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Goal based exercise therapy- pacing and grading

In the last post we talked through what constitutes a good goal to aim for. Whilst thinking about your goals to work toward, you may have thought “I need to sort my pain out first before I even think about doing *insert goal here*!”.

See this is where most people go wrong. They think that they need to remedy the issue before they start doing the things they enjoy.

In this post, you will learn:

· Why you should start working toward a goal now rather than waiting until the pain is gone

· An introduction to “graded exposure”

· The demand/tolerance equation

· The skill of adapting exercise to meet your current capacity

Don’t wait

Have you ever had or currently have a phobia? Or do you know someone that has one? Or maybe seen a severe case on TV?

Well, managing pain (especially chronic pain) and tackling phobias have many similarities.

Hear me out.

When someone has a phobia, there is essentially 2 things at play. The first is the feared “thing” and the second is feeling of anxiety, panic and fear to that thing.

When someone has pain, there is also 2 things at play. The first is the “thing” that causes pain and the second is the actual feeling of pain.

Let me ask you this. What do you think is the best approach to easing phobias?

Is it waiting for it to go?


It is exposure! The best remedy for phobias is facing the feared thing (in a controlled manner).

The same goes for pain management. The best and most efficient remedy for pain management is not waiting for it to sort itself before you do things. It is exposure.

So do you just plunge head first into painful activities? Absolutely not! This is where the skill of “graded exposure” comes into play.

Graded exposure- the underutilised gem in pain management

Let’s revisit the phobia scenario. Let’s say someone has a very extreme fear of spiders. We have established that exposure to the spider (not avoiding) is absolutely necessary for resolution.

So do we just chuck them in a room full of spiders? Uhm, no!

Exposure is broken down into many different levels. Starting with just imagining the spider and working your way up in stages until they are close to it and then holding it. The more steps within this exposure ladder, the better!

This is graded exposure.

The same can be applied for working toward exercise goals when you are managing pain.

You can decrease the demand of the activity (which requires skill) until you are within a level of comfort that is safe and tolerable. Then you can gradually layer the demand in a steady manner until you are getting more and more able and closer to your goal.

The demand/tolerance equation

Again, lets use the phobia scenario! Anxiety, fear and panic are always at bay when the “demand” (how close the spider is) is less than the persons tolerance (when the anxiety kicks in).

The trick is to getting the “demand” as close to the persons tolerance without exceeding it.

This is where the magic happens.

This is where you grow and get stronger and adaptation occurs.

You want the demand to be as high as possible whilst remaining as close as possible to the tolerance of the individual.

Let’s put this into the context of pain.

Let’s say that Sarah who is 35 has had on and off back pain for 4 years and decides that she wants to start dancing again and win a salsa competition with her partner.

There are 2 avenues that she can take.

#1- Demand exceeding tolerance

She goes to a full session straight away despite the pain and hasn’t communicated with anyone that she would like to take it easy. She has danced before and tries to do everything she used to be able to do despite being in agony.

#2 Demand lower than tolerance

She communicates with the dance coach that she has a history of back pain and wants to only do a half session to start. He introduces her to a beginner class and she takes it really easy in her first session but still enjoys it.

On her next session she feels more confident so goes for a full session but takes more breaks and leaves having sweat a little bit but not done too many wild movements.

Which one is better? Obviously avenue #2.

The skill of adapting exercise to meet your current capacity

I can hear what you are thinking “This is all easier said than done!”


It isn’t easy to adapt exercise so you can remain comfortable. It is a skill. But it is easy once you have a list of the main things you can play around with when trying to break the exercise down to a level of demand that is tolerable.

General variables to play with:


This is an easy one but often neglected. What is more demanding- a 30 minute session or a 60 minute session? Play around with duration. It isn’t hard.


How often you do things is also something to play around with. That could be the frequency of sessions you within a week. Or it could be the frequency of how many times you do the same things within a session.


How hard or easy you do something can also be played around with. You can put effort on a percentage scale and see if you can decrease or increase by multiples of 10 and see if this makes a difference.

More specific variables to play with:

Right or left

You can change what hand you play with to give you a bit of a break. You could run on a different side of the road (as the camber is different). You could change the direction of your running.

Attire/ equipment

You could change the shoes you exercise in. You could get looser fitting clothes.


A little bit like learning to ride a bike with stabilisers, you could also use aids of some sort to help support you. This could be an ankle support, orthotics, wrist splint etc etc.

Body position

This is also simple but often neglected. You could have a wider or narrower base of support when you run. You could take shorter strides. You could swing a racket lower. You could only do half swings in golf.

Ok, now I have given you some variables that you can use to adapt the demand, lets put this into context with an example.

John is 72 but and has a history of neck pain but wants to get back to a handicap of 10 playing golf. He stopped playing golf because he felts that it was making his neck worse.

In order to bring the demand on the body down he could do the following:


He could play 9 holes instead of 18


He could go twice per week instead of 5x


He could try and decrease the intensity of his swing by 20%

Right or left

He could warm up with swings on his non dominant side.

Body position

He could get lessons to change his swing. He could try a wider or narrower base. He could stand closer or further away from the ball. He could try half or ¾ swings.

You can see from this example that there are so many variables that you can use to try and change the demand on the body. It is a matter of using these to bring the demand to your current level of capacity. Once you reach the magic spot where the demand is just right- then that is when you are working at a level where growth and adaptation occurs. This is when your body and your physiology changes and you start to become more robust!

In conclusion

You shouldn’t wait for a problem to go away in order to start doing exercise and moving toward goals. You need exposure! The skill is bringing the level of demand down to a point where it is as high as possible whilst still within your capacity. Once you know you can break any exercise down into many separate variable- then you can play with these in order to get to the magic spot where resilience is built!

Thanks for reading

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