Chronic Pain and Exercise. Where to Begin?
Many people in pain want to become active but don’t know where to begin. This is a brief introduction on exercise for those with chronic pain. Before we discuss the specifics of exercise for pain, I want to take the time to explain pain. Pain is a very complex topic and it is not realistic to think that this article can explain pain in a detailed manner.
We have to start thinking of pain as the body's way of protecting itself and is not simply an indication of tissue damage. This is made clear in the definition of pain as described by the International Association for the Study of Pain:
Pain is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”
The purpose of this post is to discuss chronic pain and exercise. Chronic pain is defined as pain lasting more than 12 weeks. In many cases, the original injury has healed that led to the initial pain output from the brain. However, the brain is still outputting pain as a way to protect and warn us. I urge you to watch these short videos on YouTube describing chronic pain:
1. ‘Understanding Pain: What to do about it in less than 5 minutes’:
https://www.youtube.com/watch?v=RWMKucuejIs
2. ‘Lorimer Moseley: Why Things Hurt’: https://www.youtube.com/watch?v=gwd-wLdIHjs
Professor Patrick Wall described three stages that take place when you are injured in his excellent book 'Pain: The Science of Suffering'.
The 3 stages are withdrawal, protection and resolution.
Withdrawal is what your nervous system will do in order to remove your injured body part from the initial source of injury. Think of the time you burnt your hand on the stove and you instinctively removed it without having to think. This is your nervous system working for you in order to reduce further tissue damage.
Following the initial withdrawal phase your body will protect. Protection is your nervous system’s way to try to ensure no further painful stress and possible damage occurs. When your hand got burned, you grabbed and held it. You may have even rubbed it and blew on it. That’s your nervous system working to protect your hand from further damage. It is all done instinctively and you don’t have to think about it.
This is an important stage for healing. However, in some cases your body continues to protect the injured area long after the tissue has healed. It would be like holding the hand that was burnt close to your body and rubbing it for months after the skin has healed. This can happen and we see it with injuries to the lumbar spine. People will protect and guard the motions of their spine long after the initial strain. They’ll avoid bending and turning at the waist just like the first day they hurt themselves even though the back has healed.
Resolution is your nervous systems way to restore normal mobility and function to the injured part. People with pain that persists long after the initial injury are stuck in the protective phase. They may feel ongoing stiffness, coldness and spasms. They will also struggle with coordinating their movements. Exercise and movement may help move out of the protective phase and into the resolution phase.
During or after exercise you may feel you might feel warmth and reduced stiffness of the painful area. This is due to the body releasing pain relieving endorphins and creating blood flow into the painful area. These endorphins and blood flow can help reduce sensitivity of the area and muscle stiffness. A physiotherapist can help you create an exercise program that works for you in order to move from the protective into the resolution phase.
Many patients I see in my practice have chronic pain. My role is to provide education about their pain as well as prescribe exercise. My role is to assist your nervous system to move from the protective phase into a resolution phase. Naturally, people are hesitant about exercising while in pain. There is a misconception that movement and exercise is harmful and could make the problem worse. However, a physiotherapist is an expert in movement and will know what would be a safe starting point for exercise.
It is important to understand the concept of ‘hurt vs. harm’. When you begin an exercise program we would expect there to be some discomfort and pain. However, keep in mind these movements are safe and are not harmful to your body.
Pacing is important when returning to exercise. If you have been fearful to walk for many months we wouldn’t expect you to go for a one hour walk if the longest you have walked has been 10 minutes. This is where setting a schedule and pacing yourself is helpful. I have some clients that begin with 5 minutes of walking per day. Each week they may increase their walking time by 1-2 minutes. This might not seem like much, but it is helpful to gradually increase your distance in order to prevent pain that may last for days after exercise. This gradual reintroduction to exercise can lead to blood flow to sensitive nerves and ongoing tension on the nerves.
