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Background and Purpose: Fear-avoidance beliefs in older adults with chronic low back pain (CLBP) can lead to disability. Graded exposure-based active physical therapy could be an option to enhance physical ability in older patients with CLBP. The purpose of this study was to develop a standardized graded exposure treatment according to the fear-avoidance model of musculo-skeletal pain for older patients with CLBP and to examine its effectiveness and feasibility in the German health care system. Methods: The study represents a phase I/phase II trial of a complex intervention. Taking a first step into the hierarchy of growing empirical evidence, a prospective 1-factor observational study was conducted with repeated measurements 1 week before and within 2 weeks after the intervention. Three physical therapists, who completed an introductory workshop, provided the treatment in the form of individual therapies. Sixteen participants 65 years or older with CLBP and perceived physical limitations were recruited. Four patient-reported outcome measures and semistructured interviews were conducted. The primary outcome was physical ability measured with the Hanover Functional Ability Questionnaire. Secondary outcomes were the numerical pain rating scale, and an age-specific and adapted 11-item short-form of the Patient Anxiety Symptom Scale, the KVS-D 65 +, which quantified catastro-phizing and avoidance beliefs. Fear of falling was measured with the Falls Efficacy Scale-International. For the analysis, Wilcoxon signed-rank test for paired samples and an a level of .05 were chosen. For the qualitative evaluation, semistruc-tured interviews were conducted with the patients and physical therapists explored indicators of feasibility such as demands, acceptability, satisfaction, adaptation needs, and implementation. For content analysis, codes were primarily derived deductively and complemented by inductively derived new themes. Results: A significant increase in physical ability after the treatment was observed with an effect size (ES) of 0.95 (P = .008). With regard to secondary outcomes, there was a statistically significant decrease in pain intensity (P = .029) and a reduction in catastrophizing (ES = 0.91; P = .021) and avoidance beliefs (ES = 1.37; P = .001). The interviews revealed good acceptance and satisfaction of the treatment by the patients and physical therapists. Conclusion: On the whole, the treatment appears effective and feasible. Apart from the benefits achieved by the participants, the study provides a basis for designing future studies at a higher level of evidence. [ABSTRACT FROM AUTHOR]

Abstract: There is increasing evidence that pain-related fear influences the development and maintenance of pain disability, presumably mediated through the fear-related avoidance of valued activities. Individually tailored graded exposure in vivo (GEXP) has been demonstrated to reduce pain-related fear and increase functional abilities in patients with chronic low back pain, neck pain, and complex regional pain syndrome. The current study aimed to test whether these effects generalize towards patients with work-related upper extremity pain. A sequential replicated and randomized single-case experimental phase design with multiple measurements was used. Within each participant, GEXP was compared to a no-treatment baseline period and a no-treatment 6-month follow-up period. Eight patients who reported a high level of pain-related fear were included in the study. Daily changes in pain catastrophizing, pain-related fear, and pain intensity were assessed using a diary, and subjected to randomization tests. Before the start of the baseline period, just after GEXP, and at 6-month follow-up, clinically relevant changes of pain catastrophizing, pain-related fear, perceived harmfulness of physical activity, pain disability, and participation/autonomy were verified. When GEXP was introduced, levels of pain catastrophizing and pain-related fear decreased significantly. Clinically relevant improvements were observed for pain disability, perceived participation, and autonomy. These favourable changes were maintained until 6-month follow-up. The findings of the current study underscore the external validity of a cognitive-behavioural GEXP treatment for patients with chronic pain reporting increased pain-related fear. [Copyright &y& Elsevier]

Abstract: Fear of (re)injury/movement has been identified as a potential predictor of chronic disability in complex regional pain syndrome type I (CRPS-I). In order to reduce pain-related fears and pain disability, graded exposure in vivo (GEXP) is likely to be an appropriate treatment. Indeed, there is evidence that in chronic pain patients reporting substantial fear of (re)injury/movement, GEXP is successful in reducing pain disability. However, the efficacy of exposure-based protocols in the treatment of CRPS-I patients for reducing pain disability has not been tested. The main research question of this study was whether the reduction of pain-related fear through GEXP also resulted in a decrease of disability in a subgroup of patients with CRPS-I who report substantial pain-related fear. A single-case experimental ABCD-design was used with random determination of the start of the intervention. Eight patients with CRPS-I were included in the study. To assess daily changes in pain intensity, pain-related fear, pain catastrophizing, and activity goal achievement, a diary was used. Standardized questionnaires of pain-related fear, pain disability, and self-reported signs and symptoms of CRPS-I were administered before and after each intervention, and at 6-month follow-up. The current study supports a GEXP approach to chronic CRPS-I. The GEXP was successful in decreasing levels of self-reported pain-related fear, pain intensity, disability, and physiological signs and symptoms. These results support the hypothesis that the meaning people attach to a noxious stimulus influences its experienced painfulness, and that GEXP activates cortical networks and reconciles motor output and sensory feedback. [Copyright &y& Elsevier]