Exercise and Pain... Let's get some things straight
Now that we’ve kinda addressed the complicated shitshow that is pain, and in case you missed it, or you’re a bit of an outsider to this pain stuff, have nothing to do for a solid 20 minutes and are in the mood for a little brain fuckery, then click here. Apologies for the coarse language and all right now, but this pain stuff; though it’s not exactly my preferred jam, it really does pent up some frustration of sorts and that translates into the only accurate and compatible terms of expression; profanity.
Anyhoo, go give it a read.
But the point of all this now is to wade into the waters of how exercise specifically fits into this complex mess as a means of managing pain. Spoiler, it’s not what has been traditionally espoused. If you actually read the aforementioned post about pain, then the alert for said spoiler is probably just redundant. Everything just seems to be going against the grain at this stage, right?
But yeah, exercise can (I say the non-committal “CAN”) be very helpful for the long-term management or treatment of pain and again, not because of the reasons I’d imagine you understand it to. Over the course of time with many a physio, chiro, osteo and the rest advocating and practicing the well-intended but ultimately “less useful than first thought” methods of cracking, manipulating, realigning and “putting this and that back into place” methods of rehabilitation, it kinda also coupled with the biomechanically heavy and very complex methods of “optimal movement” or “corrective exercise.” Again, another well-intended but “less useful than first thought” paradigm of practice as a way to help people rehab.
Note: I’m not intentionally shitting on anybody, but it’s just factual with what we know now that the idea of the miracle that is the human body is “meant” to move any one or specific way is a bit of a fallacy.
To add credibility: I too lived this stuff once. That movement was “meant” to look like this or that and if you didn’t or couldn’t move “the right way”, then that was generally not optimal, risky and the most critical factor for any pain you have. And if you weren’t in pain now, it was just a matter of not if, but when…
Yes, that was me.
Anyways, back to the actual project…
Pain we know is a human subjective experience and yadda yadda yadda, but is important to note that with it’s complexity, there are many attributing factors at play which can contribute to our pain, make pain worse and more perpetual. Stress, fatigue, poor sleep, poor nourishment, INACTIVITY, interpersonal strain, and the general overall feeling of being unwell can have very pronounced effects on chronic pain syndromes. The thing about exercise and physical activity is that it is one of the most health-promoting things that one can do, with an endless list of general health benefits. Essentially, within the complex mystery that is pain, what we do know is that being or getting healthier can go a long long way to helping one recover, improve or better manage their pain.
Exercise plays a massive role in helping us be healthy.
I guess a better way to put it for folks, especially if you’re unsure, unfamiliar, or just gun-shy when it comes to exercise is that more than exercise is good, it is inactivity that is not good. It’s the non-moving and the non-engaging which essentially goes against what our bodies, and minds, are built to do and thus can seriously compromise our health in the long term. These health-compromising behaviours of sorts are real contributors to the long-term pain experience usually; more so than general exercise, or any specific exercise per se, is like a magical cure or medicine for pain.
As much as it’s a punch to the ego of many fancy exercise specialists, physical therapists, corrective exercise guru’s, strength coaches and so on that there are no “special/pain specific” exercises or exercise modalities, it’s great news for the patient and lay public. This means that anything can potentially be on the table – no special protocols or fancy techniques etc. You can engage in whatever your heart desires, in some fashion, probably.
Now let’s not go absolutely ape-shit, though. Like, no, I’m not going to condone that 85-year-old Joan with 2 hip replacements can easily and safely start Olympic lifting double bodyweight snatches for reps this afternoon. Unless she was able to do it already, that might be a tad inappropriate. It also doesn’t mean that those in pain, or anybody in general, need absolutely zero guidance whatsoever when it comes to engaging in certain sports, activities, training, and stuff like that. For the person in pain, guidance is probably required as a means of negotiating the fraught and tricky path of chronic and weird pain whilst re-engaging in exercise and/or meaningful physical activities. For average Joe/Jane who was always told they’re not “built for running” or “lifting is bad for you back” (my favourite) and so on. No, those doors are most likely open too. Though it might be wise to seek some decent advice if you’ve found anything tricky in the past, or it’s a totally novel pursuit. But some guidance to hold you in good stead, temper expectations (eg. it’s not that you’re not built for running, more that you might not break the 4-minute mile, but that’s still okay!) and essentially advise you on how to appropriately progress or get whatever you seek to get out of it all.
Okay I’ve kinda gone sideways…
The point is, being active through exercise and/or meaningful physical activities (I’ll address these at some point) – in any capacity – is a fundamentally healthy and important practice that goes a significant way to helping us manage chronic pain through the basic elevation of your physical health, the confidence it can help you foster in yourself and your body as well as helping to uplift your mental wellbeing.
“So, if exercise doesn’t cause pain, then why do I get sore knees or feet from running and stuff?”
“Yeah, I do get a sore back from gym… so if it’s not the gym, then what gives? And no, I don’t feel psychologically distressed or unwell etc…”
Okay, so the fitness fanatics/already converted exercisers/healthy folk who are dealing with pain in the crowd with their questions – and they’re valid, important questions…
Yeah, well, as already mentioned once upon a time; the human body is an incredibly robust, anti-fragile, capable, smart organism that can adapt to almost anything if given enough tolerable opportunity to. Key word: tolerable.
