Fear and avoidance
Living with chronic pain is difficult and so naturally you want to avoid making your pain worse. People often think that resting and avoiding perceived painful situations is helping their body to heal when in fact, the opposite is true. The more we avoid activities and triggers, the more sensitive we can become to them, and the more we limit our lives.
Patients start to catastrophize about their pain, meaning they start to worry and think the worst – for example: “This pain will never go away”. Patients can become hypervigilant of bodily and painful sensations. Over time, the nervous system becomes sensitized and conditioned to create pain based on thoughts, feelings and situations alone.
Fear avoidance becomes a maladaptive, unhelpful behaviour. While avoiding things that we are afraid of may reduce that fear in the short term, in the long term it compounds fear, essentially reinforcing to the brain that the situation you are avoiding ‘should’ cause pain.
Avoidance in chronic pain patients can lead to a lack of confidence, social isolation, a lack of daily functioning and subsequently often leads to depression and anxiety. This feeds the pain and stress cycle, muscles become weakened, and the avoided activities become harder for the body to perform – worsening chronic pain.
This study explains that, “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 that patients can be helped to do just this.
What is Graded Exposure Therapy?
Graded exposure therapy combines cognitive and behavioural therapy techniques to retrain the brain, teaching the brain that it doesn’t need to create pain in reaction to specific situations and movements. For chronic pain, this graded exposure is typically done in vivo, which simply means that patients are facing their feared activities directly rather than using imagination or visualization as with graded motor imagery.
It breaks the association that the patient’s brain has made between fear and a specific movement by introducing a previously avoided movement slowly. With this slow introduction, the brain is given positive feedback that this movement doesn’t cause pain and doesn’t need to be feared. As the movement is built up to being performed fully and for longer periods of time, patients gain confidence and the brain learns that it can perform that movement without any pain.
From there more difficult movements and situations can be tackled. This study explains that, “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.”
The steps of graded exposure
- Pain neuroscience education
Before you can begin graded exposure therapy, it’s vital that you understand how pain is created and why this therapy works. It’s important to understand why avoidance is a maladaptive behaviour to comprehend the need to break this cycle.
Typically, before beginning therapy patients will undergo some educational sessions to give them this understanding. Not only does this allow patients to understand their pain better, knowing the science behind the therapy can also give them confidence in the therapy and empower them before beginning. This study states that before the therapy can start, “a preparatory phase of intensive pain neuroscience education is required.”
- Identifying fear inducing situations
The first step is to evaluate and list the situations that you are avoiding due to fear of pain. These will be individual to each person and the more detail the better; the therapist will usually guide you through different aspects of your life to establish which situations you have been avoiding and spark your memory.
- Developing a hierarchy
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 the brain to adjust to not needing to react in fear or send out pain signals for these activities. This gradual approach produces the most optimal results, as well as making the process easier for the patient to cope with.
- Planning exposures
The next stage is to start planning your exposures, simply meaning 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 loved one and somewhere close to home for that extra reassurance. You may then plan gradually increasingly lengths of walks, with less support over time and perhaps in areas further away from home.
- Carrying out exposures
You will be guided through doing this in the most gradual way possible. Starting with the least fear inducing action, you will begin to gradually engage in this action and for only a limited time. If pain is felt, the therapist will talk you through understanding that this pain isn’t going to hurt you, and if fear follows then a break will be taken to de-stress and recalibrate. The amount of time you engage in that action will be increased as you start to see results on fear and pain reducing. This study explains that, “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 realise that you can do this and that these actions do not need to be feared. 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, 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.
How can graded exposure help chronic pain?
By teaching your mind that the activities you have been avoiding do not need to cause fear, you can eliminate fear and in turn reduce pain and associated symptoms. Instead of avoiding situations, you can face them head on and with confidence.
While graded exposure also helps patients to understand that even if they do experience pain, it is not going to ‘damage’ them and that they do not need to fear it. This study states that, “patients receive positive reinforcement for performing fearful activities and utilizing beneficial coping strategies”.
This means that you can function again, think about your future, maintain a job, enjoy your life and feel confident in living a life without fear of your pain. As the therapy really starts to show results, patients will be encouraged to start setting clear goals for the future in order to keep them motivated and to help them to feel empowered. It really can be life changing and the results seem to be long term, although more research is being done all the time; this study found that, “Graded exposure added to manual therapy is distinctly superior to manual therapy alone in maintaining improvements for long-term fear-avoidance behavior and physical functioning.”
Successful outcomes are typically defined in four ways:
- Habituation: Fear of specific situations decreasing over time as the patient gets used to performing the action.
- Extinction: Fear reducing or being eliminated as patients face situations head on and the brain learns it does not need to evoke fear or pain for that situation.
- Self-efficacy: The patient gaining confidence, realising that they can face things that they have avoided and that they are capable.
- Emotional processing: The patient learning how to attach healthier emotions to their chronic pain and fear; gaining a fundamental understanding of their chronic pain and how to perceive it.
How can you access graded exposure therapy?
This sort of therapy is not typically suggested by doctors, but you could advocate for yourself by presenting research to your doctor at your next appointment and asking them to refer you. Typically, it will be carried out by a physical therapist or a pain psychologist. You can also access graded exposure therapy online, through an app (update Aug 2023: Pathways is now a web app! Start our program here) like Pathways Pain Relief.
Graded exposure therapy truly can help you to get your life back. We all deserve a life that allows us to be happy and fulfilled, which allows us to experience what life has to offer without being limited; that’s not too much to ask and it is achievable if you have chronic pain.
- 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”
Please note: This article is made available for educational purposes only, not to provide personal medical advice.