Persistent Pain : Exercise or not to exercise

Exercise is the medicine movement of physiotherapist intervention. we are not specific for exercise programme for individual muscle group that we commonly understand. Yes, You should do exercise in persistent pain.

Unsurprisingly, dosage is also linked with exercise, yet in physiotherapy we still tend to focus on the typical 3 sets of 10 or 12 or 15 .
This is not suggesting that exercise does not attenuate pain, there is plenty of research on exercise induced hypoalgesia (Bement & Sluka, 2016; Frey-law & Sluka, 2017; Koltyn, Brellenthin, Cook, Sehgal, & Hillard, 2014; Lima, Abner, & Sluka, 2017; Naugle, Fillingim, & Riley, 2012) .

The reaction to exercise is an important topic of discussion. Flare ups are common and normal. As pain is a multi-dimensional phenomena, flare ups can occur for any number of reasons, and so clinicians MUST be completely comfortable with the idea that experiencing pain does not (1) harm people (2) mean they’re in danger (3) harm you. 

NIJS et al (2012), Some chronic pain disorders (e.g. fibromyalgia) are characterized by a dysfunctional Endogenous Analgesia (EA) in response to both aerobic and local muscle exercises, while other chronic pain (e.g. chronic low back pain) show a normal activation of EA in  response.  The relevance of these findings to rehabilitation practice together with future research avenues will be discussed as well.

Exploring dosage of exercise and utility in pain management

Dosage consists of frequency (the number of times you exercise typically in a week), intensity (how hard you exercise, typically measured with RPE) and duration (how long you exercise for recorded by time). Although, strict adherence to the guidelines is not always necessary i.e. Frequency could also mean the number of times you perform the activity in one session as opposed to the number in a week. In some cases, type (the type of exercise you perform – aerobic, weight training) and load (how much you lift) could also be considered.

The exercise-induced blood pressure activates arterial baroreceptors, resulting in increased supraspinal inhibition and stimulation  of  brain  centers  involved  in  pain modulation .

Exercise triggers the release of  β-endorphins from the pituitary (peripherally) and the hypothalamus (centrally), which in turn enables analgesic effects by activating µ-opioid receptors peripherally and centrally, respectively. There is more research is required for  hormonal factor in exercise induce EA 

However, after 30 min to 40 mins of exercise the β-endorphins and growth hormone are released . Therefore it’s unclear for its effect on EA. Distraction can significantly alter pain perception. For example sweating during exercise and increase heart rate .

Staud et al (2013) suggest that nociceptive input from painful muscles induced central sensitization and activated descending pain facilitatory mechanisms.  Incidentally, a systematic review and meta-analysis from Smith et al., (2017) found that exercising with pain had benefits in the short-term (but no real benefit from exercise of other treatment in the moderate and long term).

Pain & exercise

Exercise and education of pain are the foundation of the management of persistent pain. It is very effective musculoskeletal disorders. A biopsychosocial model provide physiotherapist to broad form to understand pain. by utilizing biopsychosocial approach & some critical questions is helpful in determine how physiotherapist adjust dosage of an exercises.

The reaction to exercise is an important topic of discussion. Flare ups are common and normal. As pain is a multi-dimensional phenomena, flare ups can occur for any number of reasons, and so clinicians MUST be completely comfortable with the idea that experiencing pain does not (1) harm people (2) mean they’re in danger (3) harm you. 

Booth et al 2017; Geneen et al 2017 While Exercise may be linked with increased pain or sensitivity for individuals with persistent pain which is unlikely to result in exercise-induced harm if dosed appropriately . Furthermore, utilising case formulation can provide justification for exercise dosage considering individual differences. So, if we are working with someone with increased sensitivity then 1) exercising with some pain may actually be ok and 2) reasoning dosage may provide sufficient progression in activity tolerance.

There is lack of evidence with no clear guild line for physiotherapist how it may proceed with exercises for people lives with pain.

Thank you for having a read my blog.

References :

1. Booth, J., Moseley, G. L., Schiltenwolf, M., Cashin, A., Davies, M., & Hübscher, M. (2017). Exercise for chronic musculoskeletal pain: A biopsychosocial approach. Musculoskeletal Care, (April). https://doi.org/10.1002/msc.1191
2. Bunzli, S., Smith, A., Watkins, R., Schütze, R., & O’Sullivan, P. (2015). What Do People Who Score Highly on the Tampa Scale of Kinesiophobia Really Believe? A Mixed Methods Investigation in People With Chronic Nonspecific Low Back Pain. Clinical Journal of Pain,31(7), 621–632. https://doi.org/10.1097/AJP.0000000000000143
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10. Koltyn, K. F., Brellenthin, A. G., Cook, D. B., Sehgal, N., & Hillard, C. (2014). Mechanisms of exercise-induced hypoalgesia. Journal of Pain, 15(12), 1294–1304. https://doi.org/10.1016/j.jpain.2014.09.006
11. Naugle, K. M., Fillingim, R. B., & Riley, J. L. (2012). A meta-analytic review of the hypoalgesic effects of exercise. Journal of Pain, 13(12), 1139–1150. https://doi.org/10.1016/j.jpain.2012.09.006
12. Nijs, J., Kosek, E., Van Oosterwijck, J., & Meeus, M. (2012). Dysfunctional endogenous analgesia during exercise in patients with chronic pain: to exercise or not to exercise? Pain Physician, 15(3 Suppl), ES205-13. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22786458
13. Simmonds, M. J., Derghazarian, T., & Vlaeyen, J. W. S. (2012). Physiotherapists’ Knowledge, Attitudes, and Intolerance of Uncertainty Influence Decision Making in Low Back Pain. Clinical Journal of Pain, 28(6), 467–474. https://doi.org/10.1097/AJP.0b013e31825bfe65
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