Graded exposure for fear of pain and movement avoidance belief in chronic low back pain patients

Vieira, Érica Brandão de Moraes; Pimenta, Cibele Andrucioli de Mattos

doi:10.5935/1806-0013.20160029

Brazil

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REVIEW ARTICLES • Rev. dor 17 (2) • Apr-Jun 2016 • https://doi.org/10.5935/1806-0013.20160029 linkcopy

Graded exposure for fear of pain and movement avoidance belief in chronic low back pain patients

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ABSTRACT

BACKGROUND AND OBJECTIVES: Fear of pain and movement avoidance is a belief contributing to increase disability and mood changes in chronic low back pain patients. Exposure is a technique used for such belief, however there is still no consensus about the best way to perform it in low back pain patients. This study aimed at evaluating graded exposure for fear of pain and movement avoidance belief in chronic low back pain patients.

CONTENTS: The following databases were queried for the period from 2000 to 2015: Pubmed, PsycInfo, Web of Science, Cinahl and LILACS. Eligibility criteria were established for studies selection. Studies were first selected by title and abstract. Then they were read in full. The search has resulted in 91 studies. From these, 38 were selected to be read in full. Among selected studies, 10 were excluded and 19 were repeated. Applying eligibility criteria, nine studies were included: for are before and after studies, one is a case report, one is a quasi-experimental study and three are randomized clinical trials.

CONCLUSION: Most studies of this review have compared in vivo exposure and graded activity, however they have not specified how this was done. There is still no clarity about the advantages or methods to perform graded exposure in low back pain patients and further intervention studies on the subject are needed.

