Charles Ferren, Tanner Fields, David Davis, and Joseph Eissler
April 15th 2013
PT 7539
Current concepts in Graded Exercise &
Graded Exposure in managing Chronic LBP
patient
Etiology – Chronic LBP entails constant or recurring episodes of pain in the lower back that leads to
general inactivity and restrictions in ADLs. This can lead to depression, sleep disorders, anxiety and pain
catastrophizing. LBP is the most common cause for activity limitations for people under 45 years old.(1)
Prognosis- 80-90% of patients recover from an episode of LBP in 12 weeks; however, the recurrence rate
for another episode in these patients is about 85%.(1)
Diagnosis- Chronic LBP patients are categorized by an extended duration of symptoms consistent with
LBP lasting 3 months or longer, limited activity level, and potential psychological factors
influencing impairments. Psychological factors such as fear
Graded Exercise
avoidance behaviors, hypervigilence, and kinesiophobia may
be determining factors of chronicity. (2)
Graded
Exposure
Pain Intensity (0-10)
Intervention- Commonly used interventions are supervised
stretching and muscle strengthening exercise programs specific
to the individual’s needs and impairment level.(3) Graded
exposure and graded exercise have been used and some believe
the approaches may be superior to other interventions.(4)
Bottom Line Summary- Graded exercise and exposure can
significantly reduce pain catastrophizing and depressive
symptoms, resulting in promotion of movement and physical
activity. Overall outcomes from graded exercise and exposure
has no significant difference in comparison to to each other.(4)
Also, graded exercise showed no significant difference when
compared with motor control exercises.(5) Authors suggest that
graded exercise and exposure may be beneficial to subjects
with high levels of fear avoidance and kinesiophobia.(4,6)
Pretreatment
6.3 + 1.2
4.6 + 2.1
Post-treatment
4.1 + 2.5
2.6 + 1.9
Pretreatment
56.0 + 13.9
43.3 + 12.5
Post-treatment
47.0 + 17.1
38.0 + 14.1
Pretreatment
18.7 + 10.9
14.8 + 10.0
Post-treatment
7.6 + 8.9
5.9 + 6.1
Pretreatment
23.3 + 10.2
28.1 + 15.7
Post-treatment
6.5 + 6.0
11.9 + 10.9
Pain Related Disability (0-100)
Pain Catastrophizing (0-36)
Depressive Symptoms (0-63)
Data from George et al.
Texas State Department of Physical Therapy
PT 7539
2013
Charles Ferren, Tanner Fields, David Davis, and Joseph Eissler
April 15th 2013
PT 7539
1.
Andersson G. Epidemiological features of chronic low-back pain. Lancet(serial online). Augst 14,
1999;354(9178):581-585.
2.
Hayden J, van Tulder M, Tomlinson G. Systematic Review: Strategies for Using Exercise Therapy To
ImproveOutcomes in Chronic Low Back Pain. Annals Of Internal Medicine(serial online). May 3,
2005,;142(9):776-785.
3.
Picavet H, Vlaeyen J, Schouten J. Pain Catastrophizing and Kinesiophobia: Predictors of Chronic Low
Back Pain. American Journal of Epidemiology. 2002;156:1028-1034.
4.
Gazzi Macedo L, Latimer J, Stafford R, et al. Effect of Motor Control Exercises Versus Graded Activity in
Patients With Chronic Nonspecific Low Back Pain: A Randomized Controlled Trial. Physical Therapy
[serial online]. March 2012;92(3):363-377. Available from: SPORTDiscus with Full Text, Ipswich, MA.
Accessed April 12, 2013.
5.
George S, Wittmer V, Fillingim R, Robinson M. Comparison of Graded Exercise and Graded Exposure
Clinical Outcomes for Patients With Chronic Low Back Pain. Journal of Orthopaedic & Sports Physical
Therapy. 2010; 11:694-704.
6.
Vlaeyen J, Jong J, Geilen M. The Treaetment of Fear of Movement?(Re)injury in Chronic Back Pain:
Further Evidence on the Effectiveness of In Vivo. The Clinical Journal of Pain. 2002; 18: 251-261.
Texas State Department of Physical Therapy
PT 7539
2013