graded exposure

Myths about exposure therapy

Exposure therapy is an effective approach for pain-related anxiety, fear and avoidance, but exposure therapy is used less often than other evidence-based treatments, there is a great deal of confusion about graded exposure, and when it is used, it is not always well-conducted. It’s not a treatment to be used by every therapist – some of us need to challenge our own beliefs about pain, and whether it’s OK to go “into” the pain a little, or even slightly increase pain temporarily!

Below are some common misconceptions and suggestions for how to overcome them:

Misconception: Exposure therapy causes clients undue distress and has adverse consequences.

Suggestions: Although exposure therapy can lead to temporary increases in anxiety and pain, it is important to remember that these symptoms are not dangerous, and that exposure is generally carried out in a very gradual and predictable way. Exposure very rarely causes clients harm, but it is important to know your clients’ medical histories. For example, a client with a respiratory condition would not be asked to complete an exposure designed to elicit hyperventilation.

I usually begin with a really clear explanation for using this approach, basing my explanation on what the person has already said to me. By using Socratic or guided discovery, I try to understand the logic behind the person’s fear: what is it the person is most worried about? Often it’s not hurt or harm, it’s worrying that they won’t sleep, or they’ll have a flare-up that will last a looooong time – and they won’t be able to handle it. These are fundamental fears about having pain and vital to work through if the person is going to need to live with persistent pain for any length of time.

Once I’ve understood the person’s reasons for being bothered by the movements and pain, then I work on developing some coping strategies. These must be carefully carried out because it’s so easy to inadvertently coach people into using “safety behaviours” or “cues” that work to limit their contact with the full experience. Things like breath control, positive self-statements, any special ways of moving, or even ways of recovering after completing the task may serve to control or reduce contact with both anxiety and pain. I typically draw on mindfulness because it helps people focus on what IS happening, not what may have happened in the past – or may happen in the future. By really noticing what comes up before, during and after a graded exposure task, and being willing to experience them as they are, people can recognise that anticipating what might happen is often far worse than what does happen.

Finally, I’ll work through the scenario’s – either pictures of movements and activities, or descriptions of the same things. I prefer photographs (based on the Photographs of Daily Activity), because these elicit all the contextual details such as the other people, weather, flooring or surface and so on that are often factors increasing a person’s concerns. We begin with the activity that least bothers the person and consistently work up from there, with practice in the real world between sessions. I’ll go out to the places the person is most concerned about, we’ll do it together at first, then the person can carry on by themselves afterwards.

Misconception: Exposure therapy undermines the therapeutic relationship and leads to high dropout.

Suggestions: If you give your person a clear reason for using this approach and deliver it well,  the person is more likely to achieve success – and this in turn strengthens your relationship. Additionally, there is evidence that dropout rates for exposure are comparable to other treatments.

There is something about achieving a difficult thing that bonds us humans, and if you approach graded exposure with compassion, curiosity, and celebration, you may find your relationship is far more rewarding and deeper than if you simply prescribe the same old same old.

Misconception: Exposure therapy can lead to lawsuits against therapists.

Suggestions: Survey data suggest that lawsuits against therapists using exposure are extremely rare. As with any kind of therapy, you can take several steps to protect yourself from a legal standpoint. Don’t forget to obtain informed consent, ensure your treatment is delivered with competency, professionalism, and ethical consideration.

The best book/resource by far for graded exposure is Pain-Related Fear: Exposure-Based Treatment for Chronic Pain, (click) by Johan W.S. Vlaeyen, Stephen J. Morley, Steven J. Linton, Katja Boersma, and Jeroen de Jong.

Before you begin carrying out this kind of treatment, check you have these skills (from the book I’ve referenced):

Vlaeyen, Johan, Morley, Stephen, Linton, Steven, Boersma, Katja, & de Jong, Jeroen. (2012a). Pain-related Fear. Seattle: IASP Press.

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.

How does it work? Pick your theory

I’m working with a man who has neuropathic pain in his right (dominant) hand.  He developed his pain some 8 years ago after he caught it in a woodworking machine and basically mashed it, damaging most of the carpal tunnel area.  After numerous orthopaedic, and plastic surgical procedures, he’s now left with nasty scarring, and even nastier neuropathic pain with some central sensitisation elements.  While he has almost full range of movement in his wrist and fingers, he rarely uses his hand and instead, cradles it or leaves it sitting half-curled, palm up.

We’ve been working together for a month or so, along with physiotherapy and psychology, and my parts of this programme have been to help him develop a personalised model of the factors that contribute to his pain; help him develop some self regulatory skills particularly to downregulate his very sensitive sympathetic drive; and to start the process of him being mindful of his hand rather than ignoring it or focusing on it.

