Graded Exposure

566px-Weight_lifting_black_and_whiteGraded exposure is a key concept in understanding how to reduce pain caused by movement. It’s a very common sense idea, and one that most people kind of know at some level, because there is profound truth to it. But it’s also an idea that most people will probably fail to put into practice in a systematic way. Here’s a brief discussion of what it is, why it works and how to do it.

What is graded exposure?

Graded exposure is a process by which you slowly and progressively expose yourself to some form of stress, in order to make you less sensitive to that form of stress. In the context of movement, it means the progressive introduction of threatening movements, in the right dosage and timing, in a way that makes them less painful. 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.

Tissue adaptation – make your body stronger

There is some physiological truth to the idea that what doesn’t kill you makes you stronger. According to the SAID principle, the body will adapt to get better at withstanding specific forms of stress, provided they are experienced to a sufficient degree. For example, when the muscles are stressed enough by lifting weight, this causes micro damage that stimulates changes in muscle physiology. These changes will make the muscles stronger and less likely to get damaged by the same weight in the future. With this principle in mind, you can get stronger and stronger by progressively overloading your muscles over time. The trick is to expose yourself to stress in a graded manner – enough to stimulate adaptation, but not enough to cause injury or prevent healing.

The same principle can be applied to rehab injuries, especially overuse injuries like tendonosis. The difference is that in this context, getting the right timing and dosage is much more difficult, because the likelihood of injury or incomplete recovery is greatly increased. This makes it harder to find the “sweet spot” where you apply enough stress to cause adaptation, but not enough to cause or worsen injury. A careful and systematic approach is required.

For example, if you are currently experiencing pain in your foot after running a mile, you could try running just short of a mile, and then slowly inching your way upwards in distance, making sure that you are not making the pain worse. If you succeed, this might be a sign that you are applying enough stress to the tissues to get them to beneficially adapt, but not enough to cause injury or prevent them from healing. Most clients find this strategy fairly easy to understand, if not to apply.

The more complicated explanation for why graded exposure might reduce pain associated with a particular movement is that it makes the nervous system less threatened by the movement, even though the tissues are not really adapting in any meaningful way.

Nervous system adaptation – disassociate pain and movement

We experience pain in relation to movement when the nervous system perceives that the movement is threatening to the body. Like other perceptions, the perception of threat is an interpretation that is subject to change based on a wide variety of information. A program for graded exposure can offer the nervous system new information about a movement that might cause a change in perception. If you can find a way to perform a currently painful movement at a low enough intensity that it does not hurt, you are sending the nervous system feedback that the movement is safe. If you do this repeatedly, perhaps the nervous system will start to disassociate the movement from the pain. This is the same rationale underlying many treatments for anxiety and phobias.

Here’s an analogy to illustrate. If a child wanted to convince his overprotective mother that it was safe to play at the playground, he would first need to show her that he can play without getting hurt. A good strategy would be to start slowly with the safest activities, and then move to more dangerous ones, all the while showing Mom he is safe from injury or threat. Hopefully Mom will eventually chill out. You can go through a similar process of graded exposure to show your nervous system that a particular movement is safe. If running three miles causes panic, try running just one and see if that is acceptable. Then slowly inch the mileage upward and monitor the response.

Summary: graded exposure sends good news

A major goal of any program for movement health should be to send as much “good news” to the nervous system as possible about the state of the body, and its ability to withstand the stress of movement. Whether this is done by making the body stronger, or making the nervous system less concerned about the strength of the body is sometimes irrelevant. Either way, the formula for movement success is the same. Start moving how you want to move, make sure you’re not in pain during the process, and then move a little more next time. That’s graded exposure, and it’s how we get better at anything. Like many other ways to improve health, it’s simple but not easy.

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14 Responses to Graded Exposure

  1. Great post. Thanks for this.
    I’ve experienced this on a personal basis as well where if I push to hard with my muscles I can recover for a very long time.

    I thought the analogy with the mum was good.

    I’m going to keep trying this with other things.

  2. Thanks for the interesting post. Graded exposure is easier to achieve when focusing just on the dosage. I find that the real problem arises on getting the right dosage frequency particularly when recovering from injury. How long to allow between exposing the injury to stress? Age of the person is probably a factor. Also is it better to adopt a higher frequency but with lower loads rather lower frequency combined with higher loads. I am 69 and I have personally found that higher frequency with lower loads probably works best as long as I also include rest periods as soon as I sense they are needed. I have also found that rest without stress is definitely the wrong approach when trying to recover from injury.

