29 Jul Practical advice for exercising with chronic pain
The relationship between physical activity and pain is complex. For example, people with persistent pain can experience an increase in their symptoms during and following a single exercise session, which leads them to believe they should avoid exercise in the future.
However, we know regular exercise over weeks to months helps reduce pain and improve function and quality of life for a range of different persistent pain conditions. Therefore, it is important for people with persistent pain to engage in regular physical activity to experience the many health benefits. But how can people with persistent pain keep active?
Persisters and avoiders
An important first step can be to understand your current activity levels. When it comes to physical activity in people with pain, we commonly see two distinct activity patterns – ‘persisters’ and ‘avoiders’.
Persisters are those who continue to push on with their daily activities despite pain. While this might be manageable for a time, eventually this overactivity can catch up and pain increases beyond tolerable levels, forcing someone to rest for extended periods until the pain subsides. If you feel like this describes you, try dividing your daily activities into smaller, more manageable portions and spreading out activities across the day or week. This activity pacing can be a useful starting point to stabilise symptoms before engaging in more structured graded activity.
Avoiders, on the other hand, are those who avoid activity for fear of worsened symptoms or that they are causing ‘damage’ to themselves when their pain increases with activity. Over time, this activity avoidance leads to deconditioning and subsequently a lower tolerance for activity. When avoiders do try and exercise again, their lower tolerance for activity means they may experience even greater increases in pain, so they again avoid activity, and the cycle continues. If you identify with this ‘avoider’ pattern of activity, graded exposure and graded activity are useful behavioural strategies to improve your tolerance for activities. These concepts will be discussed in more detail in this chapter.
Becoming more physically active can be difficult for many people. This can be particularly true for people with pain because of the effect physical activity can have on their symptoms. Goal setting is one of several strategies that can be useful to become more active and stay engaged in the activities.
It is very common for many with pain to want to be pain-free. Unfortunately, the complex nature of persistent pain means this is rarely a realistic goal. Instead, it is important for people with pain to aim to stay engaged in activities that matter to them.
This could be in the form of structured exercise like walking or going to the gym, or hobbies such as surfing or gardening, or even social activities like going out to dinner with friends. Research has shown that when we focus more on staying engaged in meaningful activities and on keeping active, rather than focusing on resolving our pain, we can experience some pain relief!
To help identify activities that matter to you, you could ask yourself “If I didn’t have pain, what would I be doing?” Once you have identified some goals you want to achieve, you can use the strategies outlined here, and the practical actions described below, to help you put them into action.
Practical actions for returning to activities with pain
Once you have worked out the activities that you currently struggle with due to your pain, you can use these to set up a graded exposure exercise program.
One way to do this is to take the activity, for example, walking. Start with a short amount and gradually do more and more until you have achieved your desired goal. This sounds simple but can be quite challenging and scary when you have pain.
Pain experienced during this activity can be a barrier to successfully engaging exercise. It is normal and expected that you will experience pain when returning to exercise and activities when recovering from persistent pain. In fact, painful exercises can have a significant benefit over pain-free exercises when it comes to reducing pain.
Although it is generally safe to exercise despite pain, you may find it useful to follow these guidelines regarding acceptable amount of pain:
- If you are coping with the level of pain, then continue with the exercise.
- If the pain is more than you find acceptable or tolerable, or flares up longer than 24 hours after exercise, then decrease the amount of exercise until you’re coping with it again. Some ways to tell if your level of exercise is too intense may be that you begin experiencing interruptive mood or sleep, or you are finding it harder than normal to do everyday tasks.
- It is important to adjust the exercises depending on your symptoms. This may mean increasing the number of repetitions you do or the amount of resistance that you use as it becomes easier; or decreasing if it gets too painful. Try to avoid not doing the exercises altogether, as complete rest is unlikely to help.
It’s important to start slow
When starting exercises, it can be a good idea to start with an amount that you are confident you can achieve and is unlikely to lead to prolonged exacerbation of symptoms. This may mean starting at a level of exercise that seems too easy to be beneficial, though this isn’t the case.
Starting with a small amount of exercise is a great way to increase your confidence and is a major part of the therapeutic process. We suggest that for the first few weeks, you choose exercises and activities that you are at least 80% confident that you can achieve without pain exacerbation that would cause you distress or reduce your ability to live your normal life.
When engaging in a graded exposure exercise program, it is important to remember that the goal is to increase your ability to perform challenging or painful tasks and that this might not necessarily lead to reductions in pain. Because of this, it is important to choose exercises and activities that are meaningful to you and that are currently challenging due to your pain problem.
Using a ‘time contingent’ strategy can be useful once you have become used to the exercises or activities that you have chosen. This means setting a goal ahead of time as to how much you will increase the activity despite your symptoms.
This is not to say that you should exercise into any pain that you do not consider acceptable, or that you should continue if you are having flares after exercise lasting greater than 24 hours, but this can help you increase your activity when you may think you aren’t able to. You might be surprised with just how much activity you can achieve in this way!
Taking it down a level
If you are unable to perform even a very small amount of the activity that you have chosen for your graded exposure, it may sometimes be necessary to reduce the task to start with.
For example, if your chosen activity is gardening, but you cannot currently do even a small amount, you may have to break it down into its basic parts and start with one of these. This may be as simple as doing some forward bending towards the floor, inside your house to replicate the action of pulling weeds.
From here, you might make it more difficult by doing the same movement with a small weight in your hands, gradually making the activity harder as your capacity increases, and ultimately transitioning to gardening at some point along this journey.
Where to get the right advice
Although exercise is considered a safe and effective treatment for people living with persistent pain, it is important that you are assessed by a suitably qualified exercise professional, such as an Accredited Exercise Physiologist, to make sure that there will be no contraindications (serious risks) prior to commencing exercise. These may be contraindications specific to pain (although these are rare), or to other health conditions more generally that may impact on your ability to safely perform exercise.
If you need advice or support setting up your graded exposure program, an Accredited Exercise Physiologist can help at any point along the journey. To find one near you, click here.
To learn more about exercise for persistent pain, you can download our FREE eBook here.
Written by Accredited Exercise Physiologists: Sam Rollison (AEP), Aidan Cashin (AEP, PhD) and Matthew Jones (AEP, PhD)