Integrating graded in vivo exposure into the management of chronic lower back pain may result in improved treatment efficacy and reduced pain-related fear, according to study results published in Behaviour Research and Therapy.

The study included matched pairs of participants with chronic low back pain for >6 months and elevated pain-related fear. Participants were randomly assigned to receive graded in vivo exposure consisting of psycho-educational and exposure elements, or cognitive-behavioral therapy (CBT) in a yoked design. The investigators assessed pain symptoms, disability, pain-related fear, acceptance, body confidence, self-efficacy, and positive thoughts at baseline during treatment and at 6-month follow-up.

Participants receiving graded in vivo exposure were found to have significant changes in pain perception (standardized mean difference [SMD],−0.50), perceived harmfulness of personally-relevant activities (SMD, −0.40), self-efficacy (SMD, 1.07), pain acceptance (SMD, 1.16), and body confidence (SMD, 1.18) during the exposure — not the psycho-educational — elements ( P ≤.05 for all). At the 6-month follow-up, only changes in self-reported exposure remained significant (SMD, 0.93; P ≤.05).

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In participants in the CBT group, no changes were recorded during therapy. CBT was found to result in delayed small to medium effects. At 6 months, participants in the CBT group reported significant changes in the difficulty of performing personally relevant activities (SMD, −0.62) and their expected harmfulness before engaging in these activities (SMD, −0.13) (P ≤.05 for both).

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“We thus strongly recommend integrating exposure elements in the management of [chronic lower back pain] to raise its efficacy,” the researchers wrote. “Since CBT seemed to produce delayed effects, core CBT interventions such as cognitive restructuring might be added after exposure treatment to sustain therapeutic effects.”


Schemer L, Vlaeyen JWS, Doerr JM, et al. Treatment processes during exposure and cognitive-behavioral therapy for chronic back pain: a single-case experimental design with multiple baselines. Behav Rev Ther. 2018;108:58-67.

This article originally appeared on Clinical Pain Advisor