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Chronic pain is complex, but it can help to view it from the Whole Health perspective. Chronic pain requires day-to-day management through the use of multiple self-care strategies, including setting realistic goals, pacing activity, managing thoughts and feelings associated with pain, andno less importantmoving the body. This clinical tool focuses how physical activity is important in the self-management of chronic pain and how clinicians can help patients make optimal use of this area of proactive self-care.

For chronic pain, physical activity is an important part of a self-management regimen that increases active coping. Treatment approaches that focus on increasing activity rather than avoiding activity have better outcomes.[1]

Gradual, progressive exercise improves mood in people who have chronic pain with associated depression or anxiety. For example, in studies of fibromyalgia patients, exercise not only increased fitness and function but also improved their sense of overall well-being.[2][3]

Exercise has a positive, albeit modest, effect on pain. Among organizations in the fields of pain and spinal disorders (e.g. North American Spine Society, American Pain Society) exercise is uniformly recommended for problems such as subacute and chronic back pain. A longitudinal population-based study suggests that exercise is associated with lower levels of pain and that less pain is reported during times that more exercise was reported. [4]

Exercise may have a pain relieving (hypoalgesic) effect.[5][6][7][8]In a meta-analytic review, the beneficial effect of exercise was present for individuals who had more localized pain conditions. This did not occur in individuals with diffuse pain. Although more data is needed, exercise may be pain relieving to individuals with fibromyalgia syndrome when exercising at low-to-moderate intensity.[9]

A tendency toward passive coping (e.g. taking medications or waiting for the pain to stop) in people with chronic pain may lead to high attrition rates (38-87%) from ongoing use of exercise. [10][11][12] Starting small and gradually building on success may show more positive results in patients who are inclined to cope passively.

Exercise improves overall health, disease risk, and progression of chronic illnesses such as cardiovascular disease, type 2 diabetes, and obesity.

Exercise may provide a benefit to sleep disruption, a common pain-related problem. A meta-analysis of fibromyalgia patients suggested that movement therapies (e.g. Tai Chi) lead to significant improvement in sleep.[13] Exercise does not need to be complicated, require a gym membership, or equipment. A meta-analysis found that walking is associated with significant improvements in pain and function.[14]

Sullivan and colleagues (2012) summarized empirical findings on exercise for chronic pain focusing on aerobic and anaerobic, as well as yoga, Pilates, and tai chi.[15] Findings for various types of activity are listed below.[15]

Aerobic exercise

Long-term benefits include improved mood, decreased pain perception, and improved cardiovascular fitness. It may also lead to immediate decreases in anxiety and depression.

Anaerobic exercise

• Literature supports the use of core strengthening and stabilizing exercise in chronic and subacute low back pain, but not acute pain.
• Benefits include reduced work absenteeism, enhanced personal engagement in physical rehabilitation, and improved overall functioning.
• In patients with subacute pain, anaerobic exercise may prevent profound deconditioning, kinesiophobia, and the development of chronic pain syndromes.
• No one particular strengthening method or technique has been found to be more effective than others.
• Individualized programs may offer the best rates of success (often through physical therapy).

Yoga/Pilates/Tai Chi

• Benefits include pain reduction, improved function, and enhanced spinal mobility.
• Benefits are greater than those obtained through educational interventions and equal to those obtained through participation in conventional exercise programs.
• Exercises which target stretching and flexibility show slightly less impact on pain than aerobic and anaerobic exercise.

Although not mentioned above, strong evidence exists for the effectiveness of Alexander Technique lessons for chronic back pain patients. Research suggests that this type of intervention may lead to improvement in balance skills and posture in general chronic pain.[16] One study found that exercise plus Alexander Technique led to modest but significantly greater improvement in quality of life, level of disability, andnumber of days with back pain.[17]

Once a full evaluation has been completed and red flags have been ruled out, Veterans can be encouraged to cultivate attitudes and behaviors that are helpful in the self-management of chronic pain (refer to the box below). Self-management of pain should be part of the discussion as soon as possible to prevent passive coping and a sense of low self-efficacy.

One way for clinicians to enhance self-efficacy is by reinforcing positive coping behaviors they observe. It can help for them to point out, for example, that a person is maintaining some level of physical activity, doing physical therapy, enjoying a hobby, maintaining a good family life, keeping a connection with their church, and/or continuing to work. It is also useful to provide access to materials, groups, or other resources that encourage active coping and self-management. Options might include exercise or pain management groups, individual pain management training, relaxation techniques, meditation training, and physical therapy.

During regular follow-up appointments with Veterans with chronic pain, focusing on one of the following topics might help to bring about higher functioning and better pain management. Topic 1 is an excellent place to start. When feasible, choose a topic to cover during a routine clinic visit.

Topic 1: Functional goals

Functional goals focus on improving the health, function, and quality of life of an individual. They can serve as both a target and a source of motivation for Veterans.

• The idea of functional goals can be introduced through the Personal Health Inventory (PHI). The Veteran can be provided with the pamphlet and allowed to work on it at home with the support of people who care about him or her.
• Ask them if they have any functional goals that are important to them. For example, do they want to be able to take a vacation, go hunting, or be able to sit through a movie at a theater? Explore activities they might enjoy or that would be meaningful to them, and then help take steps in the direction of reaching their goals.

Topic 2: Current Activity Level Assessment

How much can patients do on a daily basis? Are they spending the day in bed or in front of the TV? Are they attempting to do too much? Some individuals with pain do less and less over time, while others overdo. Still others may roller coaster between doing too much on a good day and not doing anything on a bad day. Knowing their patterns can allow clinicians to support them more effectively.