I’m using a combination of approaches – Socratic questioning and guided discovery to help him develop a better understanding of his pain – particularly focusing on helping him recognise that trying to control his pain through either avoiding the use of his hand, or using distraction is counter-productive.  When he avoids using his hand, he’s either limiting the activities he can get through during the day and gets bored, frustrated and is probably contributing to the pain because his neuromatrix isn’t receiving normal movement patterns.  When he uses distraction, he can almost completely ignore the pain while pushing himself to ‘do everything’ – but then he gets an overwhelming increase in pain when he stops, which is distressing.

We’ve spent quite a while discussing the nature of control – is it pain we’re trying to control? Is it his activities we’re controlling? Is it is thoughts and emotions that we’re controlling?  I’ve been using mindfulness and some of the concepts from ACT and suggesting that try as hard as we might, pain is not something to control, and neither are thoughts or emotions.  In fact it seems the harder we try to control any of these things, the more they dominate and control us!

As a result, much of what I’m working on is helping this guy to non-judgementally regard his body sensations as simply sensations, allowing his attention to go to his hand without trying to ignore it (you can’t!) or to over-attend to it, but simply to notice it.

Taking this a little further, we’ve been working on breathing and mindfully attending to breathing as one way of introducing self regulation. This involves gently guiding his attention to his breath, and just as gently, noticing when his attention drifts away and bringing it back to his breathing.  Not as easy as you’d think!

I’ve been using biofeedback as part of this process because this guy is a practical man.  He’s not one to just accept doing something without having some feedback about what is actually going on.  I’ve used skin conductance, surface EMG, heart rate, respiration rate and skin temperature to monitor his overall arousal level.  He’s aware now that he can influence usually unconscious processes just by breathing or even thinking differently!

Yesterday I took it a little further.  I asked him to look at his painful hand, and simply describe the sensations without judging them.  What this means is he told me about the tingly, burning sensation over his palm, the throbbing aching in his fingers, he noticed where the pain started and stopped on his hand and fingers, the sensation of heat where his fingers touched each other, the sensation of pressure on his forearm where it rested against the arm of the chair, the sensation where the fabric of his T-shirt touched his skin – and so on.

It was interesting for him to notice that the painful area isn’t as big as he’d imagined.  When he really started to notice the quality of his pain, it wasn’t nauseating or particularly intense, it varied in sensation.  What I noticed was that initially his readings on biofeedback jumped – but they gradually settled down as he looked at his hand and really noticed it.

We then did some deep relaxation, really a kind of hypnosis.  In this we used an imagery device I’d discussed with him before the session.  I guided him in to using his attention to become aware of his hand and in particular, its position in space and the sensations over his whole hand and forearm.  I then guided him through an imagery process where he imagined holding his hand in warm water, allowing his hand to ‘thaw’ and open.  We then spent some time imagining his hand feeling normal, moving normally and imagined opening and closing his hand to lift a cup, pour milk, and flex and extend his wrist.  Throughout I was monitoring his biofeedback readings, and using words like ‘relax’ and ‘warm’ and ‘comfortable’ whenever the readings suggested he was becoming ‘stressed’.

When we completed the session, he had achieved sustained attention to his hand for about 35 minutes, completed a guided imagery of his hand doing normal activities, and had remained calm throughout.  He reported some increased discomfort around his wrist particularly after imagining wrist extension and flexion, but what really excited me was that he’d been able to increase the skin temperature on the finger of his right hand.

So, lots of choices in terms of theory to explain what I’d been doing.

  1. Graded motor imagery and sustained attention gives the neuromatrix normalised input, while not activating what Lorimer Moseley and David Butler call ‘neurotags’ or emotionally-laden pathways in the brain.
  2. Graded exposure using visual imagery as described by Johan Vlaeyen and following the exposure paradigm used in phobia reduction.
  3. Using a behavioural model, biofeedback providing immediate feedback on progress and arousal levels, influencing both my behaviour (guided imagery) and the clients responses
  4. Hypnosis allowing the ‘judgemental’ aspects of the mind to be quietened, thus allowing the client to experience sensations without distress
  5. Mindfulness where sensations are experienced but judgements are stilled.

Take your pick!  I’m not entirely sure myself, but whatever the mechanism, I’ll be continuing with this approach to the point where this client can carry the same process out with eyes open, then when actually moving.  Oh, and at the same time, the rest of the team will be working (along with me) on helping him set and achieve goals, manage difficult emotions and maintain a regulated activity pattern, as well as work on his relationship, look to the future of work, and help him communicate effectively with his case manager.  This is why pain is often not the main focus in pain management!

