Chronic Pain and Exercise – Opinion Piece by Stephanie Tibbert

The National Institute for Health and Care Excellence (NICE) recently announced a change in its pain treatment policy, encouraging doctors to prescribe chronic pain sufferers physical and psychological therapies rather than painkillers to manage their pain.

Stephanie Tibbert is a Lecturer on the MSc Sport and Exercise Psychology course at AECC University College. She reflects on the potential of these therapies, when specifically tailored to individuals living with chronic pain, to help manage their condition:

Defining chronic primary pain

“It’s important to be really clear that these new guidelines are for the management of chronic primary pain. This means pain where no underlying condition adequately accounts for the pain or its impact. This is not to discount the pain experienced in any way, but to distinguish it from secondary pain caused by conditions that have clear pathways.

“In chronic primary pain, the pain itself has become the condition. One of the problems with chronic primary pain is that we do not fully understand the mechanisms of the pain, and because people experience and communicate pain in numerous ways, understanding the individuals’ pain is complex.”

Issues caused by chronic pain

“Chronic pain is not only detrimental to physical functioning, but it has social, economic and psychological implications too.

“Chronic pain can negatively influence daily living, an individual’s occupation, and relationships, which all contribute to a reduced quality of life.

“Additionally, because the individual has to live with pain over a long period of time there is increased susceptibility to anxiety, depression and social withdrawal.

“With depression, symptoms such as depressed mood, sleep disturbance, and a reduced interest in once important activities are commonly cited with chronic primary pain, which clearly influence quality of life.”

Disadvantages of painkillers for chronic pain

“There are a number of disadvantages around the use of painkillers for individuals with chronic pain. These include how a patient tolerates the medication, as side effects can include nausea and gastrointestinal side effects, and in the case of some of long-term prescribed medications, addiction may be a concern.

“The side effects of some of these medications can be unpleasant which leads to low medication adherence, leading to inadequate pain relief and more pain. 

“For others, patients tolerate the medication, but become accustomed to the initial medication and soon require stronger medication for the same type of pain relief. Stronger medication can produce side-effects, resulting in a cycle of inadequate pain relief or unacceptable side-effects.”

Benefit of exercise

“Some of the benefits reported from exercise with chronic pain include a reduction in pain sensitivity, reduced sleep disturbance, and more independence-related physical function.

“Exercise also reduces the risk of developing comorbid illnesses such as Type 2 diabetes, cardiovascular disease, and osteoporosis.

“NICE has agreed with the growing literature that exercise can have a pain-relieving effect for individuals with chronic pain conditions.

“But because chronic pain is complex, there have been variable responses in some exercise studies regarding reduction of pain in chronic pain populations. With any treatment for chronic pain, because the experience is individual, the amount of pain relief obtained from a treatment will also be individual.

“In the non-pain population, exercise is associated with hypoalgesia, which is a deceased sensitivity to pain. Chronic pain exercisers can also display hypoalgesia. This understanding is not universally accepted within the research, but exercise-induced hypoalgesia has been reported as one of the potential mechanisms that may explain reduced pain sensitivity following exercise.”

Alleviating symptoms

“Several symptoms of chronic pain can be influenced by exercise and physical activity. Sleep disturbance, for example, is a common symptom of chronic pain and non-restorative sleep is associated with increased pain sensitivity.

“Engaging in physical activity has been reported, across non-pain and chronic pain populations, to improve quality of sleep, therefore lowering the increased pain sensitivity associated with disrupted sleep. The cycle continues with better quality sleep and reduced pain sensitivity leading to individuals being more likely to be physically active.

“Depression and anxiety are commonly reported symptoms of chronic pain, both have been associated with increased pain sensitivity and lowered pain tolerance.

“Physical activity and exercise have been repeatedly associated with improvements in mood and anxiety conditions.

“Physical function (cardiovascular, muscular strength for independence, flexibility for joint mobility) can also be improved with various forms of exercise, studies have displayed benefits with warm water pool exercise, tai chi, yoga, cardiovascular, and muscle strengthening activities.”

Experience in chronic pain clinic

“I assisted in a chronic pain clinic overseas several years ago, delivering psychosocial interventions.

“We found that pain elicited increasing levels of muscular tension, which led to increased perceptions of pain; basically a negative spiral of muscular tension, pain, and reduced activity. When we worked with patients to reduce muscular tension, whether it was through exercise, relaxation techniques, or strategies such as Cognitive Behavioural Therapy, many patients experienced a reduction in pain perception and pain sensitivity.

“The reduction in pain symptoms meant that more patients felt able to try new treatments that they had been fearful or doubtful about, such as aquatic exercise session or flexibility training.

“One factor that was particularly important was the social aspect of the pain clinic. We found working with individuals at their own pace in a social environment with patients who were living similar stories normalised some of the patients’ concerns.

“The increased social interaction enhanced feelings of independence and self-efficacy because others, who were similar to them, were also trying out new strategies.”

Facilitating exercise with chronic pain 

“In my experience working with individuals with chronic pain, there is a sense that if individuals were able to they would happily exercise, but that their pain inhibits them.

“Some patients are understandably anxious that exercise will exacerbate their pain which leads to that negative cycle that results in an increased experience of pain.

“When any individual is faced with a threatening or fear-inducing stimulus (e.g., exercise) we often find pain tolerance decreases and so when an individual with chronic pain feels threatened by exercise, or forced into exercise, the individual can display increased pain sensitivity leading to an unhelpful association between pain and exercise. We want to avoid this.

“In chronic pain exercise sessions, experienced practitioners are aware that chronic pain does not follow a standard pathway and that there will be many ups and downs. The patient needs to be at the centre of treatment, so every exercise session will need to be flexible and meet the client where they are that day, instead of sticking to pre-planned sessions designed to meet physical activity guidelines.

“Physical activity needs to focus on alleviating anxiety and fear and trying to develop a pleasant experience that in some ways will enhance physical function, but in all ways will not exacerbate pain.”

Concerns and treatment

“The relationship between practitioner and patient needs to be supportive and collaborative, practitioners must know their patients well enough to know when to hold individuals back from too much activity and know when to listen and provide pain reduction activities.

“Measuring and quantifying pain is difficult because pain is experienced and communicated in a whole variety of ways and so working with people in chronic pain means that practitioners should have an understanding of the psychological and biological mechanisms of the pain process.

“Practitioners can now use the new guidelines from NICE to develop tailored individually-based exercise sessions, but with a focus on how each patient presents at each session, what their patient’s preferences include, and their goals of physical activity.

“There has already been much concern from several areas regarding the new NICE guidelines that individuals who rely on chronic pain medication are going to be left stranded without medication. Other concerns include where GP’s can access knowledgeable practitioners and how long this referral process might take.

“Another understandable concern is the lack of facilities and the limited number of knowledgeable chronic pain exercise practitioners who can develop and deliver tailored appropriate exercise programmes for individuals with chronic pain.

“It will be an interesting space to watch to see how these new guidelines inform practice.”