Movement with pain

Advice and tips on how to move with musculoskeletal pain to help you do the everyday things that are important to you.

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 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 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.

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

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

Movement (ie. relaxing, stretching, walking) is important for your health and a big part of pain management.

Here are some of the benefits associated with movement and pain management:

  • helps turn the 'pain volume' button down by accessing the body’s own in-built pharmacy
  • reassures you that some pain with movement is OK and does not mean you are doing harm
  • keeps you active and capable of doing what you want to do
  • helps regulate sleep patterns
  • reduces stress
  • improves mood (especially depression)
  • improves immune function (your body’s ability to fight infection or illness or stress)
  • good for your general health (heart, lungs, muscles and joints)
  • helps with weight control (important if you have additional chronic disease like diabetes or heart disease)
  • good for your brain: exercising helps maintain a healthy brain as you age 4

What if it hurts when I move?

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

Here are some of the factors that can influence 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, some pain is part of recovery and does not mean more damage; it is safe to move), 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), then your recovery is likely to be slower and you are more susceptible to getting persistent pain
  • 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!
  • catastrophizing (thinking the worst) or negative thoughts (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 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. Remember that some pain is normal when you are recovering – this pain does not mean more damage. If you are fearful of moving, this is commonly associated with tensing up your back and belly muscles when you move and can slow your recovery. It is important to discuss this fear with your health professional and get strategies to help you get moving
  • 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 activates the bodies natural neuroplasticity and appears to be very important to helping treat pain in such cases. Ask your physio about this re-training approach.

Remember that movement and exercise are only one important piece of the pain management jigsaw. It is important that you consider 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 movement and exercise.

Is there a right type of exercise for you?

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 generic (cardiovascular) exercise. A good exercise plan usually requires a balance of 3-4 main types:

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

Tips to help guide your exercise choices

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.

Try this exercise: set your baseline by taking the '6 minute walk test'. Using a regular paced walk, measure how far you can walk along a flat area in a timed '6 minute' period. This might be how far you can get down the street or how far you get in a shopping centre. Repeat the test a few times (with breaks) to set your baseline. Once you have that distance measured, you can use this to monitor how far you get within the 6 minutes. As you progress, you will cover more distance in the same time

Getting started with exercise

Step one: Finding the right time to start

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].

Step two: Taking up the challenge

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.

Step three: What can I expect when I start exercising?

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 keep moving through this temporary pain flare.

Step four: Urges to stop

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.

Where can you get more information from?

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:

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 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.

Further Information

For more information about movement with pain consumer summaries go to 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.

painHEALTH - Movement, exercise and activities

painHEALTH - Get moving guide

Pain: Considering complementary approaches eBook

painHEALTH - Relaxation exercise podcast

  1. Daenen L, Varkey E, Kellmann M, Nijs J. Exercise, not to exercise, or how to exercise in patients with chronic pain? Applying science to practice. The Clinical journal of pain 2015; 31(2): 108-14. [PubMed]
  2. Kroll HR. Exercise therapy for chronic pain. Phys Med Rehabil Clin N Am 2015; 26(2): 263-81. [PubMed]
  3. Uthman OA, van der Windt DA, Jordan JL, et al. Exercise for lower limb osteoarthritis: systematic review incorporating trial sequential analysis and network meta-analysis. BMJ 2013; 347: f5555. [PubMed]
  4. Erickson KI, Leckie RL, Weinstein AM. Physical activity, fitness, and gray matter volume. Neurobiol Aging 2014; 35 Suppl 2: S20-8. [PubMed]

This module has been developed by Professor Peter O’Sullivan Dip Physio; Grad Dip Man Ther; PhD, FACP, Curtin: Professor, School of Physiotherapy and Exercise Science; Clinical Director, Specialist Musculoskeletal Physiotherapist, Bodylogic Physiotherapy and Associate Professor Helen Slater, PhD, FACP, School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia. The information in this module is based on current best evidence research and clinical practice