pain-related anxiety

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.

More on anxiety and pain – pain-related anxiety
It seems obvious that something unpleasant is something to be avoided – and if we’re meant to avoid it, we’re likely to be just a little bit afraid of it. Yesterday I talked about health anxiety in general, and today I want to touch on a specific sub-group of health anxiety – pain-related anxiety.

Many people will be familiar with pain-related anxiety and avoidance, the model of so-called ‘fear avoidance’ that is a compelling explanation for how so many people become deactivated and disabled when they have persistent pain. It might be a surprise to some that the term ‘fear avoidance’ is actually not technically correct! There are two parts to the phenomenon: fear (or really, pain anxiety) and avoidance. It’s possible to be fearful or anxious about something but not avoid it – and it’s the avoidance part that creates the disability, which is why we are so keen to get people to DO things, even if they’re afraid.

If we look at yesterday’s post about anxiety, and review Beck’s cognitive model of anxiety, we can see that it’s really about how a person perceives a situation rather than the facts of a situation that is the problem in health anxiety. With an increased perception of the probability that something horrible will happen, multipled by the ‘awfulness’ factor we can begin to understand how some people will be really afraid of having pain. This is modifed by their personal resources and ‘rescue’ factors which might be things that other people do to reduce the person’s distress or decrease the ‘awfulness’ factor.

Pain anxiety is somewhat more problematic, IMHO, than general health anxiety. The reason being that so many conflicting messages are available in the community about having pain. It’s all around us that to have pain means ‘something is wrong’ – we’ve all grown up with this belief, developed through our own experiences with acute pain, and the media and almost all health care pushes the idea that we should not have to experience pain. Which is all very well except that it creates an unrealistic expectation for people who have persistent pain that doesn’t respond to pharmacology, surgery, injections or anything else that is ‘done to’ the person. Because like it or not, we don’t yet have all the answers to all the health care problems – just think of the common cold!

In the case of classic health anxiety, there is usually a nice clear-cut statement from a medical person that ‘there is nothing wrong’, health investigations are clear, there is nothing sinister going on, the person is not going to die from something nasty. In pain? Well all around us there are messages saying that ongoing pain is not OK, and it only takes one practitioner to suggest that there is some removable cause for their pain that will take the pain away for a person to start to worry again about their pain (and start looking for ‘the cure’).

It’s understandable. Pain isn’t pleasant – that’s part of the definition of pain! But people don’t die simply from having chronic pain. It can be depressing, distressing, and invade much of life, ruining the quality of life in many spheres – but many many people do cope well despite having pain, and have rewarding, fulfilling lives even though they have persistent pain.

The difference between being anxious about pain and living well with pain? Not so certain actually. We do know a lot about people who have pain and look for treatment. In fact, we know heaps about these people. We don’t know very much about people who don’t look for treatment simply because they don’t turn up at treatment centres. As a result, we don’t really know how people who live good lives despite their pain actually do so.

Maybe this group of people have developed ways of viewing their pain that reduces the ‘awfulness’ factor, maybe they have more resources, maybe they can be flexible about how they go about achieving what is important in their lives, maybe their goals are different, maybe they don’t have some of the vulnerability factors discussed in the paper I’ve identified today.

The fact is, we simply don’t know. Almost all our research on pain and coping is on people who are worried about their pain, anxious about it, and want it gone. Our treatments are based on models like Beck’s and Vlaeyen’s, that are developed from our understanding of people who don’t live well with their pain. So we focus on reducing the level of catastrophising, reducing the use of ‘safety behaviours’ and ‘checking’ and ‘reassurance’, increasing the use of active coping, help people confront what they fear and find out that it doesn’t make life unbearable and intolerable.

This paper by Carleton, Abrams and colleagues identifies that pain-related anxiety might be a separate type of fear that exists alongside other anxiety types – blood/needle phobia, panic, OCD and so on.

It might have taken a while to recognise it, but maybe it’s important to recognise that for a reasonably large group of people, having pain, or anticipating that pain will be experienced, is such an anxiety-provoking problem that this fear needs to be treated rather than the pain itself. This is why simply removing the pain doesn’t solve the problem – in the case of a simple phobia, just not being able to see a spider doesn’t remove the fear of there possibly being spiders under the bed, in the garden, in the shed! In fact, reassurance that there are no spiders doesn’t actually help if the person still looks for one. In the same way, removing pain through anaesthetic blocks or medication or even surgery doesn’t help if the person still fears having the pain – because they’ll be checking their body, any investigations and probably any other body sensations to try to make sure there is nothing going wrong. You can be sure that any slight change in body sensation will be monitored, and in someone who is anxious about having pain, be evidence that there is something wrong, eliciting all those worries and leading to avoidance.

