Chronic pain is a peculiar thing. Consider this: 20 percent of individuals with the worst knees on MRI have no pain, and 20 percent of those with the least affected knees have the most pain. One study found that 9% of subjects with knee pain had normal MRIs, and 88% of those with no knee pain had abnormalities on radiographic imaging. Degenerative disc disease causes pain, but many people with this spinal disorder are asymptomatic. This leads us to the notion that mechanical problems lead to chronic pain, but not always – and that pain is actually a separate condition from the issue that may have caused it in the first place. When it comes to pain, A does not always cause B. It is possible, then, for chronic pain to occur in the absence of tissue damage.
The International Association for the Study of Pain (2014) defines pain as “an unpleasant and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” According to the American Academy of Pain Medicine (2015), pain affects more people in the United States (approximately 100 million) than diabetes, heart disease, and cancer combined.
There is currently no universally accepted definition for chronic pain, but it is generally agreed that pain which persists beyond the time when tissue would normal heal (typically 12 weeks or 3 months) can be considered “chronic”. Chronic pain in later life is extremely common – in a National Institutes of Health survey, 52.8% of older adults reported bothersome pain in the month preceding the survey. Some individuals appear to be much more susceptible to chronic pain than others. In my practice, I have termed this group as having “super-sensitive nervous systems”. This is because chronic pain is complex, the result of many inputs processed through the nervous system and the brain. Exercise is a stressor, typically a useful one resulting in strength, mobility and function improvements. However, for certain individuals exercise can be overstimulating and cause the body to respond in the same manner as it would to a noxious stimuli as opposed to a healthy one.
Programming for these types of clients has taken years of practice, and to this day requires a tremendous amount of trial and error. Ongoing assessment during each and every session allows me to make program adjustments in real time. Parsing out the specific elements of an exercise program, and introducing one new element at a time, allows me to determine what is helping, and what may be having a deleterious effect. The truth is that exercise has the power to heal, yet also has the power to create injury. There is nothing closer to a magic bullet for good health and longevity as physical activity - when applied appropriately.
Here are some general considerations to take into account if you suffer from pain, and want to start exercising:
- Introduce one modality at a time. This way, you will know what is helping, and what may be exacerbating your pain level.
- Work much below your actual physical capacity, at least at the beginning. Many people with chronic pain are physically able to do much more than they should when they start out. This is easier said than done. Much of my work when I am starting with clients who have pain is to establish the exercise threshold for a given individual. This threshold is determined clinically, not by standard exercise science principles.
- Safeguard sleep. Tissue repair occurs during the deepest level of sleep (delta sleep) when human growth hormone is secreted. If you are not sleeping well, you are missing out on valuable recovery time – adaptations to exercise occur during the recovery period, not during the actual exercise session. If you suffer from insomnia, find strategies to improve your sleep, from cognitive behavioural therapy for insomnia, naturopathic sleep remedies, or even pharmacological agents if necessary. Work with your doctor or naturopath. Insomnia is a serious medical condition, as chronic sleep deficit is an independent risk factor for many diseases including diabetes, cancer, and autoimmune disorders. It must be treated.
- Exercise itself is pain medication. Exercise causes the brain to produce endorphins - powerful, natural painkillers. Regular exercise has a painkilling effect for most individuals.
- Overcome anxiety and fear of movement. When an injury occurs, we often become afraid of moving in a way that will make our pain worse. Over time, we continue to self restrict movement even though the tissue itself may have healed. We also begin to associate specific movements with pain, which can continue even after the injury is fully healed. Self-limiting movement causes pain, and normalizing movement patterns usually leads to pain reduction over the long term. This is termed “graded exposure” – gradually, millimetre by millimetre, we retrain our brains to accept normal movement patterns. Performing a movement that normally causes pain at a much lower intensity than usual will, over time, give new information to the nervous system that the movement is safe, not dangerous, and that a pain response is unnecessary.
- Be hopeful that you will improve. It can be extremely difficult to have hope when you are in pain. That being said, optimism about your ability to get better will enable you to take movement risks that you might not otherwise – increasing the likelihood of a full recovery.
American Academy of Pain Medicine. 2015. AAPM facts and figures on pain. www.painmed.org/patientcenter/facts-on-pain/.
Carey, Anthony. 2016. The Many Dimensions of Pain. IDEA Journal.
Guermazi, A., et al. 2012. Prevalence of abnormalities in knees detected by MRI in adulcts without osteoarthritis: Population based observational study (Framington Osteoarthritis Study), BMJ, DOI: 10.1136/bmj.e5339
Hargrove, Todd. 2014. Graded Exposure. Better Movement website: https://www.bettermovement.org/blog/2014/graded-exposure
International Association for the Study of Pain, 2014. IASP taxonomy. http://www.iasp-pain.org.