Using exercise &

movement for
PAINFUL
problems

Ben Cormack – Cor-Kinetic

What’s it all about?

Exercise has become a huge subject in musculoskeletal therapy with

tons and tons of research coming out daily. But in spite of this we still
don’t have many definitive answers that help to guide us using exercise
in the messy and uncertain world of clinical practice. This guide is here
to start to help you understand and navigate some of the modern
concepts and uncertainty in clinical practice.

One of the issues we face, which you probably know already, is that it is
not as simple as just taking exercise from the world of fitness and simply
porting them over into clinic. Exercise for painful problems is a different
beast from exercise for fitness and we may need a different knowledge
base and skill set to deal with it!

We should always keep in mind that the real point of any exercise or
activity program is to get people back to what they enjoy doing and not
simply just doing exercise.

Lots of uncertainty to navigate

These are a list of some common clinical questions:

Which exercise should I use?

How much should I use?
How many exercises?
What am I trying to do with the exercise?
Why are they not responding in the way I want them too?
What if it makes my patient worse?
How to get my patients to do it?

The real key is understanding more about both pain & exercise and also
the person you are working with and their painful problem! There is not a
singular answer many times and clinical reasoning is the most powerful
tool we have but does take a bit of effort!
What’s the clinical challenge?

Whilst physical qualities like strength, endurance and power are

important parts of physical function they simply don’t correlate very well
with many people’s main aims of seeing a therapist – pain and disability.

Exercise and its dosing are mostly based around changing one of these
physical factors and is pretty good at doing this consistently when we
are talking about gains in the gym. BUT this consistency is not repeated
in clinic where responses to exercise and pain can be pretty varied.

So we can say that getting stronger can enable people to function better
in a general sense but does it always help my patients pain get back to
doing what they LOVE? Often the answer is no.

Exercise, exercises, movement or activity?

People who come to see us are pretty varied in their occupations,

hobbies and sports. The way that we incorporate moving into our lives
can come in a bunch of different ways. For some it might be gardening
or housework for others the gym, sport or dance class. We have to fit the
right type of movement to the person we are working with.

So it could be more general EXERCISE, resistance training or walking

are examples that you think someone might need. It could also be a few
specific EXERCISES that you want to incorporate to load a muscle or
body part. It could also be looking a specific activity and then grading an
approach to it, so finding a tolerable baseline and then systematically
increasing the dosage to return the person to doing what they really
enjoy.

But don’t forget that a program to increase moving can involve all of
these things. Something lighter to do daily keeping the body ‘oiled’, more
of what people love to do and then also more structured exercise as
well.
Finding a program of tolerable and sustainable moving has been of great
help to many people with long term pain issues. That favourite clinical
question like “what’s the best exercise for back pain?” unfortunately
does not have a definitive answer. Instead there are lots of options to try
which is really liberating but a bit scary at the same time.

Pain science and exercise

As we are discovering, the world of pain is complex and involves many

aspects across how we think, feel and act and we have to consider how
movement and exercise fits into this newer and more complex
understanding. You cannot prescribe exercise for painful problems
without knowing more about PAIN!

Exercise & movement could influence a number of different parts of the

pain experience, not just what we feel but also how we feel and how we
function. It can be a great way to show people they are still fit and
functional but we have to consider more than just the traditional view of
exercise in how we go about doing this.
Moving can have a large effect on people’s pain but it can also have a
minimal and sometimes negative, e.g. flare up, effect. Understanding
more about pain itself can be beneficial to understanding its relation to
moving and why it may have a positive but also sometimes a negative
effect dependent on the many things that can influence us.
How does exercise work for pain?

There are lots of potential mechanisms that explain how exercise might
work for pain and this is be important for a couple of reasons.

1. Lots of different ways it might help

2. Not dependent on changing a physical component

So, let’s start with the different ways it can help. Each of the different
mechanisms might allow us to set exercise up in different ways to be
beneficial. If we think that social aspects of exercise might help someone
then finding ways to get people into a group scenario or exercise class
would be the way to go.
If we wanted to try to alter someone’s perceptions of their body’s
capability then exercise that is achievable, tolerable and is positively
reinforced might be a key.