Success! Why measuring outcome is so rewarding

Not a research post today, but a great experience that I hope will encourage anyone who is not already a fan of regular outcome measurement to get on with it!

I saw a person yesterday who has had pain for about 3 years.  Superficially she’d been managing quite well – still working, having a social life, managing all her household activities and in general, looking good.  BUT – and you knew there would be a ‘but’ – once I started to look a little deeper, it was absolutely amazing to see how much she had adapted her life to avoid specific movements.

I used the PHODA (photographs of daily activities) to assess the specific movements and activities she didn’t like to do.  I’ve blogged about PHODA (Kugler et al, 1999) before – a set of photographs of everyday activities in a variety of settings that can be used to identify and score fearfulness and avoidance.  The findings showed that although this woman was able to do things, the way she did them was to avoid ANY bending, twisting, reaching, jarring or lifting.  She was the original Gadget Queen with things to help her do everything WITHOUT bending.  An occupational therapists dream! (more…)

Working with a kinesiophobic person

One of the biggest challenges when working with someone who is fearful of pain and avoids movement is that although it’s very much like any sort of phobia, it differs on one essential point: people who are spider phobic, socially phobic, fearful of flying or heights or whatever are usually aware at some level that their fear is out of proportion to the ‘real’ risk. People who are kinesiophobic (kinesio – movement, phobic – fearful) are much more likely to believe that their fear is realistic and to have their concerns about moving despite pain reinforced both inadvertently and deliberately by others (including health professionals!).

So, to introduce the idea of beginning to move despite fear of pain or harm requires a bit of a delicate touch!

Some people advocate ‘just tell them’, and spend a good deal of time going through a psychoeducational approach about the difference between hurt and harm until they believe they have convinced the person that it’s OK to move. And sometimes this does reduce the ‘threat value’ of pain.
But just as the spider phobic person (and I was one!) is not reassured by the knowledge that in New Zealand we have very few poisonous spiders, and the one or two we do have are quite rare, the person who is afraid of moving when they are sore can remain unconvinced and continue to avoid moving despite the best ‘information’ or education available.

So, what can you do?
Well, let me tell you how I’ve started working with my current client. The man I’m working with is in his late 20’s, he has a slight disc bulge in his lumbar spine, with little evidence of nerve compression, and he has a 12 month history of low back pain.

His back pain started after he lifted some timber at work, and tripped, falling onto his side with the wood on top of him. He has had a very thorough orthopaedic examination, been seen by a neurosurgeon who doesn’t want to pursue surgery because of the somewhat equivocal findings both neurologically and on imaging studies. He’s now being seen by me and a physiotherapist, and having his low mood treated with pharmacology. He uses paracetamol for pain relief but no other medications.

Functionally, he still has good power in his lower limbs, has no neurological findings, but his activity level and movement patterns are extremely limited. He sits for about 3 – 5 minutes before getting up and slowly stretching. He walks (albeit slowly) to keep comfortable, and can stand for only a few minutes before leaning or stretching.

He has completed a set of questionnaires, including the short version of the Tampa Kinesiophobia Scale, and his score on this questionnaire was well above the cut-off we use to identify those a risk of kinesiophobia.

When I completed the 99 picture PHODA with him, he indicated he would not attempt nearly 70 of the pictures, including any pictures of bending forward, twisting his trunk, jarring (eg going up and down stairs, or riding a bike over a kerb or using a mini-trampoline), carrying anything, or reaching above his head. In his daily activities, he is not working, he makes his bed (he has a duvet only), carries out his personal activities of daily living, but is otherwise either inactive (lying down to rest), or he walks.

He is living with family who are doing all of the household activities, so his responsibilities are very low. In addition, he is quite depressed although starting to look more future-oriented, he has an unsupportive family who are quite critical of his limitations despite carrying out his household responsibilities, and he has broken up from a long-term relationship about six months ago.

I started with using a motivational interviewing approach, and suggested we review some of the areas that other people often find helpful when they are thinking about managing pain. Using a menu of options, he identified sleep, medication use, relationships and work as his main concerns.

I asked him what he had found useful about previous therapies, and also what he had found not so helpful about those approaches. My aim was to help him identify that his previous attempts to control his pain by avoiding activities had not reduced his pain, and had increased the difficulties he faced living his life according to the values he holds.

I asked him whether he thought his movement patterns were helping him or whether there were some not so good features about the way he moved. He agreed that although sometimes it meant that he could avoid doing a movement that he thought increased his pain, for much of the time his pain remained and he had to keep on being ‘careful’ of any movements he did, and this was exhausting!

