Pain and Exercise 

Introduction

Pain continues to be one of the leading contributors to disability around the globe. In fact, one of the most prominent reasons that individuals seek Physiotherapy or other Rehabilitative Services is pain.

The International Association for study of Pain (IASP) defines pain as “An unpleasant sensory and emotional experience associated with, or resembling that associated with actual or potential tissue damage.” However, more recent attention given to this topic has continuously cited the complexity of pain, and the relationship it has with factors such as: genetics, social support, psychological challenges, comorbidities, and previous experiences with pain etc.

Acute vs Chronic Pain 

When we’re talking about exercise and movement during pain, it is important to recognize that there are different types of pain. Here we will specifically talk about the difference between  acute/nociceptive pain and chronic/persistent pain:

Acute/Nociceptive Pain 

  • Pain that is directly related to a mechanism (ie. rolling your ankle)
  • Typically takes 6 weeks to heal (if soft tissue in nature)
  • Initially (2-5 days) it is Important to move safely within the tolerance of pain (<4/10), avoiding things that cause pain >4/10 at this stage
  • Sub-Acute (1-3 weeks) – we can start integrating more functional activities, even those that may increase symptoms because healing is well on its way, and research shows that exercise actually decreases pain perception
  • 3-6 weeks – no longer avoiding any activity, adding load to exercises
Chronic/Persistent Pain 
  • This is pain that is typically present for longer than 6 months
  • It can be pain that remains even after an ‘acute’ injury has healed
  • Some people even experience this type of pain insidiously (no specific cause)
  • Here it is important to consider how you are moving, are you worried and/or avoiding certain activities and can we address this?
  • Lars Berglund et al (2015)  cited a significant difference in pain intensity in patients who were prescribed exercise (independent of type of exercise)
  • Graded exercise increases confidence and strength, decreases fear of movement and promotes a return to ‘normal’ function

 

Exercising in the presence of Pain

It is highly cited in the literature that exercise has positive effects in relieving pain and improving function in symptomatic individuals. Individuals with persistent pain often have underlying muscular weaknesses, fear of movement, or nervous system hypersensitivity that contribute to their pain – all of which can be addressed with appropriate exercise participation. Sometimes we take really strongly to a certain activity, and wind up with pain as a result. The development of pain in this instance is likely due to the fact that you’ve challenged the same areas of your body over and over, and not allowed it some time to rest and adapt. To mitigate this, rather than stopping the activity all together, there is great benefit from identifying the parameters of your training program that may have irritated your tissues, and finding a modification that allows you to stay moving. In short, pain during therapeutic exercise for chronic or insidious musculoskeletal pain should not be a barrier to successful outcomes or participation in physical activity.

Traffic Light Analogy 

The traffic light analogy is a great tool that can be used to gain a better understanding of your pain and whether its okay to proceed.

Green Light

  • Your pain is less than 3-4 out of 10 during exercise/activity
  • Your pain is no more than 2-3/10 worse than baseline OR your pain improves during the activity/exercise 
    Any increase in symptoms during the activity/exercise resolves within 6 hours 

GREEN MEANS GO! You may stick with the activity or exercise that you are doing. You may consider increasing the difficulty (consult your rehab professional for more guidance). 

Yellow Light

  • Your pain is 4-5 out of then during exercise/activity
  • Your pain is no more than 2-3/10 worse than baseline OR your pain improves during the activity/exercise 
    Any increase in symptoms during activity takes more than 6 hours to resolve

YELLOW MEANS PROCEED WITH CAUTION! This is still okay, but you need to monitor your pain levels, and work with your physiotherapist to modify as necessary. 

Red Light

  • Your pain is 6/10 or greater during exercise/activity
  • Your pain worsens during your exercise/activity and stops when you stop performing the activity 
    Your pain does not resolve within 24 hours of the activity 

RED MEANS STOP!! If your pain worsens above a 6, or more than 2-3/10 from your baseline it can be an indication that the activity or exercise you are doing is too much for you. Consult you Physiotherapist for appropriate modifications and interventions to keep you moving safely.

Take-Aways
  1. Pain is a very complex phenomenon, it is not as simple as pain = damage
  2. Research show that MOVING when in pain will actually DECREASE your pain perception if done correctly, and NOT MOVING can lead to persistent symptoms!
  3. Find a rehab professional that works with you to create a plan to get you moving safely in the way that you love!
  4. Its not important what kind of exercise you are doing, it’s just important that you do it regularly and you enjoy it!
  5. Some pain during exercises or activity is OKAY!
If you are experiencing pain or discomfort – it’s important to see a physiotherapist to help you modify, adapt, rule-out red flags, and address any concerns you may have that you can keep doing the things you love!

 

References

  1. Romm M, Ahn S, Fiebert I and Cahalin L (2020) A Meta-Analysis of Therapeutic Pain Neuroscience Education, Using Dosage and Treatment Format as Moderator Variables. Pain Practice.
  2. Diagnostic triage for low back pain: a practical approach for primary care. Med J Aust.  2017; 206(6):268-273
  3. Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis. Smith BE, Hendrick P, Smith TO, et al. Br J Sports Med 2017;51:1679-1687.
  4. Musculoskeletal pain and exercise—challenging existing paradigms and introducing new. Smith BE, Hendrick P, Bateman M, et al. Br J Sports Med Published Online First: 20 June 2018. doi: 10.1136/bjsports-2017-098983
  5. Effective treatment options for musculoskeletal pain in primary care: A systematic overview of current evidence. Babatunde et al. PLoS One. 2017 Jun 22;12(6):e0178621
  6. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Lin I, Wiles L, Waller R, et al. Br J Sports Med  2019. doi:10.1136/ bjsports-2018-099878
  7. Booth, Frank W et al. “Lack of exercise is a major cause of chronic diseases” Comprehensive Physiology vol. 2,2 (2012): 1143-211.

 

Written By:

Kristen Blair , PT, MPT., B.A. Kin (Hons.)
Registered Physiotherapist

Feel Better. Move Better. Be Better.
Our goal is simple —  to provide the best physiotherapy we can!