Chronic pain is generally defined as lasting at least three months beyond the body’s usual healing time. Unlike acute pain caused by tissue damage, chronic pain, also known as persistent pain, is less about structural or tissue damage and more about the sensitivity of the nervous system and non-tissue related factors. For most people, chronic pain triggers avoidance of activity in an attempt to prevent achy flare-ups. However, sitting still leads to a downward spiral of deconditioning and a diminished quality of life. Chronic pain causes many problems beyond the pain itself, including fatigue, anxiety, depression and sleep disturbances. Chronic pain affects as many as one in five American adults.
How Genevieve and Harry became inactive
Genevieve and Harry meet the markers of the chronic pain criteria. Genevieve has fibromyalgia, a widespread pain condition that has only recently been acknowledged as a bona fide condition requiring real treatment. Harry has intermittent claudication, a cramping pain in the legs that limits his ability to engage in physical activity. Both live with sufficiently severe and disabling pain that caused increasing immobility, which eventually led to consultation with specialists.
Historically, people like Genevieve and Harry who are troubled by chronic pain were told to rest. In this day and age, general medical advice has changed, and the prescription is to keep active, whether physical activity directly eases the pain or combats other symptoms and problems associated with it. New research in kinesiology, anesthesia and pain medicine and population health provides evidence that physical activity reduces the severity of pain, improves physical function and positively affects a sense of well-being and quality of life. Physical activity is defined by the World Health Organization as “any bodily movement produced by skeletal muscles that requires energy expenditure, including activities undertaken while working, playing, carrying out household chores, travelling and engaging in recreational pursuits. Exercise is a sub-category of physical activity that is planned, structured, repetitive and aims to improve or maintain one or more components of physical fitness.”
Genevieve’s story is interesting. “I am in my mid-40s and worked for nearly 15 years as a third-grade school teacher. Two years ago, I caught a bad case of the flu, got up from it too soon and relapsed. It took me forever to feel better. I returned to work even though I wasn’t feeling completely well. I progressively developed widespread pain over my whole body, extreme sensitivity to noise and light, stiffness and I stayed fatigued all of the time. To add insult to injury, I started having a low-grade, non-remittent headache and an irritable bowel. My brain felt like I was in a fog much of the time. I kept thinking I would get better if I rested and took my time, but the symptoms just got worse. After about six months, my internist referred me to a rheumatologist who diagnosed fibromyalgia. I have been prescribed anti-seizure medications and told that I should exercise. The medicines have helped the pain some, but I can’t find a way to exercise when I am achy and foggy. The closest thing I’ve done to an exercise program is to lift my credit card to join a gym. I haven’t been back in the front door of the place and am scared to go. I’m still not working, am on short-term disability and just don’t know what to do.”
Harry’s story has similarities to Genevieve’s. He, too, is in his mid-40s and says, “I was quite a jock most of my early adult life. I’ve always been a runner and a few years ago began getting more and more frequent charley horses in my calves during exercise routines. Doing the things that I knew to relieve the cramps seemed to help, but the problem became more prominent over time. I visited my [doctor], who did some tests and diagnosed me with intermittent claudication, which I learned is a symptom of muscle pain on mild exertion. I can describe the predictable ache, cramps, numbness and increasing sense of fatigue that I felt in both calf muscles. I thought it would pass, but the cramping started happening when I was just walking, not running. Even with careful stretching and warm-ups, I could not stop the cramps from happening. I went back to the [doctor], who told me that it was early-stage peripheral artery disease. I was eventually treated with a surgical intervention putting stents in my legs. I also revised my diet. I want to return to my exercise program. The trouble is, I’m scared to death now that I have lost my stamina. Any hint of pain just sends me reeling. I’m scared of hurting. I sit down, try and relax, but do not trust that the pain is telling me how to manage my body. My [doctor] says, ‘Exercise!’ He might as well say, ‘Grow wings and fly to the moon.’”
Jeff Ford, ACSM, is a wellness coach certified through the American College of Sports Medicine, working as the director of fitness for the Skyterra Wellness Retreat in Lake Toxaway, North Carolina. He helps individuals like Genevieve and Harry. He says, “There are good and safe ways for an individual living with chronic pain to exercise. Now in 2018, significant research has shown that exercise is an essential aspect in the treatment of pain. Gradual exercise helps those with chronic pain to engage more in enjoyable activities and return with greater ease to essential activities of daily living. There are some challenges, though, in starting and maintaining an exercise program when you hurt. Most prescribers tell patients to ‘jump right in.’ This is typically a setup for failure. A person living with pain has to worry less about how much she is doing and focus more on how the exercise is managed.”
Ford continues, “The exercise goal for a pain patient is to be consistently moving, to stay constantly in motion. This starts with proper breathing, which influences the mobility connected to stiffness. Pain patients generally hold their breath more than necessary and don’t fill their lungs with good air. Gentle yoga teaches good breathing techniques and is a well-examined place to start exercise. Then, walking is the number-one catchall exercise for everything. Those living with chronic pain should find that symptoms gradually improve with movement. For some, improvement will be gauged by symptom reduction, others by a subsiding of the intensity of the pain. I teach those in pain that exercise isn’t about lifting weights. It is more about a goal of 15 to 20 minutes of activity within a safe range of motion. Intensity is measured by capacity and the amount of repetitions that a person can achieve. Less is better; consistency is everything.”
