One of the biggest changes in physiotherapy in the last few years is that, while painful exercise and activities were at one point forbidden, it is now deemed appropriate to exercise and load patients into pain with activity (1). Not everyone can or should push into pain right away, whereas others need to stop avoiding painful activities. In this article – I provide four points to consider when deciding whether to load someone into pain or whether to protect a painful area.
As an aside: I also recommend you read these articles by Ben Cormack (2) and myself (3) as well as Ben’s Masterclass on exercise for chronic pain (4) for a deeper dive into the practical aspects of this topic.
Disclaimer: these points are not black and white and patients won’t always fit neatly into these categories. Also, as with all cases of pain, it’s important to rule out red flags and serious tissue pathology first.
Point #1: Time since onset of pain
In acute to sub-acute injuries, pain serves its purpose. You wouldn’t run on a swollen sprained ankle nor would you do a lot of Jefferson Curls the day after you hurt your back moving laundry. In these situations, for the most part, it makes sense to protect the painful area… at least for a bit.
By contrast if it’s 3 years after you hurt your back moving laundry, and you still stand & sit as stiff as a board, it’s probably ok to bend it a little bit even if it’s a bit painful.
The only exception I would make to this is post-surgical clients where it’s normal to have some pain with activity early on and there is a narrow window of opportunity to regain proper range of motion.
Point #2: Pain presentation
For a nociceptive, or what some would call “mechanical” pain presentation avoiding painful activities and protecting the painful area makes sense. If the back only hurts with end range flexion, it’s appropriate to hip hinge and use what Stu McGill would call “spine sparing motion.”
Now if you’re working with a case that has constant pain with everything including bending, hip hinging, doing the McGill Big 3, sitting, standing, walking, lying down etc, it’s totally unrealistic and impractical to avoid painful activity. The only exception to this is, as above, within the inflammatory phase of an injury.
Point #3: Presence of psychosocial factors and avoidance behaviours
With patients who are more easy-going and don’t seem to have any major psychosocial factors pertaining to pain or movement (i.e. kinesiophobia, fear avoidance, hypervigilance, preference for passive treatment) I’m more apt to keep them within the pain-free movement range if possible.
When I see patients who are heavily guarded & fearful of doing any activity – reinforcing the idea that pain is bad & painful activity needs to be avoided just sends the wrong message.
If I see patients who have a lot of avoidance behaviours and a more general “sensitization” pain pattern, even if it’s earlier on post-injury, I will use a graded exposure approach – assuming that we’re past the early inflammatory phase and have ruled out red flags & serious tissue pathology that requires surgical or medical management.
Point #4: Goals of the client
Some goal activities may require pushing into some pain. Most of the knee replacements I currently work with have goals of being able to walk normally without a gait aid. For them, building gait endurance, improving gait pattern, and attaining the necessary range of motion to satisfy all of these will likely require working through some pain early on.
By contrast, some goals can be achieved without the need to go into pain-free activity. Consider the powerlifter with back pain that’s aggravated at end range flexion. Teach them to keep a neutral spine (or as neutral a spine as possible) during their lifts and use isometric instead of dynamic core exercises, & boom – they may be able to lift pain-free no problem.
The topic of whether or not to load into pain is controversial and complex. The time since onset of pain, pain presentation, psychosocial factors, avoidance behaviours, and goals are all critical factors to consider when deciding when to expose or when to protect. As always – thanks for reading.