So, outside of some type of high-velocity, significant physical trauma, if your body feels pain or a tweak or a constant something when you exercise or do whatever – it’s usually not because of an injury in the regular way we think of it; damage. It’s more likely to be a tolerance issue. Your body, for many possible reasons, is not tolerating this particular activity, in this way, right now. This could be because of one of the previously addressed things like stress, fatigue, illness or whatever. It could be something like unfamiliarity, novelty, or unpreparedness for this activity, at this intensity, at this pace, at this frequency, at this volume or any other variable you could throw in there. It could also be the remnants of an injury/pain from once upon a time and the sensitivity or, how do I say it, “pain memory” that can carry along from a significant pain experience of the past. Remember, our body/nervous system is smart and only operates to protect us – hence anything unfamiliar, unprepared for or associated with as being bothersome, unsafe, dangerous, risky and so on can connotate some “hitting the brakes” by way of pain responses, just to slow us down, you know… Even when we consciously know the activity is good for us. Yes, it’s frustrating, but whatever, I’d still prefer a pain response system than not have one.
Anyhoo, question from above.. let’s do the running example.
If your knees are sore from running, assuming there’s no like significant lesion like a tumour or other systemic illness happening at the knee, then the things that I’d first examine are things like…
How long they’ve been running, injury history, other history etc
How much it hurts and when does it hurt, like straight away, during or after
What their training frequency looks like, get an idea of how much they’re doing, how consistent they are usually vs right now and so on
Non-running factors, like sleep, life stressors and so on
When it hurts, how do they interpret that and what does it do to them (getting deep here..)
Are they open to trying some different strategies, different exercises or whatever to see how that goes?
Without getting into the nitty-gritty of an actual assessment, some key elements that I want to know that could be contributing to this “already fit exerciser” that is getting pain (despite being told that exercise is meant to help pain!) are things that can kinda contextualise the overall picture so as we can maybe explore some strategies to help resolve the issue. Everyone’s individual circumstance will always be unique, so consideration to that is wise but commonly for specific pains that runners usually deal with, it often can come down to things like plain over doing it in some capacity, and that is causing some type of flare up or pain response.
Context: usually runners love the feeling of running, and the hardest thing to get a runner to do is to stop running or alter their running practice in some way. They call it “runners high” for a reason; runners love the feeling, accomplishment and intensity of high output training, mileage, frequency and so on. And usually, runners exclusively just run as their form of exercise and physical activity. All these things are not wrong, but sometimes our body needs a rest, even from activities we love to do. Stress is stress, whether it’s physical, emotional, mental, work stress and so on. These things can sneaky pile up a little bit (because, life..) and when the runner’s best, most loved coping tool is to run, this is where the toll can start to creep up, we miss some warning signs and it all manifests itself as a notable pain response.
Stereotypically, runners will respond/react to running pain more so than respond to stress related pain from other life stuff, because runners love to run and when the brakes are put on that specific activity, there’s now a real problem. Like, “work sucks because it’s work, so a bit of headaches, stress, fatigue, tension etc from work is normal and won’t stop me soldiering on… But if my running starts to become painful enough to cause me to stop – now we have a real problem!!”
These usually aren’t conscious choices per se, it’s just our nature, conditioning around what stresses we tolerate, stresses we perceive as normal and what we fear the most. A runner’s biggest fear is inability to run, usually. So when, for some reason, something pops along potentially threatening that ability, you bet it’s a problem – more than the stiff neck from the work computer, who cares about that. We must solve this running pain thing, pronto! Fear, catastrophe, and urgency starts to embed itself into the issue, which we know doesn’t help and then the pink elephant can truly grow. This is all a bit of a stereotypical contextualisation of the wider situation that can usually arise and contribute to the runner feeling pain when they’ve seemingly not hurt themselves, or when pain is an ongoing, moving target. These are the factors that usually aren’t emphasized, coached through, or made sense of enough for the runner in pain, typically. The completion of the answer, so to say. But it’s imperative that stock be taken into these factors, and we figure out ways to effectively manipulate some of these other things somehow, maybe even utilising some other tools at our disposal in a complimentary manner and if the person is willing; such as pain meds, manual therapy, different shoes, or whatever else and approach this scenario in a more holistic integrated fashion, addressing ALL the factors we know can contribute to pain.
All this still sounds like hogwash, woo woo esotericism… Get to the prescription. What does the runner actually do??
Well, usually after conversing and grasping the wider context of why this person may be having a pain response, assuming all that goes down reasonably well and an open mind is achieved, then it can be as simple as exploring some symptom altering activities; i.e. lets do some movement and stuff that could help alter or lessen the pain response. Let’s move away from the thing that’s eliciting a pain response, for now, and rather than tell an active person to halt everything and just be inactive or rest (because we know what type of shit show that could be) lets see what the alternatives are and if they’ll help. That might look like something still specific to actual running, but different – like…
“have you ever tried jogging trails?” or
“what if we altered you stride length, just to shake it up?” or
“you normally squeeze a run in the mornings before work.. would running after work be feasible?”