Physical therapists and wellness coaches recommend combining multiple forms of exercise for those living with chronic pain. Stretching increases flexibility, loosens tight and stiff muscles and improves range of motion. When exercised on a regular basis, muscles stretch with greater ease and improve everyday movement. Then, strengthening exercises help maintain and build capacity. Cardiovascular exercises such as walking or swimming build stamina and recondition a body in pain.
Ford says, “Prioritize mobility, stability, then strength of exercise.” He continues, “It is normal and expected to experience more pain in the beginning. This should not be frightening. The initial commitment to an exercise program is two to three weeks. Investing in a trainer who has a background in functional movement screening [see sidebar] has wisdom, particularly at the beginning. A good trainer or wellness coach can hold the pain patient’s alarm and any fear that may arise as their exercise program changes the nature and intensity of familiar aches; she can also help to judge the degree of realized improvement. Consistent exercise, done properly, should have a person feeling better over a month’s time. If not, there are additional problems to address. The human body adapts to poor physical positions because of inactivity. It takes time — but less than most think — to re-acclimate to movement, then to readapt to the right kind of movement. Lifestyle effects, including those caused by chronic pain, are cumulative. Fortunately, the body tends to adapt quickly to a proper exercise program. So, I tell trainees, ‘Don’t worry about how much you are going, worry about how you are doing it.’”
Physical activity and exercise can be adapted for each individual and are something that people in pain can do to help themselves. However, simply hearing advice to “Exercise!” does not work to bring about significant change. A badly prescribed plan that doesn’t address the individual’s physical concerns and present state of fitness, such as one that does not incorporate pacing and gradual progression, will likely fail when a person lives with chronic pain.
Again, Ford offers excellent advice. “Ask yourself: ‘Where am I starting? What do I need?’ Then benchmark these as starting points. Measure your abilities at the beginning. Even if you can’t feel the difference, there will be a rapid quantitative shift. One hundred percent of people should see a lessening of symptoms over a few weeks’ time. There is one important warning sign that a person should attend to, though, and that is onset of rapid, acute pain during the performance of an exercise. This is the indication that the exercise is not being performed correctly. At best, early exercise plans should be considered from a mobility standpoint. As pain shifts, particularly early in a program, I ask a person to stay in a state of ongoing self-assessment, considering ‘If I’m a 10 [on a 10-point pain scale], then this is best for me. If I’m a 1, then I’m not OK with it.’”
Ford describes research that states the best sustainable exercise programs are characterized by group work. “Accountability helps,” he says. “Finding an exercise partner who can work with you or attending age-friendly classes, such as Silver Sneakers, makes the process more agreeable and, ultimately, more fun. Finding good partners helps adherence to the exercise while the benefits of pain reduction begin to kick in. Then when the program is built into daily life, the social benefits of working with others become very satisfying.”
So why exercise when I already hurt so much?
Exercise has specific benefits in reducing the severity of chronic pain, as well as more general benefits associated with improved overall physical and mental health, particularly associated with loss of mobility, depression, deconditioning and obesity. Current research demonstrates that a single bout of exercise increases the production of natural, internal opioids, and repeated exercise produces an increased and sustained production of the body’s own natural pain-reducing chemicals. Aerobic exercise is strongly linked to weight loss, which has implications for the management of chronic pain as the pressure on joints is reduced. Strength training improves a person’s capacity to support bone and cartilage through improved musculature that supports movement, relieving stiffness. Range-of-motion exercise around the waist and hips improves mobility, balance and flexibility and reduces the risk of falls and the potential for further pain or injury.
Ford and other wellness coaches emphasize the need for chronic pain patients to consult with a well-credentialed physiologist to help with an exercise management program. With help, an individual living with chronic pain can become more in charge of his or her physical health, psychological functioning and quality of life.
Functional movement screening
The Functional Movement Screen (FMS) is a tool used to identify physical imbalances that limit an individual’s functional movement. The FMS assesses problems in mobility and stability during seven fundamental movement patterns designed to provide observable performance of basic locomotor, manipulative and stabilizing movements. Once deficiencies have been identified through the FMS, a program of corrective exercises can be developed with the goal of preventing musculoskeletal injuries. An individual who is being assessed with the FMS can expect to be asked to squat, raise his or her arms, shoulders and legs and rotate on his or her hips. The screening has strong validity and reliability and is used by professional physiologists as an initial diagnostic tool prior to prescribing a sustainable exercise program.
Want to learn more about exercising with pain? Read “Exercise 101: Finding the Right Exercise for Pain Relief,” “Time for Yoga: Yoga Benefits for Arthritis,” and “The Power of Tai Chi to Relieve Pain.”