Maintaining a regular movement habit with someone with chronic back

pain might focus on adherence and engagement. All of these things
require more than just sets or reps.

As I have repeated a few times, exercise is often perceived and dosed to

create physical change. But many of the things that have been
discussed in relation to pain may require NO change in physical
parameters like strength or muscle mass and this has been consistently
shown in the research base. So, you could get great benefits from
moving or exercising without changing muscular activation, physical
alignment or strength/ROM etc. This is both exciting and daunting, it
gives us many new potential ways to work with moving but at the same
time means we probably need a new framework to use rather than a
purely physical paradigm.

What do we want?

Exercise and movement like all other components of rehab should have
a large helping of clinical reasoning. Part of this is to consider what
effect we are trying to get and how that fits to the patient we are working
with. This is a simple consideration guide to help think about what effect
we might want. This requires a bit of knowledge about the problem, the
person and what they want to achieve.

An ACLR repair might focus on regaining specific physical parameters

such as quadricep strength and this will require a good knowledge of S
& C parameters. Chronic lower back pain might focus on reducing fear
and safety behaviours as well as commitment to moving more regularly.
Taking a moment to consider what the person needs and how to achieve
it might be the difference between a good and mediocre effect using an
exercise approach.
New ways of working with pain and moving

As previously stated, there are lots of ways to use movement in clinic. It

does not always have to look like a gym exercise and there are some
well-defined concepts that have emerged around using movement with
painful issues.

Graded exposure

This involves specific feared activities. Fear of pain can be highly

disabling and stop people from doing things they need to or enjoy.
Graded exposure involves principles taken from phobia work to expose
people to the feared activity.
Graded exercise

Graded exercise is about using exercise as the main tool to increase

physical activity. Find a tolerable dose of exercise and systematically
increase in line with fitness and tolerance to pain. This could be the
duration, load and overall intensity of many different types of exercise
from simple walking or the gym and also resistance training.

Graded activity

Graded activity is about finding a tolerable baseline for a specific activity,

this could be an activity of daily living like hoovering or loading the
dishwasher or something more cherished like a horse-riding. Again a
simple graded approach is taken to dosage

Time contingent

This uses time rather than pain or symptoms as a guide for stopping
exercise. The aim is to reduce the associations between hurt and harm
for the exerciser and is used often used for those with longer term pain
conditions. In essence we can have pain during exercise that may not
damage our bodies or cause longer lasting pain.

Exercising and moving WITH pain

This is a key topic as we know getting rid of pain is far from easy and
exercising and moving with some pain is going to be the reality for many
people. So, understanding our attitudes to pain can be key with things
like pain self-efficacy but also knowing how much is OK. This is not up to
us clinicians to decide really, so we have to find, within reason, what is
tolerable for the person doing it. We can do that through traditional pain
scores or through verbal communication to determine that

It is important to note that research does not guide us towards pain

FREE exercise instead having some pain does not simply lead to worse
pain and can be a huge learning lesson for people in their pain journeys.
Exercise Dosing

This is a KEY skill and often requires a bit of informed trial and error.
One of the ways I use to minimise risk of flare ups is the rule of 10 (it’s
not really a rule :). This takes into account current pain level and
irritability of that pain (often missed).

We can lose trust and confidence with people if our exercise prescription
flairs them up. By taking into account their pain levels and pain
behaviour we can better dose people and progress accordingly for a
favourable and hopefully a less bumpy journey to sustainable
movement.

I simply use a lower perceived effort score (RPE) with higher VAS and
irritability. This often gives me a tolerable starting point or baseline to
work off. This is an inexact science certainly but can be really clinically
useful.
Final word

The aim of this short guide was to highlight some of the issues that need
to be overcome in using movement and exercise in modern clinical
practice with relation to pain. This is so much more than simply taking
what we know about S &C or general exercise and porting it over to the
clinic. These exercise components can certainly be part of what of what
we need to know but need to be enhanced with a better knowledge of
applying it to painful problems too!