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Episode 25: Graded Exposure for Pain

Video Highlights

Hi everybody!

Dr. Eric Cobb back with you.

Last week, I gave kind of a long lecture on pain, and while it’s a huge topic and very important, what I wanted to move to this week was discussing “what do I do if I’ve been experiencing pain for a long time?”, “I’ve spent time with my physician, I’ve spent time doing the therapies that they’ve recommended, and I’m still having pain?”

This applies to a really large percentage of the population, far more than we would like. Very often we’ll have someone, they hurt their knee or their ankle or their foot or their back or neck or shoulder, and now all of a sudden it’s 15 years later and they have avoided almost everything that would cause them to challenge that area of their body because they’re afraid and because they’ve experienced a lot of pain there.

If you listened to the blog last week, what you understand at this point is that pain is actually an action signal, and it all revolves around electrical activity in the nerves in the body in the spinal cord and in the brain itself. Really, whenever we’re experiencing pain, it is supposed to be an alarm signal that gets the brain to take an appropriate action. Let’s talk about this.

If I sprain my ankle, I’m out for a run and I fall in a hole and I sprain my ankle, an appropriate action is to care for that ankle. I’ve got to walk funny for a little while, I’ve got to do something to get the swelling down. If it seems really bad, I may need to go see the doctor and make sure that I haven’t broken anything, that nothing significantly bad has happened to the connective tissue. But there’s some appropriate stuff that I should do when I injure myself.

Now let’s imagine that we’re five years down the road from that initial ankle injury, and I’m still having pain from it. That’s because the alarm system is not functioning normally in my body. Very often what will happen is that that ankle, the pain will go away for awhile, and then when my stress level goes up or I start doing a new activity or I change shoes or whatever, I change something in my environment that my brain is uncertain about and fearful of, unconsciously — not consciously, unconsciously — very often the pain will start again.

If this sounds like you or someone that you know, what we want to talk about this week is what’s called graded exposure. This is a really simple idea to convey an incredibly powerful concept. Here’s the concept.

Whenever we have an area of the body that has been painful for a long time, we develop very often both an unconscious and conscious fear of moving that area. Let’s say I’ve had a shoulder problem. When I originally hurt it, it hurt to get up to this point. Because I am fearful of pain, I will not go quite that far. Now my brain will then begin to adapt to this, and now six months later I can only go this far without pain. This is a very, very common theme that we see, but it’s all related not to physical damage here, especially if we’re talking years later, but instead to a fear-based reaction in the brain that makes me very, very cautious about movement.

Close of a scale from poor to excellent.

Graded exposure as a concept says, “hey, let’s take a close look at what you’re afraid of, and then let’s do incremental tasks around that so that your brain can learn not to be afraid of it.” Here’s a classic example. I’m talking about the shoulder. It’s very common for someone to come in to see us and we go, “Okay, what’s your problem?” They say, “Oh, I’m having a shoulder issue.” “How long have you had it?” “Uh, twenty years. It comes and goes, and now it’s just gotten bad again.” We rule everything out and we send them to the doctor if necessary and make sure that there’s nothing weird going on.

But at that point, if we go, “Hey, this is just one of those chronic alarm system problems in the brain,” we’ll begin doing some tests. I’ll ask them, “Okay, so show me where pain begins,” and they’ll raise the arm up and they’ll usually stop around here and go, “Ah, that’s when it begins.” At that point, we will begin doing some small shoulder exercises, maybe some other stuff in the body, but if you can see, instead of having them work constantly into the pain, we will have them work right to the edge — right at the very border and stop before the pain begins.

Very often in a single training session, if people are willing to just breathe and relax and confront their movement fears, we often will see people gain 20 to 30, even more, degrees range of motion just with a little bit of work and practice and making the brain feel safe again.

Graded exposure can be applied across the board. If you’ve had a back injury and you’re afraid of bending over, you don’t start off working by going “Okay, I’m just going to dive into this.” Instead, you practice bending over just a little bit, then just a little bit more, and a little bit more over time. You make sure that your brain goes “Okay, I’m getting the idea that this is safe again.” Your brain operates this paradigm — fearful or safe. The more that we can make movement and all of the little joint things that we have to do in our body feel safe, the higher the likelihood is that we’re going to go through life with a lot less pain.

Think about this idea of graded exposure. Like I said, you can look it up online, there’s a lot of different ideas. But applying just a little common sense and going, “Okay, what bothers me? How could I do it a lot smaller and a lot slower?” Most people can start to figure out ways to retrain themselves and really what it requires is a little bit of belief and a little bit of faith that things are going to be okay.

If we can help you in any way, help any one of your loved ones that have been struggling with these kinds of issues, please let us know. We’re happy to answer questions, we’re happy to direct you to resources to learn more about pain. But for us, understanding this is really one of the biggest blessings that we’ve ever received.

To really understand pain is to no longer fear it and to know how to work with it and how to alleviate it, which I believe is one of the greatest gifts that we can ever give someone.

I hope that this week finds you pain-free, but if you found some value in this video and you think of someone that this may help, please be sure to pass it on.

Thank you so much.

Talk to you soon.

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