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 

Introduction: A common 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 disability.

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. 

Aims: To explore the current evidence around self-efficacy and fear avoidance and on the application of graded exposure within the allied health professions.


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 clinical practice.

Results: The workshop aims to provide OTs and PTs an opportunity to explore graded exposure approaches.

Conclusion: 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.