I then asked him how important it was to him to be able to return to normal activities even if it meant he needed to bring his pain along as well – and he indicated that it was very important. Using the ‘scaling questions’ (Why do you think it’s so important to you? Why give it a 9/10 and not a 6/10?), he told me that he thought his life was becoming very restricted, he wasn’t able to work, and he didn’t think there was going to be a medical way to reduce his pain.

I then went through his confidence that he would be able to carry out normal activities despite his pain, and he told me it was 3/10. Once again, using ‘scaling questions’, I asked him what it would take to help him move his confidence up a little, had he ever successfully made a change in his life despite it being quite hard, and he was able to talk about how he had worked his way up in the workplace despite not being a proficient reader, and that he knew he could make changes because if he took things one step at a time, he could see progress.

I then went through the PHODA pictures, and asked him which of the images he thought were most important for him to be able to do. He indicated that bending forward (eg to do dishes and clean teeth) was important, and also to put on shoes and pick things up from the floor.

I suggested to him that we weren’t sure why he thought he shouldn’t do these things, and asked him what went through his mind when he thought of himself doing these activities. He told me immediately that as he looked at photographs of people bending he could see himself falling forward and hitting the ground, or he could see his vertebrae grinding ‘bone on bone’ and see himself clutching his back because of the pain saying ‘I couldn’t cope with that sort of pain’.

Three things to note here:

  1. the catastrophic image which generates an emotional response,
  2. the misbelief that his vertebrae had no ‘padding’ so they were ‘grinding’ when he moved, and
  3. the belief that he ‘couldn’t cope’ with high levels of pain

Each of these automatic thoughts/images are open to reappraisal, but unless they’re paired with actual movement, they are not likely to help him actually do things.

So – tomorrow I’ll discuss the next step in his programme: working towards ‘exposure’

Reduction of pain-related fear in complex regional pain syndrome
As promised, at last a post on graded exposure for pain-related anxiety and avoidance, as applied to complex regional pain syndrome, or CRPS. This paper was published in 2005, and as far as I know, there have not been any replications carried out, so it must be seen as an initial experimental approach that needs a good deal of refinement before being applicable to people with CRPS in general, but I think the model itself has received considerable support, and therefore it merits further examination.

So, what did they do? Well the basic premise of the pain-related anxiety and avoidance model is that people can rapidly develop a ‘phobia’ for movements that are associated with increased pain and/or fear of further harm. As a result of this fear, individuals avoid movements that are the same or similar to those that they associate with increased pain or harm. And the resultant avoidance interferes significantly with participating in normal life tasks.

So far, this model has been strongly supported in people with a wide range of types of pain, and treatments based on this model have similarly given some very useful results, although not always as positive as those in the initial few papers.

In CRPS, many people describe their painful limb in terms bordering on disgust, loathing and resentment. Some ignore the limb, while others ask for it to be amputated. It’s not clear to me whether this resentment or desire for it to be removed is an artifact of having pain in a distal part of the body (where amputation is possible – unlike back pain), or whether it represents some degree of neglect as in stroke. Nevertheless, people with CRPS often report being unwilling and/or unable to use their limb in normal functional activities. As a result, their pain interferes with normal life to a considerable extent.

High distress, high reported pain intensity, and avoidance of many activities can result – and some continue to fear that their limb has not ‘healed’ and that they are continuing to ‘damage’ or ‘harm’ their painful extremity.

In this paper, de Jong and colleagues in Maastricht, The Netherlands, set out to test whether the graded exposure approach that had been used for low back pain could also be applied to CRPS. The aim of the study was: ‘Using a replicated single case experimental design, we decided to experimentally examine whether the validity of graded exposure in vivo extends to patients with CRPS-I. The main research question of this study was whether the reduction of pain-related fear through graded exposure in vivo also resulted in a decrease of disability in a subgroup of patients with CRPS-I who report substantial pain-related fear.’

This paper also again illustrates the utility of the replicated single case experimental design for testing the effect of an intervention – for me, clinically, this model of research has a good deal of merit, because it can be applied routinely as part of normal treatment, and doesn’t require elaborate randomisation or the use of control groups, as the subjects act as their own controls, and the interventions are experimentally and systematically manipulated and the results measured.

The study took 8 female patients with CRPS-1, aged 40 years (+/-10 years), and a mean duration of pain of 3 years. In two patients CRPS-I was located in the right lower extremity, one patient in the left lower extremity, four patients in the right upper extremity, and one patient in the left upper extremity. In six patients, CRPS-I occurred on the dominant side. The IASP criteria was used to determine CRPS diagnosis, and it was evaluated both by physician and based on Bruehl et al. (1999), and Veldman et al. (1993) signs: altered skin color, altered skin temperature, edema (swelling), reduced range of motion, trophic (hair, nail skin). Additionally, other inclusion criteria were that the patients reported substantial fear of movement/(re)injury (Tampa Scale for Kinesiophobia (TSK: Miller et al., 1991) score >39), pain for at least 6 months and age between 18 and 65. The TSK score was the median of the TSK distribution from a previous study of low back pain patients.

