Movement with pain

Exercise is medicine. Relaxed movement and physical activity are vital to helping you manage your pain so you can do the everyday things that are important to you¹. Think for a minute about spraining your ankle or your back: when we experience acute pain, especially when it is distressing, one of the body’s natural responses is to initially tense up and limit movement, in order to protect the body. This protective response is usually short-lived (24-48 hours), but can be unhelpful in the longer term if it persists.

Research shows us that movement, activity and exercise can be very helpful to reduce pain and improve function for people with musculoskeletal pain². Even if you have a medical condition like osteoporosis or have had surgery for back pain, movement, activity and exercise form a key component of your recovery.

Recent evidence on lower limb osteoarthritis³ shows that compared with no exercise, doing exercise (such as strengthening exercise) significantly helps reduce pain. The size of the benefit (known as the ‘effect size’) is much larger than the largest benefit shown for paracetamol in hip or knee osteoarthritis. In this context, exercise can be considered ‘medicine’.

Improving function (e.g. our ability to engage in daily activities such as household tasks, work, study, socializing etc.) through movement, activity and exercise has profound beneficial ‘flow-on’ effects, including reduced disability, reduced depression and improved physical conditioning and increased quality of life⁴.

This module is focused on integrating movement with all the “pieces of your pain jigsaw” to help you move in ways that reduce fear⁵, pain and improve your functioning. Below is an example of a small pain jigsaw. You can make your own pain jigsaw by writing out the factors that you believe are central to helping you better manage your pain in a holistic way.

Movement, physical activity and exercise may improve pain severity and physical function, and consequent quality of life with few adverse events reported⁶. Here are some of the benefits associated with movement, activity and exercise:

Sometimes, pain gets in the way of movement, activity and exercise. We may respond to pain by: stopping moving (‘underdo’), moving differently (‘tensing up’), or moving excessively (‘overdo’ or pushing through regardless).

Here are some of the factors that can guide your decision to move and exercise when you have pain:

• your beliefs: what you believe about pain can have a very big impact on your recovery. If you have helpful beliefs (for example, it is safe to move; some pain is a normal part of recovery and does not necessarily mean damage), then you are less likely to experience ongoing pain [see Rose’s story]. If you have unhelpful beliefs (hurt equals harm; I am doing more damage because I have more pain), then your recovery is likely to be slower and you are more susceptible to getting persistent pain. Beliefs can be based on myths rather than facts so it’s important to check with our health professional what’s correct.
• beliefs of your healthcare professional can also negatively and positively impact your recovery [see Rick’s story]. Consistent advice from your health professional team to start moving and exercising in a sensibly paced way, with clear instruction and guidance is some of the best advice you can get! Advice to avoid movement, activity and exercise is not helpful and is not the right care.
• thinking the worst (catastrophizing) or negative thoughts (worries, fears or cognitions) and mood (depression/anxiety) responses to anticipated or actual pain, mean that we tend to magnify the threat value of pain and can feel helpless in the context of pain [see Jamie’s story]. If you recognise this response, then talk to your doctor or health professional and ask for some help. Our approaching pain management module and the mindfulness and pain management module may also be helpful
• fear of pain or of doing harm: here you may stop moving because you feel pain when you move and you interpret this pain as doing more damage, or simply find the pain overwhelming Remember that some pain is normal when you are recovering – this pain does not mean more damage, it is part of tissues accommodating to recovering. If you are fearful of moving, for example, tensing up your back and belly muscles when you move, this can slow your recovery. It is important to discuss this fear with your health professional and get strategies to help you get moving safely
• In some pain conditions (e.g. low back pain and CRPS), persistent pain can be associated with disruption or distortion of our perception of where our body is in space. Body and mind re-integration appears to be relevant to helping recover in such cases. Ask your physio about this re-training approach.

Remember that movement, activity and exercise are only one important piece of the pain management jigsaw. Try working your way through our approaching pain and pacing and goal setting pain management modules, so you and/or your healthcare professional can plan a safe and effective approach to getting back to movement, activity and exercise.

There is no ‘one size fits all’ with exercise approaches. Exercise sometimes needs to be specific to your pain problem, as well as incorporating some general (cardiovascular) exercise. A good exercise plan usually requires a balance of 3-4 main types:

1. ‘good for your health’ exercise (walking, cycling (including stationary bike), swimming)
2. relaxation and stretching (yoga, tai chi, stretching, breathing)
3. strength and conditioning (building muscles up)
4. balance and agility

Here’s some important info to help guide your exercise choices:

• ‘Good for your health’ exercise like walking, cycling or possibly swimming can be done by most people and is beneficial for their health and helps to improve pain and function. Walking is easy, free and can be done anywhere, anytime
• a relaxation and stretching program (tai chi, yoga or simple stretching and breathing) will benefit most people, especially if you experience stiffness, tightness in your movements and pain or experience stress, anxiety or distress. There may be some ‘do’s and do nots’ depending on your condition. Discuss this with your health professional. Try our short mind/body relaxation exercise below or view a video on Tai Chi
• re-conditioning exercises need to be tailored to your specific problem. Depending on your pain condition, you may need to strengthen certain muscles, or be taught different (and more helpful), ways to move. For example, if you have a low back pain problem, you may benefit from re-conditioning of leg and buttock muscles, as these are often not doing the work they should [see Shaun’s story]
• sometimes, the wrong exercise can make your pain worse. If you tend to already stiffen your spine and are fearful of movement, then ‘core strengthening’ exercises can exacerbate your pain. See your physio to get the best exercise program to help treat your problem
• balance and agility – this is an important part of any exercise program and is often missed. Regardless of your injury, it is important to ask your health professional to assess your balance and advise you of any exercises that can help. This is very important if you have osteoporosis and are at risk of falling, view a video on Tai Chi. Tai Chi can help balance and agility

Download our movement, exercise and activity chart to use as an example.