What to do? Not sure yet – while we can help individuals, it only takes one person to re-establish that fear by inadvertently suggesting that ‘something is there’, or that pain ‘must be’ abolished – and the whole anxiety process starts again. More on this tomorrow!

Carleton, R., Abrams, M., Asmundson, G., Antony, M., & McCabe, R. (2009). Pain-related anxiety and anxiety sensitivity across anxiety and depressive disorders☆ Journal of Anxiety Disorders, 23 (6), 791-798 DOI: 10.1016/j.janxdis.2009.03.003

Theory and really practical clinical reasoning
I’ve been mulling over my delight and joy in theory, and wondering whether this turns people off reading my blog.  So today I thought I’d draw a link between theory and everyday work in pain management.

Theory and models really matter!  They form the organisational framework for the data we collect (ie the things we look for when we assess people), from the models we use, we develop hypotheses, or potential explanations for the way the person presents.

It’s these hypotheses we test when we actually carry out therapy: to confirm our predictions.  If our predictions don’t hold, we’ve probably got the wrong explanation and need to look for another one, if they do hold, we can probably work with the underlying theory or model to develop other hypotheses or interventions to predict.

It’s important then, that we have knowledge of a good number of theories or options to have as alternatives when we start gathering information/assessing a person’s presentation.  If we only know a couple of theories (eg we only know about biomechanical models, or psychodynamic explanations, or even cognitive behavioural models) we’re going to be really limited in terms of looking for appropriate information to notice – and it will be hard to organise information that doesn’t fit with our pre-existing model.

For a really practical application of theory to pain management, we don’t need to look too much further than Fordyce.  I’m quoting directly from Dunn and Elliott’s paper on ‘The Place and Promise of Theory in Rehabilitation Psychology Research’ (Dunn & Elliott, 2008).

‘Fordyce effectively developed ideas derived from operant conditioning and principles of reinforcement (e.g., Fordyce, 1971) to motivate clients undergoing rehabilitation. Fordyce (1976) specifically focused on how individuals with acquired disabilities understood and responded to their environments, the people within them, and the contingencies and secondary gains associated with them. As Fordyce (1971) wrote:

The development of an effective treatment relationship with a client or patient . . . . can be enhanced considerably by the professional’s awareness of his client’s [verbal or nonverbal feelings]. What is suggested here is that a more expeditious way to help the disabled person is to focus in helping him to change his behavior. It is quite possible that feelings will follow rather than lead these behavior changes. (pp. 77)

This landmark work initiated an appreciation for operant principles in the development and reinforcement of disabling behaviors, and for use of operant approaches to facilitate and reward healthier, adaptive behavior (Patterson, 2005)’

We have much to thank Fordyce for in our modern pain management approach – applying theory from operant conditioning to a real-life clinical situation offers us as clinicians new opportunities to help people live well.

Similarly, The idea that people are more than their disabilities comes directly from social psychology, where the relationship between the individual and the society or community is the focus. The concept of disability as a communal problem rather than an individual problem, and that disability can motivate people to develop awareness of previously under-used aspects of their abilities has lead to the strengths-based approach in rehabilitation. Tamara Dembo (1969) is cited in Dunn and Elliott’s paper as identifying the view that ‘outsiders assume a disability is all-encompassing so that insiders must always be preoccupied with their physical or mental states; the idea of living a normal and fulfilling life is rejected by these observers. Preferring to focus on their abilities, however, insiders affirm that disability is independent of identity.’ This view comes directly from social psychology.

Many research questions within rehabilitation are identified in response to a gap in knowledge, often clinically related knowledge. This knowledge gap is ‘the psychological distance between what is known and what knowledge is needed’. Typically in rehabilitation we’re trying to solve a problem. When existing information doesn’t ‘solve the problem’ – it’s time to start searching for more information!

I suppose what I’m trying to say is that most of the time we work in a clinical framework where an individual comes to see us with a problem.

It might be a problem of pain itself, or it might be a problem of the effects of pain in some part of the person’s life. By carrying out a comprehensive assessment of the features of this person’s presentation we allow for lots of information to be available so we can sift through to find features that are stable:

  • this person mostly avoids doing certain movements;
  • this person takes three hours to get off to sleep and can’t stop his mind from racing;
  • this person is 12 years old and everyone runs around helping her because she’s using crutches

By referring to our theory-based (and our theories are developed from and are confirmed by good empirical evidence), we can decide which theory generates hypotheses that best fit the person’s presentation.