Keywords: Exposure; Fear of pain and movement avoidance; Low back pain

Study data	Study design	Objective	N°	of evaluation tools	Outcomes	Sessions/du ration	Interventions	Results
Vlaeyen et al.¹¹	Before-and-after with crossover	To examine the effectiveness of in vivo exposure and compare with graded activity to decrease fear of pain and movement avoidance, catas-trophizing and disability in chronic low back pain patients with high fear of pain and movement avoidance.	4	TSK PASS PCS EAV PCL RDQ	Fear of pain and movement avoidance Anxiety Catastrophizing	Not mentioned	In vivo exposure followed of graded activity Graded activity followed by in vivo exposure	There has been improvement only during in vivo exposure and not during graded exposure, regardless of the order of treatment. Analysis of pre and post-treatment differences has shown that decreased fear and movement avoidance were related to pain, disability and catastrophizing decrease in half the cases.
Vlaeyen et al.²	Before-and-after with crossover	To test the effects of exposure in chronic low back pain patients with fear of pain and movement avoidance.	6	EAV TSK Symptom Checklist (SCL-90) PVAQ RDQ	Fear of pain and movement avoidance Catastrophizing Pain vigilance Pain intensity Disability Monitoring of activity	4 weeks	In vivo exposure versus graded exposure Patient’s education showing the fear, beliefs and behavior model. Exposure was tailored and ranked movements with regard to fear of movement causing damage or pain.	There has been pain improvement related to fear and catastrophizing only during in vivo exposure It was observed that decreased pain-related fear was related to decreased pain and increased levels of physical activity. All improvements were maintained in one year of follow-up. In vivo exposure has decreased pain between 29.6% and 38.7% in visual analog scales.
Boersma et al.²⁷	Before-and-after	To describe in the short term the consequences of the effects of in vivo exposure in patients with high fear of pain and movement avoidance.	6	PIRS OMPSQ FABQ TSK PHODA	Fear of pain and movement avoidance Pain Functionality Ranking of fear	Not mentioned	Educational session and explanation of the fear and avoidance cycle based on patient’s experience In vivo exposure	Reduction of 54% to 100% in fear of pain and movement avoidance scores until follow-up Reduction of 50% in PHODA scores Improved functionality Mild decrease in pain intensity
de Jong et al.³	Before- and-after	To examine the contribution of education and graded exposure, compared to education and graded activity to decrease fear of pain and movement avoidance and associated to disability and physical activity.	6	TSK PVAQ Roland Disability Questionnaire Activity Monitor PASS PCS VAS PHODA	Fear of pain and movement avoidance Vigilance of pain Pain intensity Disability Level of activity	Education and exposure group: 7 sessions Education and graded activity group: 9 sessions	Education Exposure Graded activity	Results were better when education came before in vivo exposure with regard to graded activity program Activities performance was not affected by educational session and has significantly improved only with in vivo exposure
Woods & Asmundson¹⁶	Randomized clinical trial	To compare graded exposure in vivo, graded activity and waiting list of low back pain patients.	83	Pain Disability Index QPDS McGill Pain Questionnaire- Short form Pain self-efficacy questionnaire TSK FABQ PASS PCS Working Alliance Inventory	Primary: Functionality Secondary: pain, disability, emotional distress, self-efficacy, fear of pain and movement avoidance anxiety	2x per week for 4 weeks	Graded in vivo exposure Graded activity	Improved fear of pain and movement avoidance, anxiety and self-efficacy scores in the exposure group as compared to the graded activity group. Improved fear of pain and movement avoidance, anxiety and selfefficacy scores in the exposure group as compared to the waiting list group Exposure group patients has maintained their scores after one month of follow-up
Linton et al.²⁸	Randomized clinical trial with crossover	To examine the effectiveness of graded exposure in vivo on fear of pain and movement avoidance and disability in chronic low back pain patients	46	OMPSQ TKS PCS PHODA - authors used 40 photos	Fear of pain and movement avoidance Disability Pain Perception of loss	2 sessions per week for 8 weeks After the 14^th week there was a crossover between groups	Graded in vivo exposure Waiting list	Comparison between groups has shown significant results with regard to functionality for the exposure group, but not for fear and pain When the control group received the intervention, after the crossover there were significant results for functionality, fear and pain. Exposure had better results in the group receiving usual assistance first.
Leeuw et al.⁶	Randomized multicenter clinical trial	To evaluate the effectiveness of exposure versus graded activity in chronic low back pain patients and moderate fear of pain and movement avoidance.	85	Quebec Pain Disability Scale; Patient Specific Complains PHODA -SeV TSK Catastrophic thoughts scale McGill Pain Questionnaire	Disability Physical activities Fear Catastrophizing thoughts Pain intensity	2x per week lasting 1h 16 sessions graded exposure group and 26 sessions graded activity group	Graded activity Graded exposure	Exposure has decreased pain catastrophizing and perception of damage caused by activities; There has been no difference between groups with regard to disability, pain intensity and daily activity level; Half the patients improved disability Exposure effect was mediated by decreased catastrophizing and losses perceived during activities. During 6 months of follow-up there have been no differences between exposure and graded activity groups.
George & Zeppieri²⁹	Case reports	To describe graded exposure applied to physiotherapy	2	Numerical scale FDAQ FABQ Oswestry Disability questionnaire	Disability Fear and avoidance Anxiety Pain	3 sessions/ 3 weeks	Education to decrease fear and threat associated to low back pain Graded exposure	There has been decrease in fear, pain intensity and disability scores.
Georgeet al.²³	Quasi- experimental	To compare pain and disability in patients receiving graded exercise and graded exposure. To investigate whether changes in fear of pain and movement avoidance and catastrophizing are associated to changes in pain scores and disability.	33	Numerical scale Oswestry Disability questionnaire Fear of pain questionnaire FABQ TSK FDAQ Coping strategies questionnaire Beck depression inventory	Pain Disability Fear of pain and movement avoidance Catastrophizing Depression	3 to 5 weeks 7 hours per day	Physiotherapy with graded exercise Physiotherapy with graded exposure	Both groups had decreased pain and disability scores Fear evaluation tools have not shown statistically significant decrease. Catastrophic thoughts and depression were decreased in both groups. There has been positive correlation (r=0.56) between pain intensity and depressive symptoms. There has been positive correlation between disability and catastrophizing (r=0.65)

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[TFN2] FABQ = Fear Avoidance Beliefs Questionnaire; TSK = Tampa Scale for Kinesophobia; HADS = Hospital Anxiety and Depression Scale; PHODA = The Photograph Series of Daily Activities; PASS = Pain Anxiety Symptoms Scale; PCS = Pain Catastrophizing Scale; FDAQ = Fear of Daily Activities Questionnaire; VAS = visual analog scale; PCL = Pain Cognition List; RDQ = Roland Disability Questionnaire; PVAQ = Pain Vigilance and Awareness Questionnaire; PIRS = Pain and Impairment Relationship Scale; OMPSQ = Orebro Musculoskeletal Pain Screening Questionnaire.