By Kelvin Tan, Editor For Men’s Health Singapore
Chronic pain is tough- I know, I’ve been suffering with bad back pain that won’t quit since a bad car accident two years ago. But that doesn’t mean that exercise is out of the question. In fact, sometimes, exercise can actually be a way of alleviating the pain- in my case, I’ve found hamstring stretches actually help with the back.
We spoke to Dr Darren Leong, senior physician at Changi General Hospital (Singapore) and the Singapore Sports Institute and Singapore Sports Council, who shares his expert opinion about why those with chronic pain avoid exercise, and how and when exercise can help their condition.
Why does it seem counter-intuitive for patients with chronic pain to exercise?
Some patients with chronic pain may feel that exerting themselves might increase their pain. Those who have attempted exercise at higher intensities and suffered more pain, might not be comfortable returning to physical activity.
What kinds of pain-causing conditions can be treated with exercise?
Conditions such as cancer, fibromyalgia, osteoarthritis complex regional pain syndrome, spinal pain, chronic neck pain and chronic back pain can be treated with exercise
Do exercise prescriptions vary based on what is causing the pain for the patients? How so?
Yes, patients should approach trained exercise physiologists or doctors who can take the time to thoroughly go through their conditions and concerns, to spend time understanding how the patient perceives their chronic pain, and then plan out a very specific, individualised exercise program.
What does (a) reducing exercise (b) exercising correctly regularly actually do for patients with chronic pain?
The benefits of exercise for these patients include:
a. Increased joint mobility, i.e. the joints get lubricated and glide easier.
b. Improved function of nerves / intervertebral discs. Structures, such as our bodies, need movement to get nutrients to stay healthy.
c. Improved strength, balance and endurance. Muscles will get stronger and not get fatigue as easily.
d. Relaxation that comes after a bout of exercise when the nervous system winds down.
e. Exercise can help to reduce flare-ups of their conditions.
f. Improvement in mood as it helps to modulate/reduce anxiety and depression.
g.. Natural painkillers, endorphins, are produced by our body with exercise. After a bout of exercise, pain tolerance increases (for up to an hour depending on the exercise). This is on top of the reduction in risk of other chronic medical conditions.
How is exercise prescribed for patients with chronic pain?
Chronic pain is a big burden on the patient’s bodily systems, resulting in physical and emotional changes, e.g. functional decline, anxiety, depressed mood, depressed immune system, poor concentration and memory, and disturbed sleep.
The patient should be approached holistically, whereby the management of his/her condition is not just to help with pain but also their underlying conditions.
Chronic pain is best treated actively by focusing on pacing up and developing effective coping strategies to manage and cope better with symptoms rather than passive treatment.
The exercise session should be:
a. Fun, enjoyable – correlating with higher compliance
b. Can include aerobic / cardiovascular exercise, e.g. walking, swimming
c. It should be started slowly and slowly paced up (increased). It is important to increase exercise volume before intensity.
d. Initially, they should be closely supervised. Patients should heed advice to not overdo on good days when pain is better, and not do less on bad days. In relation to exercise for chronic pain, the motto is ‘know pain or no gain’ as opposed to ‘no pain, no gain’.
It is normal for patients with chronic pain to experience discomfort/increased symptoms as they gradually become more active. Guidance on acceptable and non-acceptable pain can be very helpful and reassuring. This guidance can be provided as we plan (pre-exercise), with regular reviews on how the patient is progressing.
Why do some doctors still advise their patients with chronic pain to reduce exercise?
A possible reason may be that patients often report pain with exercise, and doctors may not have the relevant expertise to evaluate if the pain is due to overload or injury from exercise. Thus, to err on the side of caution, they may advise their patients to avoid the activity.
Is it difficult to get patients with chronic pain to exercise?
Generally speaking, every patient is different, so the level of ‘difficulty’ in getting two patients with chronic pain to exercise is likely different. Factors we consider in prescribing exercise to a patient include:
· Stage of change patient is at (e.g. if he or she is even contemplating exercise)
· Comorbidities the patient may have (including chronic pain)
If we are able to address the patient’s ideas, concerns and expectations toward exercise, it would help to get them listen to us and hopefully start becoming more active.
And if you’re trying to get an aged parent who suffers from age-related chronic pain like osteoarthritis to exercise, here’s some advice from Adj. Asst Professor Ivy Lim, a consultant in sports medicine, and the president of the Sports Medicine Association of Singapore.
What is the compliance rate of patients with chronic pain undertaking exercise as prescribed?
An overview of Cochrane reviews published in 2017 (LJ Geneen et al, 2017) on physical activity and chronic pain in adults reported a slightly higher withdrawal / dropout rate in the exercising group (82.8 per 1,000 participants versus 81 per 1,000 participants in the control group). However, it is important to note that this difference is non-significant.
What, in the patients’ mind, are deterrents to embarking on an exercise regimen?
Common reasons that patients have given me include lack of time, lack of facilities, as well as fear of injury or aggravating an existing injury.
What are the factors that determine a patient’s compliance rate?
Some factors are whether the type of exercise prescribed suits the patient, and whether the exercise is carried out in a group or embarked alone. As every patient is different, it is important to find out the patient’s preferences. An exercise prescription that caters to the patient’s preferences would help to improve compliance. Regular follow-up with gradual progression of exercise would also help.
How is exercise for an osteoarthritis patient different from exercise for patients with other causes of chronic pain?
Osteoarthritis can result in chronic pain. The exercise prescription will have to take any presence of pain into account. For osteoarthritis, we will also take into account the joint or joint compartment being involved, and prescribe exercises that do not overload these joints or joint compartments.
What part does medication play in managing pain for patients with (a) osteoarthritis and (b) other forms chronic pain?
Medication such as anti-inflammatories help in situations when the pain is inflammatory, for example when there is a flare of osteoarthritis, or in autoimmune conditions. Viscosupplementation is sometimes given to patients with knee osteoarthritis as well as an adjunctive treatment. Depending on the patient’s pain levels, we may use medication for pain management on top of exercise therapy.
Is it possible for patients with (a) osteoarthritis (b) other forms of chronic pain to be able to reduce painkillers if they are diligent with the prescribed exercise regimens? How so?
Yes, it is possible. In osteoarthritis and other joint pains, weight loss that may occur with exercise can help reduce forces across a joint and thus reduce pain and the need for painkillers. Addressing modifiable factors such as muscle weakness, inflexibility or muscle imbalance may also help to reduce abnormal loading of a joint and as such help to reduce pain.
Do you have any case studies of a patient or patients who improved his or her quality of life by exercising in spite of pain?
I do not have a specific patient in mind, but patients with chronic pain often exercise with their pain. It is important for healthcare professionals to assess if this pain is baseline, and also if the pain is ‘good pain’ (e.g. muscle soreness from muscle strengthening) or ‘bad pain’ (an aggravation of the current injury or new injury). Once patients have a better understanding of their pain, and learn to discern which pains are okay to exercise with, and which pains need further evaluation and management, they are often able to continue their exercise and reap the benefits despite the chronic pain.
The two doctors will be presenting topics under the “Tailored Exercise Programmes for Patients and Athletes” track at the MEDICINE + SPORTS conference at the MEDICAL FAIR ASIA on the 29th of August 2018.