For example, one explanation for avoiding certain movements could be that this person believes her fusion means she will inevitably wear away the vertebrae above and below the fusion, and her surgeon told her immediately after surgery to ‘be careful about moving’, and everyone has told her not to slump because it’s ‘bad for your back’.

What are our clinical options?
provide information about degeneration in the vertebrae above and below a fusion site (and no, there isn’t much evidence that these vertebrae do degenerate more quickly than others)
– if she’s fearful because she thinks she might do further damage, and it’s simply about protecting her spine, this information should reduce her fear, and help her feel safer about moving.
– if we add in the suggestion that immediately postsurgery it makes sense to be a little careful, but now it’s 12 months later, so any healing that needs to occur has already, this may also help her revise her beliefs about harm from moving.
– and if we demonstrate that any body position becomes uncomfortable if you haven’t done it for a while, if you’re a bit worried about doing it because people have said it’s not good, and that lots of people do sit in very poor posture without any problem at all, then once again we might help her revise her beliefs, reduce her fear and help her feel more confident about moving.

At the same time we can draw from very robust evidence from anxiety management to suggest that

  • if we start her moving again using activities she’s not too worried about,
  • gradually progress towards more demanding activities;
  • we make an attempt to understand what she is worried about
  • demonstrate that these things don’t happen (using applied experiments),
  • help her develop ways of coping with any increased physiological arousal (based on our knowledge from anxiety disorders) –

once again we have an intervention that is really practical, based on theory.

And you thought theory was only for academics!

Dana S. Dunn, Timothy R. Elliott (2008). The place and promise of theory in rehabilitation psychology research. Rehabilitation Psychology, 53 (3), 254-267 DOI: 10.1037/a0012962

Dembo, T. (1969). Rehabilitation psychology and its immediate future: A
problem of utilization of psychological knowledge. Rehabilitation Psychology,
16, 63–72.

Fordyce, W. E. (1971). Behavioral methods in rehabilitation. In W. S. Neff
(Ed.), Rehabilitation psychology (pp. 74–108). Washington, DC: American
Psychological Association.
Fordyce, W. E. (1976). Behavioral methods in chronic pain and illness. St.
Louis, MO: Mosby.

Patterson, D. R. (2005). Behavioral methods for chronic pain and illness:
A reconsideration and appreciation. Rehabilitation Psychology, 50, 312–

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

Are you afraid to push your patients?

We have all heard about fear avoidance, or pain-related anxiety and avoidance in patients (Vlaeyen & Linton, 2000). This model of pain disability has become increasingly prominent over the past 10 years and research has demonstrated its effectiveness in predicting those who will develop long-standing disability, as well as providing amodel for treatment approaches – the graded exposure approach being one (Vlaeyen, 2002; Leeuw, Goossens, van Breukelen, deJong, Heuts, Smeets, Koke, Vlaeyen, 2008)).

Shortly after the model was introduced, researchers posed the question – are we as clinicians fear avoidant? Do we avoid asking our patients to ‘push’ themselves – either into increasing pain, or possible harm? (Linton, Vlaeyen, Ostelo (2002) is a good example).

In this recent editorial, Ostelo and Vlaeyen (2008) ask the question: have things changed? Do we still limit our expectations of people who experience pain because of our own beliefs and attitudes? Do we project our own concerns onto our patients, and in so doing, increase their risk of ongoing disability?

Bishop, Foster, Thomas & Hay (2008) suggest in their study that indeed, our treatment behaviour is correlated with our personal beliefs and attitudes, and that this affects our expectations and recommendations for our patients. Although there are several criticisms of that study (low response rate, yet another questionnaire with relatively little cross-validation of the content, and the use of vignettes rather than observing actual clinical practice), it nevertheless raises questions that haven’t previously been asked about the influences on patients, rather than focusing only on patient beliefs and attitudes.

It’s not an easy area to study, but intriguing, and opens the fear avoidance model up to include more environmental factors than are currently included. So, a question for all of us: how do we feel about asking patients to persist with activities despite pain? What do we do – both intentionally in terms of recommendations, and unintentionally in terms of our verbal and nonverbal behaviour?

Ostelo R.W.J.G & Vlaeyen J.W.S.(2008) Attitudes and beliefs of health care providers: Extending the fear-avoidance model Pain (135:1-2), pp 2-3.