EXERCISING WITH CHRONIC PAIN: HOW TO ALLEVIATE STRESS ON THE BODY
WHAT ARE THE DIFFERENT TYPES OF CHRONIC PAIN?
There are several types of chronic pain though the most common types of pain seen in a personal training practice are neuropathic, musculoskeletal, and inflammatory in nature. Here are a few examples:
NEUROPATHIC PAIN
This type of pain is caused by damage to the nerves and is often described as burning, tingling or numbness. This type of pain can be seen in diabetics (diabetic neuropathy), in individuals with a history of Alcohol Use Disorder, and in some cases, the result of chemotherapy.
MUSCULOSKELETAL PAIN
This classification refers to pain stemming from either the muscles, connective tissue (tendons, ligaments), joints, or fascia. Some examples of musculoskeletal pain could be low back pain, plantar fasciitis, and osteoarthritis.
INFLAMMATORY PAIN
This type of pain arises from chemicals released from immunocytes invading bodily tissues. It can affect the entire body or certain parts. Inflammatory pain can result from chronic conditions such as autoimmune disease, chronic oxidative stress, and low levels of chronic inflammation (Pahwa & Jialal, 2019).
WHAT IS THE LINK BETWEEN OBESITY AND CHRONIC PAIN?
Obesity can directly or indirectly cause all three of these types of pain. First, obesity is a significant risk factor for the development of diabetes and subsequently diabetic neuropathy. Comparably, increased loading on the spine and other joints (i.e., knees and hips) can lead to increased compression forces, degeneration of connective tissue, and closing of joint space leading to conditions such as osteoarthritis and degenerative disc disorder. Singh et al. (2015) conducted a study measuring the compressive forces on laborers with a BMI over 35 kg/m2. The compressive forces on the spine from lifting moderate loads in these individuals exceeded the Occupational Safety and Health Administration (OSHA) safe limit. The researchers concluded that excess body weight can in fact lead to chronic pain from musculoskeletal dysfunction. Similarly, obesity can lead to endocrine changes which creates a chronic low level of inflammation in the body such as macrophage accumulation in fat tissue in addition to increased levels of C-reactive protein (CRP) and interleuekin-6 which are both markers of chronic inflammation. Likewise, it is common for individuals affected by obesity to also suffer from sleep apnea reducing the likelihood of achieving restorative sleep. This can further predispose someone to chronic pain (Okifuji & Hare, 2015).
WHAT TYPES OF EXERCISE CAN HELP WITH CHRONIC PAIN?
Exercise has been frequently studied as an alternative to pharmacologic therapy in treating chronic pain. First, exercise is often part of a weight management program to treat obesity. The achievement of a healthy body weight may reverse a chronic inflammatory state, increased mechanical loading on the joints, and sleep disturbances associated with chronic pain disorders. Similarly, physical activity alone (without weight loss) can improve sleep and reduce chronic inflammation in the. In fact, avoiding movement, even in those dealing with chronic pain, may lead to loss of strength, range of motion, and independence body (Ambrose & Golightly, 2015).
STRETCHING/SELF-MYOFASCIAL RELEASE (SMR)
Stretching is often looked at as the first line of defense so-to-speak when using exercise to treat chronic pain. In general, regular flexibility training can improve range of motion, increase circulation to the muscles, and activate the parasympathetic nervous system. All these factors will allow for greater movement. Additionally, many chronic pain syndromes can be the result of improper length-tension relationships of various muscle groups. For instance, shortening of the back extensor and hip flexor muscles can lead to lordosis (abnormal spinal curvature) due to increased mechanical stress on the spine. Likewise, shortening of the hamstrings can alter the range of motion in the hips, possibly leading to back pain (Gordon & Bloxham, 2016). Regular stretching combined with SMR or “foam rolling” can help to restore appropriate length tension relationships thereby decreasing the potential for pain.
