What is Graded Exposure and What Does It Have to do with Chronic Pain?

Graded exposure is a simple tool anyone can use to help map out what causes fear and gives you a way to move through it and then past it. It’s a therapy that helps you face your fears in a gradual way. It can be used for any sort of anxiety but is often used to break the pain cycle by tackling fear-based avoidance which so often accompanies chronic pain. 

 Anyone that has experienced chronic pain has stories about how we end up adjusting our lives to avoid making our pain worse. Sometimes it’s looking for the holy grail of chairs, or mattresses. Knowing we can only bend a certain way on the second Sunday of even months. That we CAN do x but we CAN’T do y or z. Walking the dog hurts, so we avoid and slowly move our boundaries closer and closer to ourselves and our worlds get small as pain creates fear.

Living with pain is really hard. So of course we want to avoid doing things that make the pain worse. Like rest, we often think resting will avoid more pain and help heal whatever is causing the pain. The problem is – this isn’t true. The more we avoid activities and the less we move the more sensitive we become to them and the more our lives are limited. 

While I hate the word “catastrophize” in relation to pain, I do understand that the longer we are in pain and the more it disrupts our lives the easier it is to start thinking” this pain will never go away.” The draw to eliminate the pain and “figure it out” causes a hyper-focus on the body and its sensations. Over time these thoughts and vigilance help sensitize the nervous system. It conditions the nervous system to create pain on thoughts feelings and situations without the need for injury or damage.  

The hard reality is as our boundaries get smaller and smaller our avoidance goes from helpful to maladaptive, and unhelpful. While avoiding things that we are afraid of may reduce that fear in the short term, in the long term it essentially is reinforcing to the brain that the situation you are avoiding ‘should’ cause pain. How much does that suck!

This study explains, “Long-term avoidance behaviour has been hypothesized to have psychological (hyperalgesia and depression), physical (limitations in physical performance and disuse syndrome), and societal (chronic disability) consequences. However, breaking this cycle is possible, and graded exposure therapy is one-way people in pain can be helped to do just this.

What is Graded Exposure?

Graded exposure is a process by which you slowly and incrementally expose yourself to some form of stress or load so that you will be less sensitive to that form of stress. Since we are talking about pain, it means the progressive introduction of threatening movements, in the right dosage and timing, in a way that makes them less painful and more tolerable. The point is to teach the brain it doesn’t need to create pain for these situations and movements. 

This might happen in one of two ways – through causing a change in the body, or a change in the way the nervous system perceives threats to the body. For chronic pain, graded exposure is typically done by facing their feared activities directly rather than using imagination or visualization as with graded motor imagery. 

The point is to break the association the brain has made between the fear and the movement. This is done slowly and allows the individual to gain confidence and positive feedback. As the activity is repeated without pain or an increase in pain, the fear starts to subside. This leads to trying a little more. With more positive results less fear and we gain confidence and the brain learns it can do the movement without pain. 

As I started to gain confidence in PT with smaller movements I began to try to expand my world with walking. I was afraid to be too far away from home or a place to sit. I started walking around my house with plenty of places to sit and increased my time and my distance slowly.

I became confident walking around my home where I had not been months earlier. Fear threatened me again when I considered getting the mail. It felt silly, but it was outside with people and different textures of sidewalk and grass and a sloped driveway. It took time to decrease my fears about my trip across the street to get the mail, but I was eventually successful and decided to take my newfound freedom and walk around the block.  Oops… too much too soon. Pain and flare and set back occurred.

So I broke down that task of the block and added a house or two. Now I am able to walk mile after mile with no pain and no fear. It works! It just takes time and patience and willingness to readjust the plan!

This study explains, “Exposure proceeds in a hierarchical fashion, starting with exercise or activity that elicits minimal amounts of fear and then gradually increasing to situations that elicit larger amounts of fear.”

So start small and build from there. Rome wasn’t built in a day!

How do I try to use Graded exposure?

1. Understand a few basic things about pain science. Why? Well, it makes the whole thing a lot easier.
   1. Hurt/ pain doesn’t mean there is damage, there is a perceived threat.
   2. Pain is ALWAYS an output of the brain 100% of the time, but that does not make it fake or not real. It’s how we experience pain. Just like hunger and love are ALWAYS an output of the brain 100% of the time.
   3. Pain is influenced by multiple factors. For example, sleep, thoughts, activity, and or stress.
   4. Acute pain serves an important purpose of being protective to warn of danger or injury.
   5. Chronic Pain results from a hypersensitive nervous system and usually is no longer warning of actual danger.
   6. There are many treatments that help “turn down” a hyper-sensitive nervous system which can improve quality of life and decrease pain.

