Overcoming Movement Barriers

An Introduction to Graded Exposure Stretching

By Erik Dalton, PhD

Key Point

• Graded exposure stretching works by systematically subjecting a client to their feared stimulus in a controlled manner, helping them break the cycle of avoidance and fear reinforcement.

Bodyworkers know chronic musculoskeletal pain often follows a pattern. First, an injury causes pain. Clients fear that any movement will aggravate the pain or cause more damage to the area, so they alter their movement patterns and reduce their activity levels. At some point, the injury heals, but for many clients, the pain pattern becomes ingrained and disability persists. 

Some clients fall into sedentary lifestyles where a lack of movement further exacerbates their physical condition. Other clients attempt to return to chores, work, exercise, and activities they once enjoyed, but they encounter challenges. 

One challenge arises when feelings of anger, grief, and anxiety about the condition increase pain sensations. Additionally, people living with chronic pain are prone to central sensitization, a broad term referring to nervous system hyperexcitability. Clients might experience hyperalgesia (increased sensitivity to pain) and allodynia (the perception of pain from exposure to nonpainful stimuli). Central sensitization may result in defensive muscle spasms, muscle imbalances, and ongoing compensatory issues. Living with ongoing pain is also exhausting and may lead to decreased energy levels that make physical activity daunting. 

In Myoskeletal Alignment Techniques (MAT), therapists use graded exposure (GE) stretches to improve flexibility and help clients engage with painful movement barriers. GE stretching reduces the anxiety associated with a particular movement pattern or situation. 

Principles of Graded Exposure Stretching  

The underlying principle of GE stretching comes from cognitive behavioral therapy, where gradual contact with anxiety-producing stimuli promotes healing from phobias and anxiety disorders. If a person avoids movement, they inadvertently reinforce their fear. Over time, this avoidance behavior becomes deeply entrenched. GE stretching works by systematically subjecting the person to the feared stimulus in a controlled manner, helping them break the cycle of avoidance and fear reinforcement. 


To perform a GE stretch, the therapist moves the client’s body to the first mild pain barrier and instructs the client to contract their muscles against the therapist’s resistance for a count of five, then relax. The therapist then moves the client’s body to the next mild pain barrier and repeats the sequence. The therapist might repeat the stretch multiple times until the client becomes comfortable with the movement.  

Movement Enhancers 

GE stretching also employs “movement enhancers” with appropriate stretches. The therapist starts in a position that targets the desired muscle group or joint and then instructs the client to introduce additional dynamic movements. For example, the therapist might ask the client to tilt their pelvis, twist their torso, or move other body areas that aren’t the primary focus of the stretch. Exploring different movements and angles of movement produces a comprehensive stretch. Similarly, activating opposing muscles with movement can help relax and lengthen the targeted muscles through reciprocal inhibition. Dynamic movements further stimulate proprioceptors, potentially leading to deeper relaxation and lengthening of the target muscles. Most importantly, movement enhancers give clients a sense of control and introduce novel stimuli that hold the brain’s attention. The feeling of control and curiosity helps downregulate nervous system hyperactivity, thereby releasing regions of dysfunction from protective muscle guarding. 

Example Techniques 

The following two GE techniques for the lower body serve as an introduction to this methodology. Watch the video accompanying this article for an example of movement enhancers, such as asking the client to bridge while holding their knees. 

It’s crucial to understand the client’s health picture and when particular methods might aggravate a client’s condition. If you don’t perform procedures correctly, there’s a potential for overstretching and straining the client’s muscles. These techniques should not feel painful, so discontinue any maneuvers that cause increased pain and discomfort. 

Hip External Rotators Stretch (Image 1)

In this GE stretch, place the client’s right foot across their left knee and ensure their toes point toward the end of the therapy table. Control the knee with your right hand while your left hand braces the client at the right anterior superior iliac spine (ASIS). Ask the client to gently push their knee into your hand to a count of five and relax. Push the client’s knee toward the table, stretching external rotators until you find their restrictive barrier. Ask the client to push their knee against your resistance to a count of five and relax. Repeat this procedure five times on both sides of the body.    

Quads Stretch (Image 2)

With the client on their left side, ask them to grasp their left knee with both hands and pull their leg into flexion. Use your right hand to grasp above the client’s knee and use your left hand to brace the client’s hip. Flex the client’s knee and place your body against the client’s tibia. Bring the client’s knee into flexion and their hip into extension to the first restrictive barrier. Ask the client to gently push their leg against your body to a count of five and relax. Bring the knee and hip to the next flexion and extension barrier and repeat this process 3–5 times on both sides of the body. Avoid this technique on clients with hip or knee replacements. 

Erik Dalton, PhD, is the executive director of the Freedom from Pain Institute. Educated in massage, osteopathy, and Rolfing, he has maintained a practice in Oklahoma City, Oklahoma, for more than three decades. For more information, visit erikdalton.com.