Chronic musculoskeletal pain (CMP) encompasses a diverse range of conditions such as osteoarthritis, discogenic spinal pain, fibromyalgia and chronic widespread pain. There is consistent evidence for the benefit of exercise to improve pain and function in CMP, although there is considerable uncertainty concerning the best exercise modality and dosage. This makes establishing definitive exercise guidelines for CMP difficult and it is further complicated by the potential need to individualize treatment. Even within seemingly specific subgroups (e.g. CLBP, fibromyalgia), the impact of exercise on pain can vary considerably between patients. For example, movement based therapies such as yoga and Tai Chi (Lee et al., 2014) and submaximal walking exercise (O’Connor et al., 2014) may improve symptoms in CLBP even though the conclusion of a recent review states that only specific strengthening and stabilising exercise reduce pain (Searle et al., 2015).
With the uncertainty surrounding exercise dose and modality, exercise prescription for the same patient presenting with a CMP condition can vary considerably between clinicians. However, despite very different exercise approaches patient presentation will often improve. Could it be that exercise interventions which benefit patients with chronic pain do so by means other than just improving physical function? Support for this notion is decreased pain and disability following exercise for CMP being unrelated to changes in physical function (Steiger et al., 2012). If changes in pain and disability can arise independent of changes in physical function/performance, then specific exercise modalities and dosages may be less relevant for individuals with chronic pain compared to healthy people.
It is now well accepted that with chronic pain, the secondary pathologies or consequences of persistent pain including fear of movement, pain catastrophizing, anxiety and nervous system sensitisation appear to be the main contributors to pain and disability. Exercise treatments which also address the secondary pathologies may benefit patients with CMP above programs more focused on physical function. This could also explain why research to date has not shown any exercise modality or dosage to be superior, or why a patient with CMP might respond to exercises which can vary greatly between clinicians. The common theme shared by efficacious exercise interventions for CMP might be their ability to positively impact on secondary pathologies independent of physical function.
How might clinicians better deliver exercise treatment for CMP? Implementing exercise using a biopsychosocial treatment approach that acknowledges and aim to address the physical, psychological and social factors underpinning pain and disability align with contemporary pain rehabilitation practices and is superior to standalone physical therapies (Kamper et al., 2014). This requires a thorough initial assessment so clinicians can identify the primary biopsychosocial factors contributing to pain and disability to be addressed during treatment. Understanding how pain and injury is impacting on a patient’s function, daily activity and their thoughts, beliefs and behaviours concerning physical activity pain and injury assists clinicians to implement combined patient-tailored exercise and targeted education (Moseley and Butler, 2015). This necessitates that clinicians have an in depth knowledge of contemporary pain biology concepts so they can engage in meaningful and positive pain dialogue to assist patient better understand their pain experience and integrate this into their daily life. ‘Explaining pain’ should commence in the first consultation, be ongoing and reviewed during treatment and target unhelpful cognitions and behaviours identified in the initial assessment.
It is imperative that all exercise and activity be perceived as safe and meaningful by the patient. Clinicians need to frequently reassure patients that is safe to become more active despite their persisting symptoms. Patients must understand and believe that it is safe to exercise with discomfort that: plateaus and does not continue to rise significantly; they can cope with and feel is manageable; and gradually decreases after they have finished exercise. It is not necessary to assess pain intensity during every session as this does not provide any additional benefit and by not doing so the clinician will reduce the risk of encouraging a vigilance to pain. Exercise modalities that patients enjoy and associate with achieving their goals can improve treatment adherence. As the patient’s confidence and physical activity tolerance increases, principles of progressive overload can be applied to their daily activity and exercise. While some patients will engage in higher intensity exercise, the majority of exercise prescription for CMP will involve low to moderate intensity exercise. In contrast to the recommendations of moderate to high intensity exercise to improve health and fitness in healthy individuals, patients with CMP appear responsive to lower exercise dosage (i.e. low to moderate intensity exercise; (Booth et al., 2017). In instances where the clinician is unsure about exercise dosage, allowing patients to self-select exercise dosage can be helpful.
Some time ago I saw a course called ‘the art of exercise prescription for chronic pain’. I liked the title because it implies flexibility in applying evidence to best suit the patient’s needs. I also feel that it embodies the notion that in some instances, irrespective of exercise, simply engaging with the patient, developing their confidence with movement, assisting them to become more active and pace up their daily activities has the potential to reduce the impact of pain and improve quality of life.
Aspects of this article are discussed in more detail in a recent clinical update on exercise and chronic CMP (Booth et al., 2017).
About John Booth
John is an Exercise Physiologist and principal of a multidisciplinary practice in Wollongong concerned with musculoskeletal rehabilitation, with a special interest in chronic pain. He is also a fractional academic in the school of medical sciences, faculty of medicine, UNSW. He has a research interest in exercise and pain and the influence of patient and clinician communication on treatment outcomes. He lives a stone’s throw from some neat surf breaks and mountain biking trails which he knows very well.
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