Read also: Foam Rolling - Applying the Technique of Myofascial Release
YOGA
Yoga is a practice that began in India more than 4,000 years ago. The practice includes components of balance/flexibility through various postures, control over breathing, and meditation. The breathing and relaxation techniques taught through yoga have been demonstrated to increase relaxation and help individuals with chronic pain syndromes deal with the emotional aspects of these conditions. The balance/flexibility portion of yoga can help an individual with chronic pain improve range of motion and circulation to the muscles and reduce the potential for disability associated with chronic pain (Vallath, 2010). Holtzman & Beggs (2013) conducted a meta-analysis of randomized controlled trials examining the affect of a regular yoga practice on chronic low back pain. The researchers determined that regular yoga practice can significantly improve low back pain, especially in the short-term and reduce markers of functional disability in these patients. Based on these findings regular yoga practice may be a great first step in exercising to reduce chronic pain.
Read also: Heart-Opening Yoga Poses
RESISTANCE TRAINING
Resistance training can help to reduce chronic pain in a few ways. First, strength training can be used as a tool for strengthening muscles that are relatively weak which could be a potential source of pain or as part of a constellation of muscle imbalances leading to painful movement. For example, clients with chronic low back pain may have a history of sitting for long periods of time. This position shortens the hip flexors, lengthens the gluteals and causes a persistent anterior pelvic tilt altering the position of the spine (Clark et al., 2014). A corrective exercise program that helps to inhibit/lengthen the hip flexors and activate/strengthen the gluteals and transverse abdominis (TVA) can help to relieve this pain. To elaborate, researchers identified 30 patients with chronic low back pain of 3-12 months and more than 12 months. Both groups were given a core/gluteal strengthening coupled with a lumbar flexibility program and pain was reassessed after a six-week intervention period. The results showed that nearly all the participants had significant improvement in low back pain regardless of how long the back pain had persisted prior to the intervention (Kumar et al., 2015). The benefits of resistance training are not limited to just alleviating low back pain. Engaging in a regular resistance training program can also help strengthen muscles surrounding joints affected by osteoarthritis or other conditions. Several studies have demonstrated that even in older adults with osteoarthritis received significant benefit in pain reduction and functionality when engaged in a regular and progressive resistance training program (Latham & Liu, 2010). Overall, regular resistance training can improve many conditions causing chronic pain.
WATER AEROBICS
Water aerobics can be an excellent choice of exercise modality for individuals who have conditions causing chronic pain. There are several reasons why this is the case. First, water provides buoyancy which helps to provide some offloading of stress on the joints while simultaneously providing resistance for exercise. Second, the hydrostatic pressure experienced during a water aerobics session can help to increase the load on the respiratory system as fluids are driven towards the trunk in addition to providing additional supported allowing the client to gain better postural control. Last, hydrodynamic drag forces allow for resistance to increase as the participant increases their speed, yet, as soon as movement is stopped, the resistance is also stopped. This allows the participant complete control over how much resistance feels safe to them (Zamunér et al., 2019). (Baena-Beato et al. (2013) conducted a randomized controlled trial to evaluate the effectiveness of a water aerobics program on low back pain in 49 sedentary adults. The results demonstrated that in the cohort that engaged in water aerobics 5 times per week over the two-month study period, there was a significant reduction in low back pain as compared the control group which did not participate in an exercise program. The researchers concluded that water aerobics is an effective non-pharmacologic treatment for low back pain.
BIKING AND WALKING
Low intensity activities such as walking, and biking are generally very easy on the joints and are considered a very safe and effective exercise modality for those living with chronic pain. Likewise, cycling and biking are a good introduction to physical activity that can help chronic pain sufferers break the cycle of inactivity which leads to further pain and disability. These activities can help reduce chronic pain caused by generalized inflammation by assisting with weight loss, improving circulation, and in the case of pain cause by osteoarthritis, help to move synovial fluid through the joints allowing for less pain and increased range of motion (Milosavljevic et al., 2015). It is also important to note that walking can be incorporated into other activities (i.e., yardwork, house cleaning, etc.) which will increase overall daily step counts.
CONCLUSION
There are many choices for exercise which are safe and beneficial for individuals struggling with chronic pain. A well-rounded exercise program which combines several of these exercise modalities (i.e., resistance training, yoga, walking/cycling, and water aerobics) can provide the most benefit as each addresses different aspects of conditions or movement imbalances leading to chronic pain.
Incorporating even a few of these exercise modalities in yours or a client’s weekly schedule can go a long way to helping them feel better and keep moving.
