After reading more ‘exercise plus [insert therapy]’ than I’d like to count, here’s a study I’d really like to see – and why.
Exercise for chronic or persisting pain is widely touted as a means to reduce pain and maintain function. So much so that when I do a search in Google Scholar using the terms ‘exercise and chronic pain’ in 0.10 seconds ‘about 2,450,000 results’ show up.
I can’t even hazard a guess at how many research papers have been produced looking at various types of exercise for various types of chronic pain – the most recent ‘general’ Cochrane Review of exercise for chronic pain is from 2017 by Geneen and colleagues (2017), and reviewed 381 studies of which 264 studies looked at exercise vs ‘no exercise/minimal intervention’ but countless numbers of RCTs have been published since then.
What’s wrong with this work? Well, nothing – except perhaps we could be asking stronger research questions. The effect sizes of exercise, with or without ‘other therapies’ are disappointingly small. Exercise and education, however, are cited as ‘the most common interventions reported in 80% and 20% of studies’ (Lyng et al., 2023) – yet 50% of these studies were rated critically low quality, 25% low quality, and only 15% high quality. In Lyng et al., study, pain intensity and physical functioning were the most reported outcomes – follow-up periods were short (0 – 3 months), with only a small number using long-term (12 month) follow up. Only a minority of these studies included emotional functioning, participant ratings of global improvement, symptoms, adverse events and participant disposition. Only 2% of these studies included an economic assessment of the impact of the interventions.
Here’s my summary of the state of play regarding exercise:
- Movement practices of any kind have an overall health benefit outside of any effect on pain intensity or pain interference – but as for all long-term interventions, you need to keep doing them.
- If people need to keep doing movement practices, the practices need to fit into daily life routines and habits. They need to be accessible. They need to be modifiable to take into account lifestyle factors like job changes, caregiving responsibilities, age and stage changes, and because people like variety there need to be options.
- I still can’t identify any specific exercise/movement practice that is (in general) better than any other, and we need to remember that exercise for low back pain has probably been the most widely studied – while other painful conditions may not feature nearly as often (maybe fibromyalgia? but still not as regularly studied as CLBP), so we don’t know whether any specific exercises/movement practices are ‘better than’ any others.
- When movement practices are being suggested, we need to ask ourselves what outcomes are being valued. Hayden et al., (2021) argued that Pilates, McKenzie therapy and ‘functional restoration’ were more effective than other types of exercise treatment for reducing pain intensity and functional limitations – but this study was only looking at ‘specific types of exercise treatments on pain intensity and functional limitation outcomes.’ This is in spite of the IMMPACT outcome domains developed with people who live with pain (ie the people who are directly affected by pain and who are looking for treatments that will help their lives) finding that sleep, sex life, taking care of family, relationships with family, relationships with friends, employment, household activities…. ALL these things were considered important (Turk et al., 2008). Gardner et al (2015) found that when people were seeing physiotherapists, goals they set weren’t able to be measured using the tools used by physiotherapists – suggesting that clinical outcome measures might not be providing accurate information about meaningful outcomes as viewed by people with pain.
I think we can call it quits on much of our exercise research. We know there are some small effects on pain and interference. We know this from decades of research. What we don’t know is whether people doing these exercises are getting what they really value. I’m not sure the underlying premises of many of these exercise regimes have truly considered the need for people to make lifestyle adjustments to accommodate both pain and a commitment to movement practices that take time and energy to continue doing.
Exercise has many effects – yet most of the studies in pain research investigate pain intensity and functional limitations. Some look at self efficacy, some add in reduced fear and avoidance, many look at particular aspects of motor control or strength/cardiovascular fitness but what about the social aspects of dance or going to the gym? What about the boost to fun and humour from connecting with others doing a Parkrun? What about the sense of self identity that comes from viewing yourself as a ‘sporty person’? Social connection, fun, self identity are all impacted on by pain and along with sleep are among the areas people with pain really want to be addressed.
The assumption that ‘exercise’ must be one of the active ingredients in pain therapy could be challenged. I’d love to see a comparison study where people are randomised into movement practice/exercise with the comparator being ‘supported to do the life activities you most value’ using whatever means available. What might happen if people were supported to do their usual gardening/fishing/walking the dog/household activities/dancing instead of ‘exercise’? What if their goals to play the guitar, sleep better, have sex, and hang out with friends were honoured and prioritised? And most importantly, what if we followed people over time to see what movement practices look like as we age, have families, work in different jobs, go through menopause, retire, add other health problems in to the mix? Viewing ‘exercise’ as a Thing We Do For [insert health problem here] rather than Part of Daily Life can lead us to think of movement practices as something separate rather than an intrinsic part of how we live.
Gardner, T., Refshauge, K., McAuley, J., Goodall, S., Hübscher, M., & Smith, L. (2015). Patient led goal setting in chronic low back pain—What goals are important to the patient and are they aligned to what we measure? Patient Education and Counseling, 98(8), 1035-1038. https://doi.org/https://doi.org/10.1016/j.pec.2015.04.012
Geneen, L. J., Moore, R. A., Clarke, C., Martin, D., Colvin, L. A., & Smith, B. H. (2017). Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database of Systematic Reviews, 4, CD011279. https://doi.org/10.1002/14651858.CD011279.pub3
Hayden, J. A., Ellis, J., Ogilvie, R., Stewart, S. A., Bagg, M. K., Stanojevic, S., Yamato, T. P., & Saragiotto, B. T. (2021). Some types of exercise are more effective than others in people with chronic low back pain: a network meta-analysis. Journal of Physiotherapy, 67(4), 252-262. https://doi.org/10.1016/j.jphys.2021.09.004
Lyng, K. D., Djurtoft, C., Bruun, M. K., Christensen, M. N., Lauritsen, R. E., Larsen, J. B., Birnie, K. A., Stinson, J., Hoegh, M. S., Palsson, T. S., Olesen, A. E., Arendt-Nielsen, L., Ehlers, L. H., Fonager, K., Jensen, M. B., Wurtzen, H., Poulin, P. A., Handberg, G., Ziegler, C.,…Rathleff, M. S. (2023). What is known and what is still unknown within chronic musculoskeletal pain? A systematic evidence and gap map. Pain, 164(7), 1406-1415. https://doi.org/10.1097/j.pain.0000000000002855
Turk, D. C., Dworkin, R. H., Revicki, D., Harding, G., Burke, L. B., Cella, D., Cleeland, C. S., Cowan, P., Farrar, J. T., Hertz, S., Max, M. B., & Rappaport, B. A. (2008). Identifying important outcome domains for chronic pain clinical trials: an IMMPACT survey of people with pain. Pain, 137(2), 276-285.