There’s never a ‘right time’ to start on a challenge like regular daily exercise and activity! There’s often an excuse or reason to put it off. It’s hard to have to DO something yourself. It sometimes seems much easier to use a passive approach (relying on someone else to take charge or relying on medications to ease the pain).

Managing your pain means YOU need to be in charge: daily exercise and movement form one of the key pieces of the pain management ‘jigsaw’. [see making sense of pain].

Taking up the challenge of improving your pain and your health by starting regular, sensibly paced activity is an important first step in improving your quality of life. Depending on your pain condition, you may be able to start working on exercise and movement using the advice here or you might need to consult a healthcare professional. Your healthcare professional can be your coach; guiding you along the way.

Asking for support from friends and family is important. Don’t be afraid to reach out if you are having a hard time and ask for the help you deserve. Family and friends can support you by joining in your exercise routine or supporting you from the “sidelines”. Being ready to change, and ready to add regular daily exercise to your routine can be hard when you are in pain. Make sure you download our getting moving with pain help guide for tips to help you get started.

Remember it takes courage to start exercising, it takes effort and commitment. Be kind and gentle to yourself along the way and choose a daily, ‘good for your health’ exercise that you like.

When you start exercising, and depending on what exercise you do, it is very common to experience a temporary increase in pain, body soreness or stiffness. Think of this as a ‘positive’, body re-training response.

Muscle soreness usually lasts 24 to 48 hours and is a normal response to unaccustomed exercise and this reduces as muscles adapt to new exercise. Occasionally you will get a temporary pain flare. Don’t be afraid: this does NOT mean you are doing damage! A pain flare is a common response to starting a new exercise, and it takes a bit of time for your body to adapt. To avoid pain flares, make sure that you are relaxed when you exercise and are aware of the pacing (doing small bits often) approach to exercise, or finding the middle road.

A paced approach helps you to avoid overdoing or underdoing exercise and activity. If you are an “over-doer”, or try to push through your pain, before starting your new exercise plan, try our pacing and goal setting pain management module. The pacing module will explain how you can set an exercise and activity baseline and get moving safely without causing a pain flare. Progressing your exercise and activity using a paced approach, allows you to keep moving through this temporary pain flare.

Regardless of your pain levels, continuing daily exercise, moving often and maintaining your activities is important. Like any new behaviour that requires us to commit and do the “hard yards”, there will be times when you don’t want to exercise! You will need to plan for these times to ensure that you stay moving and exercising.

You may find that simple analgesia used as a short course (e.g. paracetamol or anti-inflammatories) helps you stay active if you are having a pain flare. You may also like to take a friend with you to help motivate you to keep to your schedule [see Shaun’s story].

• remember that a time-contingent approach to exercise is the key. Using a time-contingent approach means that you improve your exercise, activity, function and quality of life, despite the pain
• using a pain-contingent approach means you stop exercise and activity when your pain is worse. This results in gradually withdrawing from exercise and activity and results in worse long term health outcomes for you
• you may find that tools like ‘Apps’ (available through iTunes) for your smart phone and devices (e.g. iPhone/iPad) can be useful to log your exercise progress. Many Apps are free and allow you to log your daily exercise, your energy expended and some even have GPS tracking to allow you to measure how many steps you take, distance travelled or time taken
• you may find it helpful to have your family or friends use smart devices (iPhone/iPad or Smart Phone) to video you every few weeks, so you can see your progress (e.g. your flexibility). Watch Shaun’s pain story to see how he monitored his movement and flexibility progress.

Because pain involves the whole person, in order to get the best outcomes treatments and management usually require a combination of some of the following approaches:

• Pacing and Goal Setting
• Approaching Pain
• Mindfulness and Pain
• Yoga and pain

Alternatively, you can search for useful Apps (these are ‘applications’ you can download to use on your smart phone or Android device/iPhone/iPad. Many of these are free. Try to find apps that may help you with:

• Exercise (fitness or physical activity; yoga stretches); try and select one which you can integrate with your nutritional plan
• Sleep (different sounds that help you relax and sleep logs)
• Diet and nutrition (some ‘Apps’ integrate with your physical activity and allow you to monitor your energy expenditure; many of these are free)

Discuss the use of any ‘Apps’ with your health professional to make sure it is appropriate for you.

For more information about movement with pain, find consumer summaries at Cochrane Summaries. In addition, you can read a story on movement therapy and chronic pain or download a video about the science of yoga and safe use for managing low back pain.

Alternatively, if you need to speak to your GP or healthcare professional, please seek further assistance.