Anything that can reframe the task, alter the demand or whatever is on the cards here, usually.
Endorsing the concept of graded exposure usually helps here too. I.e. doing some novel alternative to regular running, such as trails, might still be painful at first. But appropriately leaning into the pain, learning to reasonably tolerate it and desensitize ourselves to those feelings can be an important part of the reconditioning process. Much like overcoming a fear of heights, usually we need to intelligently expose ourselves to the trigger in order to better tolerate it. It’s all a bit nuanced, but essentially, we’re changing the context of the activity and moving away from the primary provocateur, for now – but not forever – till we can settle things down, then build ourselves back up (through graded exposure), as Greg Lehman would say. How we settle things down can look a million different ways, it truly depends on the person; but fundamentally we’re still keeping an active person here active, occupied and engaged in something novel whilst concurrently navigating other potential impactful stressors that might be playing a role. Or it could just be as simple as giving our body (and minds) the physical variation that it sometimes craves, i.e. different forms of enjoyable exercise and training. Or it too could be the “changing things up” as a way of decreasing the physical demand/stress on yourself; permission for a heavy exerciser to turn it all down a notch. Like for example, there’s nothing inherently magical about yoga for runners and pain, but usually, yoga comparably as a practice is just waaay more chill than frequent endurance running, and it’s that acceptance and self-permission of turning the training stress down, via yoga in many cases, is what actually gives the body and mind the chop-out it craves, rather than some special unique quality of yoga.
The same could be said about strength training making the runners body sturdier, stronger and thus too biomechanically resilient and robust for pain. No, it’s probably not so much because learning how to squat or deadlift “correctly” gives your hips or knees the strength it was missing to be able to withstand the “wear and tear” of running, hence resolving pain. No, as much as improving your strength can be great for anybody (I will always espouse this), being strong doesn’t bullet-proof you from pain. It’s probably more the novelty of the exercise/training, having some time out from the running to do something else and building yourself up a different way that is probably driving these effects. Without getting too far into the weeds on this one, getting stronger can usually be good for almost anything – but, just like the yoga example, it’s effects on pain is not for the reasons we may logically understand.
(Not intentionally shitting on yoga or strength training, I love yoga and strength is my jam. It’s just that, like any exercise for pain – it’s not universally magic or special, probably)
So, in a nutshell, taking the time for this runner to understand their pain, what it means and why it’s most likely happening to them. Reconciling those concepts with other possibilities (not restrictions) at hand to help settle things down, do some other things and take a temporary step back, and then patiently working through and getting back up to scruff with “normal running”, now with a more accurate idea of what the odd niggle/pang means, having less fearful attitudes about it all as well as some troubleshooting skills to help themselves navigate these once scary waters. When armed with this “DIY toolbox”, so to speak, then that fosters a very important quality for folks when handling themselves, their pain and any future threats to the activities they love; self-efficacy.
High self-efficacy is quite important for the individual in pain. It encourages notions of control of the situation, agency, optimism and therefore less fear. This is the big thing that many folks in general, not just runners, don’t usually get ample opportunity to work on when it comes to managing these things. It’s not the same as just lumping everything on them to do and away you go, but a person with feelings of say, control and optimism in their journey is powerful. So as practitioners, there’s a critical element of engaging this side of the equation.
Okay, I didn’t want to get ranty, preachy or too specific about an intervention, but it just happened, and I apologize. For the sceptics it might also seem convenient that I’m not getting very specific about “what ado?” for pain and exercise, like a politician talking all wind rather having actual answers. But the honest to gods here is that pain is truly a complex system that has very nuanced and individual answers and if there were a silver bullet mode or exercise to “fix” low back pain, chronic pain, neck pain and all the other pains that is such a modern societal scourge, then it would probably be sorted out by now… And that principal can probably apply to most medical conundrums out there.
In the end, exercise and/or physical activity (especially meaningful physical activity) is strongly encouraged for most people in pain and can be an excellent adjunct (not whole solution) to sorting out the pain puzzle as it is a fundamentally health promoting activity and, by definition, staves off a much worse clinical outcome; prolonged inactivity. Exercise when prescribed appropriately for an individual, along with other factors relating to their pain being reasonably accounted for, is a powerful piece of the pain intervention. Exercise is a way of reconditioning, both physically and mentally what one can tolerate through exposure. Exercise can help encourage a strong sense of robustness, anti-fragility, fitness and vitality by keeping one moving and physically engaged whilst dealing with pain, as well as help to foster a level of self-efficacy, control and authority in their pain journey.
To boil it all down, rather than it being exclusively due to any type of purely physical/mechanical altering phenomena, the mechanisms of exercise when it comes to dealing with pain is still somewhat mysterious, but from what we do know, it seems to be more because of the general “wellbeing” qualities, both physically and mentally that it can foster when appropriately prescribed and adopted..
That’s about the best way I can put it, honestly.
**Authors note; I'm quite thrilled about getting my first useful (kinda) Seinfeld video into the mix on a piece of writing