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  • Michele Curatolo

Exercise for chronic pain: when patients and health care professionals are not on the same page

Physical therapy with exercise is standard of care for the treatment of chronic pain. However, the goals of physical therapy should be primarily the long-term improvement of function or prevention of deterioration, rather than reduction in pain.

Physical therapies that involve exercise aim to improve muscle strength, endurance, coordination, and range of motion, among others. These treatments are mostly "active" in nature, unlike forms of "passive" physical therapy, such as massage, passive stretching, etc. While exercise is the form of physical therapy that is most widely recommended, it has the least acceptance from patients with chronic pain.

"Exercise makes my pain worse"

We hear this is a statement daily from patients with chronic pain. The reasons are multiple and include, among others, stimulation of degenerated or inflamed joints/ligaments, enhanced pain sensitivity, and psychological factors such as anticipation of pain with exercise.

There are different ways to react to this situation. One is to abandon exercise because it has been tried, and has been ineffective or even detrimental. Another one is to convince patients that exercise is standard of care and should be tried again. Both approaches will unlikely be in best patient's interest.

Exercise will unlikely reduce patient's pain

Patients come to us primarily to have their pain treated. Can we tell them that exercise will reduce their pain? The results of published studies are far from being consistent. This raises the fundamental question whether reduction in pain is the right primary goal of exercise.

Exercise rarely reduces pain in the short term.

If short-term pain relief is rare, is a reduction in pain in the long-term a reasonable goal? Again, the published evidence does not give a clear answer. Even assuming that exercise reduces pain in the long-term, the effect size is modest. In simple terms, this means that the proportion of patients who will report a substantial reduction in pain, compared to not exercising, is small. Therefore, long-term reduction in pain should not be promised to patients.

And yet, exercise is a must

This only apparently contradicts the previous considerations. The fundamental question is:

What is the goal of the treatment?

Reduction in pain intensity is not the only goal of pain management. Patients have substantial limitations in physical function, sleep, social functioning, as well as psychological problems. All these elements, together, make chronic pain, and all of them have to be addressed.

Improving physical function and preventing worsening in physical fitness are key goals of pain management: this is what exercise primarily addresses.

Addressing physical function should be our focus when proposing exercise to patients.

This is particularly important for those patients who have tried exercise and gave up after few sessions because their pain worsened.

"My physical function will increase if my pain is fixed."

However, this is in most cases an unrealistic goal. Chronic pain can very rarely be "fixed", and the treatments that we can offer to reduce the intensity of pain are mostly insufficient to allow improvement in physical function without the contribution of therapeutic exercise.

Overestimated and underestimated

Not uncommonly, health care professionals propose physical therapy as a treatment for pain, which patient understand as a mean to reduce their pain. This does not make sense to patients who have experienced worsening in pain with previous trials. Also, without thorough explanation of the mechanisms of action of exercising, patients will not understand why exercise should lead to less pain.

Lack of patient's acceptance is the result of a misconception of treatment goals.

The only way for patients and health care professionals to come to the same page is to address the right treatment goal, which is not primarily a reduction in pain. We want patients to be able to do more in daily life and prevent further deterioration in their physical functioning. Patients rarely disagree on these goals. This is a long-term process that requires patient's engagement, and also their willingness to take worsening in pain in the short term. Physical therapists with experience in chronic pain will find the way to determine an exercise plan that is associated with tolerable pain.

I tell patients that an indirect effect of exercise might be a reduction in pain in the long term. However, I tell patients that I consider this outcome as a possible "bonus".

Exercise is an investment in physical fitness. If it eventually leads to less pain, we take it.
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