Monday, November 20, 2017

Differences In Graded Exposure And Graded Exercise

Sometimes I get confused.

Okay, actually, I get confused A LOT.

There are lots of terms in our profession, some sound alike, but mean completely different things. As a result, I get some of those terms mixed up and can’t always remember the difference between things like isometric, isotonic, or ginandtonic.

Thus the inspiration for this post. To understand the difference between graded exposure and graded exercise, as they both sound the same, but mean different things.

Then comes the question of how do we apply both of these in practice, and are both actually effective?

Graded Exposure

Quite often we get patients who come in after an injury, or diagnosis and are afraid to move because they’re worried it will make the injury worse.

We used to preach to patients that movement was a bad thing during an acute injury, so would always recommend complete rest and immobilization, which also played into this fear that movement was bad. And of course, we’ve all had those times where a patient has been told by another practitioner things like: “if you move your disc bulge will get worse,” or “your pelvis is out of alignment, so we need to stabilize it and reduce movement.”

All these statements do, is put a fear of moving into the patient. Some of these patients have been hearing the same stories for years from various practitioners, so many of those beliefs are deeply ingrained.

Graded exposure is a way to gradually expose patients to those feared movements.  It is probably used in psychology (as a means to treat anxiety and phobias), way more than it is in manual therapy, but it has become a valuable tool for us to use in practice. In anxiety or phobia situations, they expose a patient to whatever their fear is in small doses until they can gradually control their fear.

For us as manual therapists, we can use this to gradually expose patients to whatever their feared or restricted movement is. Our biggest role, in this case, is education and helping the patient to understand the ramifications of long-term fear avoidance. One case study showed how using graded exposure as part of a biopsychosocial approach helped a patient who was restricted in spinal flexion (due to concern about disc damage) actually overcome that fear, start to exercise, and return to work.

One of the great ways to do this in practice is to get a patient to move in a different plane of movement, or passively move them during treatment. Imagine a patient comes in complaining of low back pain, and when you ask them to touch their toes, they can’t do it. Try putting them in quadruped on the table, and just have them drop back so their gluts touch their heels. Explain to them how this is essentially the same movement, as their spine has gone into flexion, which also demonstrates that they don’t need to be fearful of the movement. Or if a patient comes in with limited shoulder abduction, passively move that shoulder (gradually) into abduction during the treatment, then show the patient how it is possible for their shoulder to move that far. When they see how the movements are possible it gives positive reinforcement, which you can build upon to continue movement and treatment.

These are just simple examples, but it demonstrates how to start using graded exposure in your practice. Todd Hargrove wrote a great piece on how to start implementing graded exposure in your practice which you can read here. If you don’t follow Cory Blickenstaff, check out his blog where he talks about this kind of stuff a lot and gives some clear direction on how to use it appropriately. 

Graded Exercise

So, this is where I got a bit confused.

Because we can use graded exposure to get a patient moving, isn’t that the same thing as exercise?

Well, the way I read it, graded exposure is more of a method to change belief systems by demonstrating certain movements are possible, thus instilling confidence in the patient. It’s basically a way to get them moving again.

Once you have them moving again, this is where graded exercise comes into play.

If we look at doing any kind of rehab with a patient, exercise and movement should be a fundamental part of getting them back to activity, whether it is an athlete wanting to get back to their sport, or someone who has been in a car accident and needs to get back to work.

Part of my confusion is that graded exposure is actually a part of a graded exercise, as we are going to provide more resistance and load to those feared movements. Graded exercise is where we start the patient moving, then gradually increase it, this could be via increased load or endurance, depending on what is necessary for that patient. 

One study shows that when you compare graded exposure to graded exercise, the exercise is more effective in reducing catastrophizing when it comes to back pain, and also points out that catastrophizing may play a  part in the transition from acute to chronic pain. The same study had patients do group exercise which consisted of cardiovascular, stretching, strengthening, and functional movement and they saw several functional and objective improvements over an 8 week period. The study also went on to say there is no credible evidence that patients with chronic low back pain should avoid exercise, yet activity restriction is consistently recommended.

So lack of movement and exercise can actually contribute to a patient catastrophizing and making their condition worse, yet because of old habits, this is precisely what gets prescribed to patients! 

As Massage Therapists, we could start with some contract-relax stretching/movement while the patient is on the table, then depending on tolerance, increasing load with specific movements after treatment is done. I know prescribing exercise is out of scope for some MT’s, yet it’s okay to do passive and active range of motion. If this is the case for you, start your patients with passive movement on the table, then progress them to active ranges of motion. When they get off the table, just have them do bodyweight movements that load whatever portion of the body they are having difficulty with. You’re not prescribing exercise, you’re just having them move in specific ways, which is part of your treatment. The evidence is mounting on how effective this is, especially when combined with manual therapy, so while you may have to be creative, start incorporating it into every treatment.

Now I have to go do some research on ginandtonic movements. 


from Beauty Salon, Spa, Massage

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