Author: Nicole Golden
REFERENCES
Ambrose, K. R., & Golightly, Y. M. (2015). Physical exercise as non-pharmacological treatment of chronic pain: Why and when. Best Practice & Research Clinical Rheumatology, 29(1), 120–130. https://doi.org/10.1016/j.berh.2015.04.022
Baena-Beato, P. Á., Artero, E. G., Arroyo-Morales, M., Robles-Fuentes, A., Gatto-Cardia, M. C., & Delgado-Fernández, M. (2013). Aquatic therapy improves pain, disability, quality of life, body composition and fitness in sedentary adults with chronic low back pain. A controlled clinical trial. Clinical Rehabilitation, 28(4), 350–360. https://doi.org/10.1177/0269215513504943
Berrueta, L., Muskaj, I., Olenich, S., Butler, T., Badger, G. J., Colas, R. A., Spite, M., Serhan, C. N., & Langevin, H. M. (2015). Stretching Impacts Inflammation Resolution in Connective Tissue. Journal of Cellular Physiology, 231(7), 1621–1627. https://doi.org/10.1002/jcp.25263
Dahlhamer, J., Lucas, J., Zelaya, C., Nahin, R., Mackey, S., DeBar, L., Kerns, R., Von Korff, M., Porter, L., & Helmick, C. (2018). Prevalence of Chronic Pain and High-Impact Chronic Pain Among Adults — United States, 2016. MMWR. Morbidity and Mortality Weekly Report, 67(36), 1001–1006. https://doi.org/10.15585/mmwr.mm6736a2
Geneen, L. J., Moore, R. A., Clarke, C., Martin, D., Colvin, L. A., & Smith, B. H. (2017). Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database of Systematic Reviews, 4(4). https://doi.org/10.1002/14651858.cd011279.pub3
Gordon, R., & Bloxham, S. (2016). A Systematic Review of the Effects of Exercise and Physical Activity on Non-Specific Chronic Low Back Pain. Healthcare, 4(2), 22. https://doi.org/10.3390/healthcare4020022
Holtzman, S., & Beggs, R. T. (2013). Yoga for chronic low back pain: A meta-analysis of randomized controlled trials. Pain Research & Management : The Journal of the Canadian Pain Society, 18(5), 267–272. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3805350/
Kumar, T., Kumar, S., Nezamuddin, Md., & Sharma, V. P. (2015). Efficacy of core muscle strengthening exercise in chronic low back pain patients. Journal of Back and Musculoskeletal Rehabilitation, 28(4), 699–707. https://doi.org/10.3233/bmr-140572
Latham, N., & Liu, C. (2010). Strength Training in Older Adults: The Benefits for Osteoarthritis. Clinics in Geriatric Medicine, 26(3), 445–459. https://doi.org/10.1016/j.cger.2010.03.006
Milosavljevic, S., Clay, L., Bath, B., Trask, C., Penz, E., Stewart, S., Hendrick, P., Baxter, G. D., Hurley, D. A., & McDonough, S. M. (2015). Walking away from back pain: one step at a time – a community-based randomised controlled trial. BMC Public Health, 15. https://doi.org/10.1186/s12889-015-1496-9
Okifuji, A., & Hare, B. (2015). The association between chronic pain and obesity. Journal of Pain Research, 399. https://doi.org/10.2147/jpr.s55598
Pahwa, R., & Jialal, I. (2019, June 4). Chronic Inflammation. NIH.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK493173/
Singh, D., Park, W., Hwang, D., & Levy, M. (2015). Severe obesity effect on low back biomechanical stress of manual load lifting. Work, 51(2), 337–348. https://doi.org/10.3233/wor-141945
Vallath, N. (2010). Perspectives onYogainputs in the management of chronic pain. Indian Journal of Palliative Care, 16(1), 1. https://doi.org/10.4103/0973-1075.63127
Zamunér, A. R., Andrade, C. P., Arca, E. A., & Avila, M. A. (2019). Impact of water therapy on pain management in patients with fibromyalgia: current perspectives. Journal of Pain Research, Volume 12, 1971–2007. https://doi.org/10.2147/jpr.s161494