  3. I find my biggest challenges is to get people to step away from the “no pain, no gain” approach. Even after multiple sessions of coaching my clients and giving them a distilled version of this info, many of them still insist they must force themselves into pain. Any strategies that author/readers have found helpful?

    Thanks as always fr the good read and straight forward writing.

  4. Hi Todd
    I just wanted to say how much I enjoy your blog posts. I’ve been a subscriber for quite some time and yours is one of the few subscriptions that I’ve maintained. Well done and thanks for sharing.
    Best wishes,
    Sandra Bradshaw, GCFP

    • Thanks Rohan,

      The book is almost done. Just a little bit more proofreading to go and should be out in a couple weeks.

  5. Good read Todd. Definitely going to help when i’m recommending exercises to patients and explaining to them when and when not to increase difficulty. Especially when i can use the playground analogy.

  6. Great post Todd – well-stated, with clear, practical suggestions!
    What follows is not intended to be contradictory, but supplemental to your post.

    We have been playing with teaching people to do their best to keep their breath calm and muscle tension ‘low’ at the same time as they move their body to a place where they feel safe AND feel increased pain, or to a place where they are not certain they are fully safe, but that they believe there will not be an adverse flare up.
    Calm breath, body, and mind to help teach the nervous systems that the movement isn’t so dangerous.
    I mention this because sometimes it is not possible to find a movement with no pain – even imagined movements might produce pain.
    I am guessing that as you move people forward, you would suggest they start to try to push into the pain more – as much as they can while continuing to send the messages to the nervous systems that this is not that dangerous.

    Playground analogy – the mother believes the activity might be dangerous. If she cannot maintain some calmness, even though nothing dangerous happens, she might not desensitize. e.g., if her nervous systems continue to play the stories of tragedy while the child plays, the happy ending might not be enough to alter the brain’s interpretation.

    • Hi Neal,

      Thanks for the comment. Great point about the need to move into pain sometimes. Especially when there is no other choice! The way I think about this sometimes in myself or in my client is that it is Ok to move some way and cause pain in the short term, so long as that movement is not making your progressively worse over time. For example, let’s say my foot hurts a little all the time, and when I run it hurts worse. If I run 2 times a week these short term flareups don’t change the baseline. If I run 3 times the baseline gets worse. In this example, running twice would be OK, 3 times too much, and I would try to increase my running to 3 without increase in the baseline pain.

  7. Great stuff. I just found you through a link from Dean Somerset. This is the 4th article that I have read from continuous linking. Your addictive. I am 67 and have been active all my life. I became a trainer CPT, CES, Golf Fitness, and soon Functional Aging Inst. Certified when I retired from corporate life. I deal with pain always. I work with a great pain management doc. I have had multiple surgeries due to football and then 30 years of running 6-8 miles a day and then starting weight training with some really bad advice from the Muscle and Fitness crowd 20 years ago. Long way around, if I had not been active all my life I would be in a lot worse shape. I have an MRI of my cervical vertebrae that several doctors have called “scary”. The Neuro surgeon said that the bad news was that he could help me because he could not fuse my whole neck. The good news was that since I was in good (relative) shape I did not have to have surgery. I am my own living lab. I could go on about myself but I want to move over to my clients as well. I work with a lot of seniors (that means at least 10 years older than me) in assisted living homes and memory care homes. My observation in the assisted living homes is that if I had had access to many of these folks earlier they would not be in pain or need the walkers. My oldest client is 107. She was active all her life as a professional tap dancer until she was 87. When she was moved to the assisted living home she stopped the active life style. After 6 months of functional strength and balance work she uses the walker now as just precaution but does not need it to get around. Her “aches and pains” have significantly reduced. Sorry for the long epistle.
    Love your work. I am a convert.

  8. Great article. Would you say graded exposure not only applies to pain, but also to other neurological symptoms? Would you agree? e.g. sensory changes, balance problems, etc.

    • Hi Mike. Great question. Here are some thoughts.

      I think there are a few basic reasons why our movement or perception is not optimal. First, we haven’t learned the movement or perception very well yet, and to remedy this we need education or motor learning. Second, we have already learned the right way to move, but because we perceive the movement as threatening, we adopt protective strategies such as creating pain, stiffness, weakness or altered coordination. In this case, we need graded exposure to the threat or other inputs that change threat perception. Third, we might have a disease process that affects neurological functioning – a tumor, injury, or autoimmune problem affecting the way the nervous system processes inputs and creates outputs. In this case, I don’t think either motor learning or graded exposure address the root problem but they may help to counterbalance or compensate for deficits.

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