• Have them describe a typical weekday and a typical weekend.
• If they appear to be fairly low-functioning, consider doing the following:
  • Work with them on setting small, progressive goals for exercise that incorporates functional goals.
  • Encourage any positive activity, however minimal.
  • You might include family members or significant others to assist with encouraging activity and providing positive reinforcement when activity occurs.

If people appear to attempt to do too much, discuss:

• Pacing activities to optimize energy use and avoid flare-ups. It is best not to let activity levels fluctuate too greatly.
• Breaking activity into smaller tasks. For example, plan to mow half the lawn today, and half tomorrow.
• Taking breaks or rest. Refer to the “Taking Breaks: When to Start Moving, and When to Stop” Whole Health tool.
• Alternating activity periods with rest.
• Setting time limits for activities that lead to overdoing. For example a person can set aside 30 minutes (or whatever time frame will not cause them to have increased pain) for lawn mowing, rather than stopping only when the entire lawn is mowed. After a rest period, they can engage in another round of time-based activity, followed by more rest, until the task is complete.
• Asking family and friends for help might be appropriate when it comes to tasks that are difficult or might exacerbate pain.

Topic 3: Depression

Depression is a common pain comorbidity. So are stress and anxiety.[21][22][23][24][25]Consider the following:

• Is depression impacting activity? Fatigue and low motivation can be symptoms of depression.
• A depression screening tool, such as the PHQ9, may be useful.
• If depression seems to be having an impact, the Veteran might benefit from:
  • Anti-depressant medications.
• Counseling for issues related to loss.
• Pain psychology to address the impact of pain on mood.
• Joining a pain management and/or coping group to decrease isolation and increase coping skills.
• Engaging in aerobic exercise.

Refer to the “Depression” overview for more information.

Topic 4: Pain flare-up

A flare-up of pain is an exacerbation of more typical levels of pain. Pain flares can be used interchangeably with break-through pain, although this term may be used more specifically for instances when pain medications are not working effectively for pain management. Rather than being static, pain is commonly a dynamic experience; it changes over the course of a day or week for many individuals. Pain fluctuations are associated with higher levels of depression, as well as decreased work productivity and more disability.[26] Certainly, both unpredictability of pain and pain flares can interfere with physical activity.

• Encourage self-management of pain flares. This can create more self-reliance for the patient and decrease reliance on emergency department and clinic visits, not to mention medication use.
• If pain flares are a problem, help the patient create Pain Flare Management Plan. For more information refer to the tool, “A Pain Flare Management Plan: Suggestions to Offer Patients.”
• If a flare or fluctuating pain levels interferes with patients progress toward their goals, do not encourage them to stop an activity; rather, have them cut back for a few days and then slowly increase activity again.

Topic 5: Fear of pain Part A

If someone continually avoids reasonable activities, it may be from fear of the pain. Avoiding painful stimuli initially with pain onset is natural, but can prove to be a maladaptive response when continued over time.[27][28][29][30][31] Avoidance can lead to decreased functioning, increased disability, more days off work, and impaired physical performance.[32][33]

Clinicians can help by exploring with them why they are avoiding activity. If they are concerned about hurting themselves when they engage in movement, it may help to review the concept of Hurt versus Harm. They may be experiencing hurt (unpleasant physical sensations) but it is not causing harm (lasting damage). Reassure them and encourage them to continue with activity.

Topic 6: Fear of pain Part B

Some individuals may need specialized assistance to help them with the fear of their pain. Consider referring them to one of the following:

• A physical therapist who can assist with graded increases in activity and/or develop an individualized plan for them to ramp up movement.
• An interdisciplinary pain program, if available.
• A behavioral health specialist or pain psychologist skilled in cognitive behavioral therapy, who can explore maladaptive thought patterns. Research is clear that pain catastrophizing (overestimating the probability of an unpleasant outcome, feeling helpless, and having distress-amplifying thoughts about pain) are detrimental for a patient with chronic pain.[34][35] Unfortunately, it appears to be a common occurrence.[15][36]Catastrophizing is closely associated with disability level and pain intensity.[15][37][38]Treatment approaches that focus on increasing activity rather than avoiding activity lead to better outcomes.[1]

Topic 7: The role of sleep

Explore the role of sleep as a contributing factor in the ability to stay active. Chronically painful conditions are frequently associated with sleep disturbances,[24] including changes in sleep continuity and sleep architecture as well as increased sleepiness during waking hours. Sleep deprivation and sleep disruption may increase pain sensitivity and vulnerability to pain.[39] It may also create a vicious cycle between sleep difficulties and chronic pain where one augments the other.

• Address basic sleep hygiene with chronic pain patients (refer to the “Recharge” overview) to improve patients dysfunctional habits surrounding sleep.
• Explore what occurs when they cannot sleep. If a patient tends to ruminate at night, a referral to a psychotherapist for anxiety treatment might be helpful.
• Provide relaxation strategies that can be used at bedtime or when awaken in the middle of the night.
  • Patients might benefit from meeting with a behavioral specialist, such as a pain psychologist.
  • Clinicians can instruct them in breathing exercises as appropriate. For more information refer to the Power of the Mind tool, “Breathing.”

Consider whether sleep aids are needed, or if the patient may benefit from a referral for cognitive behavior therapy (CBT) or CBT-I (CBT for insomnia). Many providers are surprised to learn that these treatments, which include sleep hygiene intervention, have been shown to produce comparable, and sometimes better, results than medications.[40][41][42]

Moving the Body in Chronic Pain: What Clinicians Need to Know was written by Shilagh A. Mirgain, PhD and by Janice Singles, PsyD (2014, updated 2016).