Overcoming Chronic Pain with Exercise and Pain Management Techniques

Pain is a complex and emotional subject.

What’s agonizing for one person may be just a discomfort for another. And those responses can reverse in another situation and context.

It’s unavoidable, and frankly a necessary part of all of our lives. In the simplest terms, pain is a protective measure, your body’s way of signaling danger. For example:

• when you absentmindedly touch a hot pan without oven mitts (you’ll instinctively pull your hand away, avoiding further harm)
• or the sharp pain you feel when you break a bone (you’ll automatically stop moving that area, which would otherwise cause more damage)

These examples illustrate why we actually need pain. In both cases, the pain is limited and temporary, and hopefully won’t last any longer than required.

When pain is longer lasting, that’s when it can affect our daily lives and activities, and distress us to the point where we’ll try just about anything to make it stop.

You could spend years studying the complexities of pain and how to affect it. What I’d like to do in this article is give you an overview, plus some advice you can use right away.

What is Pain? Acute vs. Chronic

We’ve all experienced different types of pain at some point, and we know the difference between the pain of stubbing a toe vs. a nagging back ache that just won’t go away.

Let’s look quickly at what you need to know about these different types of pain.

Acute Pain

When we talk of touching hot pans and broken bones, those are examples of acute pain, very quick and immediate sensations along the nerve pathways warning of tissue damage.

Getting hit, falling, and other “insults” to your body can create pain. We all know this. It happens all the time.

I won’t talk too much about acute pain since it most often resolves on its own and simply requires some activity modification. For example, if you feel a twinge in your back while training one day, in most cases you probably just need some rest to let the area recover.

One interesting thing to note about acute pain is how the central nervous system (which we’ll get into in greater depth below) processes pain in different scenarios.

If you’re running on a trail zoned out with your music and the rhythm of your effort, you may brush against a branch, get a relatively deep cut on your leg, and not notice your injury until you finish.

In another situation, you may be filling out paperwork at your desk, get a shallow paper cut, and feel intense pain immediately.

As we’ll discuss below, pain is a message delivered to you from your central nervous system, and it’s a message that can be altered by dozens of different factors. Depending on the current situation, your personal history, and what other things are happening in your life, you can be more or less sensitive to that message.

Chronic Pain

Here’s where things get complicated. Chronic pain, defined as pain lasting over 12 weeks, is emergent, complex, and without simple solutions.

This is clearly seen in the millions of people dealing with a variety of back, neck, and extremity pain, some resolving quickly and some turning into years of problems despite many types of treatment.

The 12-week definition is based on “normal” wound healing processes that include inflammatory, proliferative, and maturation phases. Theoretically, by the end of that cycle, pain should end. In reality, this “regular” process of pain resolution isn’t as cut and dry for a lot of us.

It’s common for pain to last longer than this course, even when all the x-rays and other scans reveal that the tissue is fully healed. Which is more than a little frustrating when the doctor declares you should be all good.

The pain you’re experiencing here is a response to a perceived danger. A danger that may have passed, meaning the tissue damage is actually “okay” now, but your nervous system still perceives the issue as unresolved.

Because of this, the rest of this article is devoted to understanding this phenomenon, and how you can help yourself if you’re in this unfortunate situation.

The Nitty Gritty of Chronic Pain

Pain is an interpretation of the totality of inputs to the brain. This includes, but isn’t limited to:

• tissue damage
• inflammation and its chemical outputs
• other sensory information, like pressure, sight, heat/cold, etc.

All these inputs, and their complex relationships with context and nervous system interpretation, explain why the pain response is so variable.

This is where it gets confusing: separating tissue damage from sensitivity, and accounting for all the factors that influence the perception of pain and suffering. Stress, anxiety, life situations, your history, and other circumstances all come together to determine how pain waxes and wanes beyond your body tissue’s actual “physical” status.

The latest science reveals that there can be little correlation between tissue damage and the perceived pain.

You can take two MRI scans of different people that show similar structural problems, and one will report no pain while the other can barely move without wincing. When you consider all the inputs that go into creating a pain sensation, it’s clear that it’s not as simple as tissue damage = pain.

It’s a lot more complicated than that.

“Emotional Component” does not Equal “It’s all in your head”

One important type of input that many people don’t think about, or even discount, is psycho-social input such as stress, anxiety, depression, and belief that you can (or can’t) get better.

The stress and emotional components of suffering don’t imply that the pain is “in your head” or that your pain isn’t “real.” It’s an assertion that pain can increase or decrease based on the totality of what’s happening in your life, and based on what other inputs are affecting your nervous system.

Recognizing this is an important part of addressing your condition, as it often creates a cycle that’s difficult to deal with and break.

The term “pain and suffering” is instructive because they really are distinct entities. Suffering relates to how you deal with the presence of pain in your life, and this specific reaction should be addressed as much as any physical treatments.