The paper clearly describes the study design – an ABCD -design with random determination of the start of the intervention. At point A – baseline measures were undertaken. All patients received education, then measures were taken (B), Graded exposure was then undertaken (C), and finally there was a 6 month follow up (D). Commencement of the various treatment phases was started at random time periods. A number of outcome measures were also taken including functional disability – measured in the upper limb by the Radboud Skills Questionnaire (RASQ: Oerlemans et al., 1999, 2000); and in the lower limb the Walking Stairs Questionnaire (WSQ: Roorda et al., 1996a; 2004) and Questionnaire Rising and Sitting Down (QRS: Roorda et al.,1996b) were used.

Fear of movement was assessed using the Tampa Scale for Kinesiophobia, and the PHODA, or Photographs of Daily Living. The final set of measures were self reports of signs and symptoms, using a daily diary method.

I’ll describe the exposure treatment more fully. Each person developed an individualised fear hierarchy by means of the Photograph series of Daily activities for the upper extremities (PHODA-UE: Dubbers and Vikstro¨m, 2003) or the lower extremities (PHODA-LE: Jelinek et al., 2003).

The most essential step consisted of graded exposure to the situations the patients had identified as ‘dangerous’ or ‘threatening’. Based on the graded hierarchy of fear-eliciting situations (PHODA), individually tailored practice tasks were developed. Further, the general principles for exposure were followed. The patient agreed to perform certain activities or movements or stay in situations that he or she had been avoiding. Patients were also encouraged to engage in these fearful activities, movements or situations as much as possible until anxiety levels had decreased. The therapist first modeled each activity or movement. Finally, the graded exposure was presented as a start only, and the patient was encouraged to continue exposing him or herself to more activities in everyday life after termination of the treatment sessions. To facilitate independence and to promote generalization, the presence of the therapist was gradually withdrawn, and contexts were created that mimicked those of the home situation.

Well, what did the study show? The first surprising result was that ‘in every case, at the end of the GEXP all the patients report a positive change for the better in CRPS-related signs and symptoms.’

For all patients a significant reduction in TSK scores is observed at the end of graded exposure and during followup as compared to baseline and education alone. TSK scores decrease from a mean score of 55.0 (>80th percentile) to a mean score of 19.75 (<10th percentile). Similar results were found for the PHODA.

And functionally? All patients reported reduction in pain-related disability as measured both by standardised measures, and on the individualised tasks the patients had identified as things they would like to work on.

To summarise, all the patients reported, after the graded exposure treatment, decreasing levels of pain-related fear, pain disability, and pain intensity. As the authors say ‘This last result is remarkable because pain intensity is not the target of the graded exposure treatment.’

For theorists, it would be great to try to work out how this approach works – graded exposure in vivo is a strategy that aims to activate cortical networks. Graded exposure may disrupt internal body schema by focusing on how the body prepares for movement (eg motor intent), perhaps by practicing a movement the mismatch between motor intent and sensory feedback is ‘rewired’. Alternatively it could have been the process of visual and mental attention on the limb which reintegrates the neural networks, reorganising the cortical representation of the painful limb.

For me, graded exposure directly addresses the meaning people attach to their pain (in particular the belief that ‘I can’t cope with variations in pain’, or ‘this pain means harm’), as well as the behavioural avoidance that interferes so much with daily function – and serves to reinforce the belief that ‘I can’t cope with this pain’. We know that pain intensity is influenced by the meaning people associate with the sensation – and the judgements about what the pain means about them and their lives. If we can help people gradually return to enjoyable activities, we will be doing them a real favour.

I encourage you to review single subject experimental design – and I’ll post more on it!
I also encourage you to consider developing your skills in graded exposure and perhaps reduce the focus in CRPS on avoiding activities that ‘flare pain up’ and instead, consider gradually working up to normal and enjoyable activities on the basis of addressing and experimenting with fears and avoidance.

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DEJONG, J., VLAEYEN, J., ONGHENA, P., CUYPERS, C., HOLLANDER, M., RUIJGROK, J. (2005). Reduction of pain-related fear in complex regional pain syndrome type I: The application of graded exposure in vivo. Pain, 116(3), 264-275. DOI: 10.1016/j.pain.2005.04.019

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