When beginning an exercise program it’s important to avoid the “no pain, no gain” approach. Your nervous system is already sensitive and protecting. If you push past your pain threshold you can further irritate the already sensitive nervous system defeating the purpose of exercise which is pain relief. If you cause yourself pain and feel worse for days after exercise you run the risk of feeling defeated and giving up.
The second mantra to avoid is “if it hurts, don’t do it”. This is common since many think that they’re damaging their body when they feel pain. This approach could lead to fear of movement and further atrophy of the body. You won't reduce your nerve sensitivity and achieve resolution if you never push your body to some extent and reproduce some pain. The key is that the amount of pain you experience should be acceptable to you and not leave you sore for days after you exercise.
Finally, you should follow the “tease it, touch it, nudge it” mantra. Here you are expected to exercise to the point of slight discomfort but not push through the pain and ignore it. As you challenge your body and move slightly further than you’re used to you will notice a reduction in pain. You’ll also see a gradual increase in the number of sets and reps you can perform as well a distance you can walk. This will gradually lead to improvements in your function which should always be your focus rather than decreasing pain.
There are several forms of exercise you can perform that can lead to reduced pain and improved function. I am going to focus on aerobic exercise and strength training. Movement is considered to be the greatest pain-killer that exists. Long distance running has been shown to be a proven form of analgesia. Of course, we wouldn’t expect you to start with running for miles as a form of exercise. The point is that exercise is a proven pain reliever. In fact, think of your brain as having a drug cabinet full of pain relieving hormones. Exercise unlocks this drug cabinet and releases these hormones into your bloodstream.
It has been shown that short bouts of exercise can lead to pain relief. Aerobic exercise at a level of 50% VO2 max and for a duration of 10 minutes is required to elicit exercise analgesia (Hoffman et al 2004). In order to achieve 50% VO2 max you should aim to exercise and raise your heart rate to 100-110 beats per minute. This is a level that can lead to exercise analgesia. You could start with 5 minutes and each week add 1-2 minutes or more as you improve. Before long, you’ll be walking for 30 minutes.
Strength training has also been shown to reduce pain. Evidence suggests that lighter weight and higher reps should be used with patients with chronic pain (Brosseau et al 2008). There’s no need to start with a heavy weight that you can only lift 6-8 reps. Instead, find a light weight that you can lift 15-20 times for 2-3 sets. You may only be able to perform 1 set of 15-20 reps which is also fine. Remember, the goal is to gradually increase activity over time. There is no quick fix to chronic pain. Don’t focus on the pain as you exercise. It’s more important that you track the weight, sets and reps that you’re performing.
Hopefully this is helpful information and motivates you to start to exercise as a way to mange your pain. Contact one of our 4 physiotherpists at Advantage Physiotherapy Fredericton, New Brunswick to help design an exercise program that's right for you.
Written by: Rob Willcott Physiotherapist
Advantage Physiotherapy 102 Main St. #15 Fredericton NB
www.advantage-physio.ca
twitter: @advantagephysio
References:
Brosseau L, Wells GA, Tugwell P, Egan M, Wilson KG, Dubouloz CJ, Casimiro L, Robinson VA, McGowan J, Busch A, Poitras S, Moldofsky H, Harth M, Finestone HM, Nielson W, Haines-Wangda A, Russell-Doreleyers M, Lambert K, Marshall AD, Veilleux L (2008). Ottawa Panel evidence-based clinical practice guidelines for strengthening exerices in the management of fibromyalgia: part 2. Phys Ther. Jul;88(7):873-86.
Hoffman MD, Shepanski MA, Ruble SB, Valic Z, Buckwalter JB, Clifford PS (2004). Intensity and duration threshold for aerobic exercise-induced analgesia to pressure pain. Arch Phys Med Rehabil. Jul;85(7):1183-7.
Wall, P. Pain: The Science of Suffering.May 7th 2002 by Columbia University Press.