoing, he has found that not only do their RISKS outweigh their benefits, that they are ineffective and they can actually cause more harm and spreading of RSD. This also includes spinal cord stimulaters. He is not against pt, in fact he believes it is important. But pt should ONLY be “pain focused” i.e., Excersize only up to the pain level, NOT above it. You do NOT demand more input despite Flare ups of pain. We RSDers need to LISTEN to our bodies. The saying “no pain, no gain” is the complete opposite for RSD. Also he says to “”AVOID ALL therapies that involve electrical stimulation, other than a TENS unit””. Why stimulate nerves that are already overstimulated to begin with. He does suggest ‘Mirror’ therapy and a TRIAL of Graded Motor Imagery, which you mentioned,. He has also found that BENEFITS of ketamine infusions far out weigh the risks in fact it has been shown to be very effective. Again, what works for some may not work for others. Many of the techniques may work for other types of pain issues, such as those you mentioned, but should NOT be used for people with RSD/CRPS. According to the McGil pain index RSD/CRPS is the MOST painful condition there is. As far as grimacing, saying ouch, etc. we try very hard to avoid those words. If anything we try to hide our pain from others. Unless someone suffers from this horrible disease they have no clue how painful it is. And how we struggle, one day at a time, to have somewhat of a normal existence.
    Thank you for sharing your thoughts

    1. Hi Liane
      Thanks for pointing that error out – now corrected! My bad.
      I do know about the alternative approach to CRPS which is the “avoid stirring up a sensitised system” or avoid painful movements – that’s the key difference between the approach I’ve described in this post, and other approaches espoused by researchers like Moseley. As I don’t have CRPS I can only report what the studies show – and this seems to show equal results from either approach (see the first study listed in my references). I’m more familiar with the Moseley approach, because that’s what has been used in the center where I’ve worked. In previous clinical settings I have used the pain exposure approach but more for typical neuropathic pain rather than CRPS. At this stage I don’t think we can argue that one approach is better than another – it’s certainly a complex problem with many different factors contributing to the situation. What does seem important, and one point I hope I made, is that the person living with chronic pain feels confidence in the approach being taken, and is fully on board what whatever is being recommended.
      I also know that many people living with chronic pain (and I’m one of them – I have fibromyalgia) do restrain themselves from demonstrating pain behaviour. This can work against us! But in this case, the approach deliberately and explicitly makes pain behaviour a focus of therapy. Don’t shoot the messenger! And I know you weren’t – but this is the approach taken in pain exposure treatment. I’ve used this approach (graded exposure) for other types of pain problems and it has been really successful – but as I say, it HAS to be done with the consent and agreement of the person living with pain. BTW I don’t know how to compare different types of pain – they all have qualities that make life difficult at times, and I don’t think it’s helpful to try to argue that one kind of pain is worse or better than another. They can all be disabling, distressing – and they’re all pretty much invisible.
      Thanks for taking the time to respond to my post and thanks for the correction,

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