There’s a been a lot of debate on social media recently (as of the time I’m writing this) regarding the topic of exercise for people with persistent pain. Some debate what type of exercise we should use and others debate whether or not exercise is even beneficial. A lot has been written on the topic – but I wonder if we’re missing the forest for the trees in these discussions?
Are we missing the forest for the trees with exercise?
If you’ve worked with people with persistent pain and/or followed the research(1) on it you’ll know that exercise, while helpful, is by no means a panacea and often (both in the research and anecdotally) results in a smaller improvement in pain and a small to moderate improvement in function.
It seems a bit hypocritical that we spend so much time debating about the effectiveness for pain yet we’re the same people that want our patients to emphasize functional improvements over pain improvements. Seems a bit inconsistent doesn’t it? Just some food for thought.
We absolutely need to scrutinize our thought processes & biases and evolve them based on the scientific literature but sometimes, by focusing just on pain improvement and not on all the other health & functional benefits of exercise, we “miss the forest for the trees.” There are so many other benefits(2) of exercise including improved heart health, muscle mass, bone density, strength, power and endurance that looking solely at pain outcomes is rather shortsighted IMO. So…
Yes we should include exercise – but with a few caveats…
1) As my friend & colleague Ben Cormack has so excellently written about in this article(3) for Physio Network – dosing exercise for fitness isn’t the same as dosing it for pain. This can be a greyer area when trying to work on both during a rehab program.
2) Pain is a complex and multifactorial experience and simply saying that it can be “exercised away” isn’t appropriate or in line with the literature. It can also be very disheartening for some patients who are diligent with exercise but aren’t experiencing the improvements they want. Patients need to be educated on the risks and benefits of active exercise therapy just as we’d expect them to be with pills, injections or surgery.
3) As Greg Lehman has written about and discussed some people; particularly those with high psychosocial factors; may not tolerate much exercise very well and will need an emphasis on managing psychosocial factors, beliefs, and lifestyle factors in order to maximize the benefits from physical rehab.
What types of exercises should we recommend?
Now that we’ve discussed exercise for people with pain and some of the less discussed logistical aspects of it … its time we tackle the type of exercises to recommend.
Some people would argue “we should just let people do what they want and let that be their activity.” I don’t disagree with that – and while valued activities promote greater adherence the problems with that approach are:
1) The activities may not get consistently done – i.e. walking outside or gardening during rainy, hot or snowy weather
2) The activities may not promote heart health, bone density, muscle mass or strength to an extent that can withstand the effects of aging. As an example – cyclists and swimmers are very physically fit but have low bone density and higher osteoporosis risk.
3) These tasks may not give people adequate fitness to do more strenuous ADLs with an adequate reserve afterwards. An example of this, particularly where I live in Canada, would be cases of people who have heart attacks when shovelling snow.
4) The individual may be so poorly deconditioned that they may not be able to do those tasks yet. Take for instance the client who wants to run but is still dependent on a cane to walk safely … or the 70 year old lady who’s humerus fracture is healed but is so weak & frail she can’t lift her arm up to grab a coffee cup off the shelf.
We know from considerable research that improvement in many physical deficits (i.e. core “stability,”(4) and scapular kinematics(5)) may not correlate well with improvements in pain – but sometimes physical deficits, particularly for people who are very deconditioned, may need to be addressed to enable people to get back to their desired activities. The same goes for clients returning to highly demanding sports or jobs – although the level of strength & endurance required is higher. I don’t have the desire to turn my PT clients into powerlifters – but the physical capacity needs to be something that’s not a barrier to reintegrating into tasks.
In truth – a combination of both specific exercises to address physical deficits and reintegration into valued activities is probably best IMO and should be programmed appropriately based on goals, prior activity levels, tolerances, and medical history.
To wrap this up, while exercise isn’t a panacea for chronic pain, there are many health and functional benefits to exercise that should be accounted for and (in my opinion) an ideal program directs a client towards goal activities while addressing potential physical deficits that hinder performance of those activities. Exercise needs to be dosed appropriately and incorporate individual factors.
I hope this article provides a different perspective on the ol’ “exercise and chronic pain” debate. As always, thanks for reading.