Methods such as cognitive behavioral therapy (CBT) and mindfulness based stress reduction (MBSR) are important complements to a physical treatment protocol.

Treating Chronic Pain

As you can see from all the complexity described above, it’s impossible to make sweeping recommendations for treatments that work for everyone. There’s no such thing.

When people ask us if any of our programs or articles are appropriate for a client’s conditions, or whether they’ll help overcome pain, this is a very difficult thing to answer. It depends on so many factors happening with you or the person you’re trying to help.

Of course we want to help, and it’s no better to just throw in the towel and give up. But it’s also more appropriate to emphasize improving function and capacity than to assume something will relieve someone’s pain.

I make educated decisions with my patients and these yield good results, based on prior clients’ successes and their reactions to treatment. But it would be disingenuous, even deceitful, to say a particular approach is the solution for all ills.

The intricacy of pain and our personal variabilities require an approach that’s flexible and adaptable to our individual situations.

Science is a Guide

Scientific research works incredibly well in evaluating a particular therapy or modality against chosen variables, especially in comparison to another type of treatment, or simply doing nothing at all. It cannot be stressed enough how important good science is in our understanding of how our bodies work and how they react to interventions.

If there’s an intervention we can be nearly 100 percent sure will help, it’s exercise. For example:

• Low Back Pain: We have good data showing that exercise of almost any kind has a positive impact on low back pain.
• Achilles Tendinopathy: Research supports the use of eccentric and concentric exercise for relieving pain from achilles tendinopathy.

And of course the trick is in the proper application of exercise: appropriate dosing of intensity, frequency, and volume for each individual.

There are also many studies that show various concoctions (homeopathy, herbals, etc.) and treatments (“energy work”, ultrasound, etc.) have no benefit. That said, I think it’s unhelpful to tell someone that whatever intervention they’ve used to help with their pain is not “real” even if the particular mechanisms behind the treatment are scientifically dubious.

When a patient tells me this cream or this herb or whatever really helped them, and I know that the research may say otherwise, I have never told them “what you are feeling is WRONG!” How can that be helpful?

Disregarding someone’s personal experience is a great way to distance yourself, and frankly, make you look like a jerk.

Placebo and Nocebo

You’ve likely heard of the placebo effect, where an intervention that should induce no physiological change (the sugar pill is the classic example) creates a change.

It’s easy to dismiss this as a mere psychological effect and call a sugar pill or sham treatment “fake,” but it’s actually a very complicated process. It involves environment, patient and practitioner expectations, prior history, emotional effects, and many other factors.

It’s very real and at times very helpful.

Just as our variable emotional response to pain doesn’t make the intensity less real, when someone experiences a positive result from a therapy, even if it may be due to the placebo effect, that doesn’t make the benefit less authentic.

To dismiss a positive benefit as “not real” is wrong, and most thoughtful clinicians will say nothing of the sort.

Along with placebo there is its opposite, the nocebo: the introduction of something that should create no biological effect yet, intended or not, causes an adverse response.

And this is what I see happening with the various debunkings and skepticisms of certain treatments. Of course, I’m not rejecting science. It’s equally wrong to say “well then everything works sometimes for some people.”

And I’m absolutely not saying we shouldn’t expose poor practices and treatments that are shown to be harmful or worthless.

What I am saying is that there’s a difference between uncovering dangerous methods and being so cynical that what people are hearing is “don’t try anything else but these few things we know about for certain.” This can be as much of a nocebo as telling someone there is nothing at all they can do for their pain and they just have to live with it.

Being so antagonistic about styles of treatment can make a person think “well, nothing really works.”

Again, I would never espouse something that’s known to be harmful. But the interplay between physical and psychological aspects of pain relief is incredibly elaborate, and no one can truly have the “one answer.”

I favor a pragmatic approach over a dogmatic one.

You Won’t Know Until You Try

It may seem too simple a concept, especially when we’d all like to know if something will be exactly what we need before we start. The reality is that you won’t truly know if something works for you until you try it.

This is the essence of science.

You give yourself a trial of an intervention over a reasonable amount of time, then measure the results and evaluate how to proceed. That’s about as scientific as it gets.

I tell my patients and clients to give me 2 weeks, with my standard line being: “in that time you should know if what we’re doing is helpful, probably not 100% better but enough to know that this is the right track for you (or not).” If in that time there’s progress that’s meaningful to the individual, that’s a good sign to continue on.

Using the Central Nervous System to Your Advantage

As we’ve discussed, the nervous system is an amazing and convoluted structure that’s responsible for how we interact with everything around us. We can actually use this interplay to our advantage.