Thanks to MACQUIRE University for sharing their 6 core concepts of pain.

2. Identify the movements of situations that cause you fear.

If you are anything like me, this list is likely to be long. So don’t overwhelm yourself. Just start writing down things that you have a fear that you will bring on pain, or you know will bring on pain, so you avoid it. Write as much as you wish.

3. Develop a priority or hierarchy list of the things you identified.

The next step is to rank these activities from the least fear-inducing to the most fear-inducing. Patients will be encouraged to break down larger situations into smaller bite-sized pieces. 

Graded exposure therapy tackles the least fearful situation first before you make your way gradually up the hierarchy in a step-by-step way. This allows your brain to adjust to not needing to react in fear or send out pain signals for these activities. Doing this gradual approach produces the best results, as well as making the process easier for you to cope with. It may seem overwhelming, but hang in there it’s worth it. I promise.

4. Plan your exposures

Alright, you got your list. You’re ready to tackle the first thing on it. hold up. Before you act… make a plan. The next stage is to start planning your exposures, which simply means planning how you are going to tackle each activity. For example, if you have identified going for a walk as an activity that you fear will cause pain, you can start planning a very short walk, perhaps with support from a friend or a loved one and somewhere close to home for that extra reassurance. Then plan gradually increasing lengths of walks, with less support over time and perhaps in areas further away from home.  Sounds crazy, but it works. I am so looking forward to my trip to Disney in the fall without worrying about how far I can walk now!

5. Do it! Enact your plan.

Starting with the least fear-inducing action, begin to gradually do this action for a limited time. If pain is felt, remember that this pain isn’t going to hurt you and if fear follows then stop and de-stress and recalibrate. The amount of time you engage in that action should be increased as you start to see results on fear and pain reduction. This study explains, “Patients are instructed to safely break the cycle of inactivity and deconditioning by engaging in activity in a controlled and time-limited fashion.”

It can feel scary to start facing your fears but you will find your confidence growing as you see results; you will begin to realize that you can do this and that these actions do not need to be feared. It is frightening at first, but it is so freeing.

This study explains, “Therapists should try to decrease the anticipated danger (threat level) of the exercises by challenging the nature of, and reasoning behind their fears, assuring the safety of the exercises, and increasing confidence in a successful accomplishment of the exercise.”

Not only will you be actively training your brain away from fear and pain, but you will also be building up your muscle strength and making your body physically fitter. Sometimes graded exposure will be done alongside or as part of physical therapy, particularly for those who have had a previous injury.

Graded exposure can be used alongside prescribed medication and other therapies such as mindfulness techniques. Often mindfulness techniques may be implemented as part of the therapy, as a way to deal with the fear when engaging in activities and keeping stress levels down.
and don’t forget to breathe! It’s hard to be anxious and afraid when you are breathing slowly.

Grab my simple solutions guide on ways to change your breathing and as always, join our Facebook group to get more support and celebrate your wins. Click here to join!

References

• Manual Therapy, Jo Nijs, Enrique Lluch Girbes, Mari Lundberg, Anneleen Malfliet, Michele Sterling, (2015), “Exercise therapy for chronic musculoskeletal pain: Innovation by altering pain memories”
• Archives of Physical Medicine and Rehabilitation, Ariza-Mateos, Cabrera-Martos, Ortiz-Rubio, Torres-Sánchez, Rodríguez-Torres J, Valenza MC, (2019), “Effects of a Patient-Centered Graded Exposure Intervention Added to Manual Therapy for Women With Chronic Pelvic Pain: A Randomized Controlled Trial.”
• Steven Z. George, PT, PhD, Virgil T. Wittmer, PhD, Roger B. Fillingim, PhD, Michael E. Robinson, PhD, (2010), “Comparison of Graded Exercise and Graded Exposure Clinical Outcomes for Patients With Chronic Low Back Pain”
• Journal of orthopaedic & sports physical therapy, Steven Z. George PT., PHD., Giorgio Zeppieri JR., (2009), “Physical Therapy Utilization of Graded Exposure for Patients With Low Back Pain”
• American Psychological Association, “What is Exposure Therapy?”
• Physical Therapy, Volume 90, Issue 6, Luciana G. Macedo, Rob J.E.M. Smeets, Christopher G. Maher, Jane Latimer, James H. McAuley, (2010), “Graded Activity and Graded Exposure for Persistent Nonspecific Low Back Pain: A Systematic Review”
• Psychology Research and Behavior Management, Daniela Roditi, Michael E Robinson, (2011), “The role of psychological interventions in the management of patients with chronic pain”
• https://www.bettermovement.org/blog/2014/graded-exposure