Should Occupational Therapists and Physiotherapists Deliver Graded
Exposure in Pain Management?
P. Lagerman* and B. L. Thompson*
Department of Orthopaedic Surgery & Musculoskeletal Medicine,
University of Otago, Christchurch, NZ
complaint by patients with persistent pain of musculoskeletal origin is the
association with disability (Ferreira et al., 2010). In this instance the nervous system perceives
that the movement is threatening to the body resulting in a pain experience and
According to Vlaeyen & Linton (2000) fear-avoidance is the name
that describes the association of fear and pain in individuals that tend to
refrain from performing movements or activity. In individuals that experience
high levels of pain related to movement it is often common to identify
increased levels of pain catastrophizing and low levels of self-efficacy.
Through use of the Photograph of Daily Activities (PHODA) (Leeuw,
Goossens, van Breukelen, Boersma, & Vlaeyen, 2007) Vlaeyen et al (2012) identified
movements and activities that individuals living with back pain were
particularly fearful of performing. After developing a hierarchy of fear
related movement, use of graded exposure was a means of addressing fear
avoidance related to movement.
Graded Exposure is based upon the classical conditioning model
where learning occurs by association. It is the intention of exposure therapy
to aim to confront the unconditioned stimulus (pain) paired with the
conditioned stimulus (movement) to extinguish the conditioned response (fear). Graded Exposure
can offer Occupational Therapists (OTS) and Physiotherapists (PTs) ways of supporting
patients, such as performing painful movement at a low enough intensity that it
does not hurt, essentially sending the nervous system information that the
movement is safe. Through repetition it is possible to dissociate the movement
from the pain.
As OTs and PTs are regarded as health professionals that work
primarily with movement impairment, activity limitation and participation
restriction (World Health Organization, 2013), it would be deemed pertinent for
OTs and PTs to have a grounding in graded exposure particularly in the
discipline of pain management.
To explore the current evidence around self-efficacy and fear
avoidance and on the application of graded exposure within the allied health
Revisit the fear-avoidance model and discuss pain catastrophizing,
pain self-efficacy and fear related to movement and activity.
Discuss the classical conditioning model and its application
within pain science.
To introduce a proposed version of an adapted and updated PHODA
applicable to NZ.
To identify metaphorical models of movement for OTs and PTs in
The workshop aims to provide OTs and PTs an opportunity to explore
graded exposure approaches.
Graded exposure is widely used in psychology for a range of
maladapative behaviours including anxiety, fear, obsessive compulsive
disorders. The talk aims to propose the effectiveness of graded exposure and
its application within allied health.