We know that when chronic pain is present, it affects the nervous system in myriad ways. For instance, those with chronic pain experience:

• Decreased Two-Point Discrimination: This is a skin sensation test that measures a person’s ability to discern whether there are two distinct points touching the skin vs. one point. When a person is in chronic pain, they have a lessened ability to distinguish this accurately.
• Impaired Proprioception: The awareness of the relative position of your body in space, which is important for movement, balance, and coordination. Those suffering from chronic pain often have decreased proprioception as well.
• Sensitization: An astonishingly complex topic that fills entire courses and textbooks, of which two of the most readable and entertaining researchers are Lorimer Moseley and David Butler. Rather than adding another dozen pages to this post trying to work through this deep subject, we can simply state that sensitization means pain begets more pain. In long standing pain issues, the body/brain is made more sensitive to recurrences based on sensory inputs that might otherwise be ignored if there wasn’t a previous pain response. Pain becomes like a particularly bad habit, frustratingly hard to get rid of.

With these concepts in mind, we can begin to understand how to use them to break free from the pain cycle.

If your body sensations and proprioception are affected by pain, it stands to reason that working on body awareness and proprioception can affect your pain. Spend time on a variety of movements that provide different stimuli and influences on your body sensations, and you’ll induce changes in pain perception.

Likewise with sensitization. If pain begets pain, you need to “convince” your body to lose its memory of pain.

After an injury, there’s invariably a period of very limited movement. In this case, even the simplest rehab exercises can have a profound impact on acute pain. I’ve seen people come into the clinic barely able to move, and with some gentle handling and exercise, they walk out feeling significantly better.

And the same can happen with more chronic issues.

The more you can replace poor memories of painful experiences with new memories of the “good news” as Todd calls it, the better. Part of this is doing what feels “good” and avoiding what feels “bad.”

Some years ago there was a big push for classifications of conditions to better affect treatment, and out of this came the concepts of flexion (forward bending) or extension (backward bending) intolerance. So instead of specific diagnoses we now look at situational factors that can aggravate your issues.

Activities such as being slumped at the steering wheel or at the computer provoke back problems in some, while standing for long periods and reaching up bother others. It’s a simple thing, but recognizing exacerbating activities and limiting their duration and frequency helps quite a bit in managing symptoms.

My Own Experiences Dealing With Pain

In addition to my experience as a physical therapist treating patients in pain, I’ve also been “on the other side of pain” so to speak.

I’ve had mid and low back pain since I was a teenager, and as my young co-workers remind me quite often, I’m old now. Thankfully it’s managed well with exercise and understanding of the primary aggravating situations.

I’ve had a lot of different treatment interventions over the years, from rolfing to spinal manipulation, and osteopathic technique to dry needles.

I had very good benefit from many of them, especially in the acute periods following an exacerbation. But the treatments didn’t “cure” my condition. They allowed me a window of opportunity where the pain was reduced enough to get back to the flexibility, strength, and motor control exercises that mitigate the pain.

• Improving motor control can help pain conditions for the reasons we’ve talked about above, with the practice of bettering sensation discrimination and body awareness.
• Working on your flexibility can help, not necessarily because of structural changes, but more likely because it improves your ease of motion and replaces the memories of pain and stiffness with amended experiences.
• When we talk about strengthening for pain control, it’s not because you’re building up an “armor” as a protection from insult, but more often it’s for the sensation of stability, to keep all the sensitized structures feeling secure and stable.

If I were forced to summarize the best approach to pain management in one sentence, it would be this:

Improving your body awareness and tolerance in different movements, and modifying your habits as needed, especially those that generate pain, is the key to long lasting change.

You CAN Overcome Your Pain

I’ve had the opportunity to treat many patients over the years, and have many examples of when this approach has worked.

• One patient came to me with low back pain that had been going on for years. After one treatment with me, she told me she had immediate pain relief that lasted several days.
• Another patient had daily headaches for 20 years. After one session and teaching her one specific exercise, she’s had lasting relief from her headaches.

I don’t share these to boast of my “magic” techniques, but instead as an illustration of how pain cannot be simply related to tissue damage or structural issues. Otherwise, how could they be affected by one session after years of trouble? It isn’t that simple at all.

There was some very complex interplay between our expectations, education, and physical intervention, and the particular patient/therapist dynamics that led to the result.

I would be lying if I said I knew exactly what. Be wary of anyone who says they know for sure.

The best way to decrease and prevent pain issues is to work on them gently and progressively. Build strength and flexibility in all motions, explore your active movement in new and creative ways, and remember that pain doesn’t necessarily mean damage from one causative factor.

Pain is a complicated issue, and anybody selling you the “one secret way” to deal with it is either deluded or predatory.

This isn’t something you fix once. It’s a practice you maintain. With consistent attention to body awareness, strength, and mobility, you can stabilize your body, move with ease, and use the relationship between pain and the nervous system to your advantage.