Factors affecting persistent/chronic pain are not only biological, but also psychological, social, and cultural. The treatment of pain must address all of these factors to truly help people get moving again!
One hopeful method of addressing psycho-social issues related to pain along with activity is the idea of ‘graded exposure’ or ‘graded activity’. In this article, we will review what this method is, how it might work, and what the research has to say about it.
Then, we will summarize some guidelines you can use to help you get moving.
Before reading this article, it might help to watch a couple quick videos on pain that I have posted earlier. These videos will give you a good understanding of how pain works and why things hurt. These are quick videos, one 5 minutes, the other 15. They are entertaining and easy to understand. Since understanding pain can help you deal with it, your time is well invested!
How pain works – Simple 5 minute video.
Why things hurt – Fantastic 15 minute video.
The ‘Fear-avoidance model’ of Pain
The ‘fear-avoidance model’ is a theory on people with chronic pain 1. It suggests that some of the primary factors related to pain moving from acute to chronic may be related to changes in your behavior. These changes in your behavior are due to fear of pain and fear of movement (kinesiophobia) associated with pain.
For example, if you strained your back lifting the garbage can, you will likely avoid that task in the future, even after the strain has healed. Furthermore, you may even feel pain months later when doing the same thing, because of what your brain learned from that painful experience. The task now sets off that ‘pain tune’ in your head, like how a love song that reminds you of a break up can make you sad.
Avoiding activities (and even particular contexts and environments) then starts to lead to serious changes in your daily life. This may start a cycle of increasing pain and disability.
Graded Exposure and Activity
Graded Exposure and Activity are methods of returning a person to those activities and contexts that they have come to avoid. It uses a progressive, step-by-step approach to returning to these activities. By helping people learn that these things need not be feared, and that they are actually capable of doing them, hopefully we can decrease pain and have them regain their physical abilities.
Graded Exposure involves identifying and making a list of feared activities, then approaching these activities from least to most feared. As activities are approached, people are assisted by a therapist to discuss the fears and beliefs, and then address them to reduce anxiety around the activity. In this way, a person gradually returns to the activities they once feared.
Graded Activity isn’t much different. Rather than the specific activities a person fears, simple functional activities are chosen for the program (for example: lifting something, bending over, walking up stairs etc.). The program is made more advanced as time goes on, regardless of pain, with positive reinforcement and encouragement given as the person progresses through the tasks. Hopefully a person realizes that they are not as limited by their pain as much they once thought.
Personally, I think great therapy would utilize a combination of the above. People need to learn they can do things, with or without pain. And we as therapists should be making people fear movement less.
When we show those spine models with grossly exaggerated disc bulges (google to see what I mean) we are not helping! We are scaring the crap out of people!
The research for the methods described above isn’t anything to get excited about. 2
A systematic review article (huh?) concluded that these techniques generally do have positive effects on pain and disability scales when compared to control groups who had “minimal treatment”. When reading the study (not just the abstract) you can see confidence interval plots (wha?) demonstrating a slightly better effect by graded exposure than graded activity. I postulate this to be due to the fact that graded activity is a little more crude, having people move through pain. But obviously that doesn’t make it ineffective.
However, the effect sizes (wha?) were small, and neither technique did any better than “exercise”. The authors of the review conclude: “There is no evidence that either is superior to a traditional exercise program for persistent low back pain”.
So it seems exercise, no matter how it’s done, is helpful for pain and disability. There seems to be no magical type of exercise for chronic low back pain. It’s all good.
Let’s not throw the baby out with the bathwater!
Think about it… was exercise actually haphazardly prescribed to patients in pain who were not in the ‘graded’ groups of the experiments? I doubt it. Exercise prescribed by professionals is almost always progressive/step-by-step in nature, and patients in pain are generally always instructed to pay close attention to the pain, avoiding or minimizing it. No one is going to ask a patient in pain to jump into an exercise program without easing into it slowly. Furthermore, no one who is in pain is going to jump into an activity they think will hurt them without easing into it slowly. Therefore, these types of experiments (like most) are hard to do properly.
Personally, I believe almost any exercise program serendipitously utilizes some sort of graded exposure effect. The whole point in exercise for pain is to help people stop being afraid, and get moving. If you can do that, you will help them. This isn’t really that surprising, considering what we now know about pain (watch the videos referred above). It has more to do with perception than an actually damaged or deconditioned body part.
- It seems that if you have persistent pain, you should probably keep moving. It should decrease your pain.
- When it comes to what exercise, it seems not to matter. Do something you like!
- Take a careful, step-by-step approach (duh!). Don’t jump into high volume or intensity exercise; gradually build yourself up to more complex and difficult movements.
- Pay attention to your pain, but don’t baby it either. “No pain, no gain” = not true! Completely avoiding pain also seems to make things worse. As usual, it’s all about the middle way! Think not about ‘sucking it up’, but more like ‘finding a way’.
I hope this article was helpful!
As always, its best to see a health professional yourself.
Try finding someone who is educated in current pain science.
In the end, don’t be afraid, and keep moving.