I’ve written before about exercise – actually I’ve written quite a lot about exercise here, here, here and here and definitely elsewhere on my blog. Exercise is, without a doubt, one of the most commonly ‘prescribed’ approaches for persisting or chronic pain. Whether ‘exercise’ is the thing, ‘movement practices’ or ‘meaningful movement’ is ubiquitous. So much for not enjoying exercise, if you have persistent pain you’re going to get told to do some.
Movement is delicious. Maintaining muscle, bone, joint and brain function gives us the scaffolding for all the things we need and want to do. Back in the day (yes, 1980s!) it was common and reasonable to take to your bed for seven days with a bout of acute low back pain. SEVEN DAYS! Not to mention seven days before you were allowed to get up and move after a hip replacement… But there’s a big difference between knowing that avoiding movement is harmful and advocating for exercise for all pain. For the avoidance of doubt, I’m an advocate for meaningful movement, I just don’t think the emphasis on exercise is as well-founded. BTW exercise is defined in this paper, and works well enough for me (Caspersen, Powell & Christenson, 1985).
We’re pretty clear that exercise and movement are great – this recent review summarises the various benefits from genetics to psychology to physiology (Wang & Ashokan, 2021), so there’s no argument there from me.
What I’m less convinced by, though, is the pain and disability reduction focus of exercise-for-chronic-pain. I think exercise is being over-sold, and the obsession for rigid exercise protocols doesn’t seem to set people up for including movement practices now and over their lifespan.
I’ve written before that I think exercise is a vehicle for graded exposure, learning about consistency, and to gain confidence in a body that can feel like it’s betrayed the person in it. Exercise is simplified daily life. It’s repetitive. In the early days of rehabilitation it’s done in the presence of a ‘safe’ clinician who encourages and acts as a safety monitor.
In that earlier post I concluded by saying “I don’t think movement or exercise [for pain] is much about fitness or other physiological factors… we need to build confidence, awareness, willingness to go gently into these uncomfortable experiences.”
Possibly the most important point I made then – and repeat here – is that exercise for pain needs “…to sustain practice in all the life contexts so we can be able to do the things exercise and movement are supposed to promote: healthy living.”
Our clinical skills need to shift if the aims of movement practice for pain move from “strength”, “pain reduction”, “correcting dysfunction” to emphasise confidence, willingness to move even when sort, movement variability and flexibility, and most importantly, to being able to do the things that make up life.
Clinicians, we need to develop our skills to guide people through new experiences of their body, and often when they’re feeling their most vulnerable. This probably means learning those skills that feel most challenging: skills where being ‘right’ is not a strength, where being sensitive and compassionate is critical, where knowing principles rather than reciting recipes, and where really deeply observing how an individual responds to anything they’re asked to do becomes The Way Forward. Because, as I learned in the early 1980’s at occupational therapy school, ‘Start where the learner is at, and move at their pace’. This really is how we best support people as they move through transitions in life.
Let’s make meaningful movement what we do – not ‘exercise’ unless the person in front of us WANTS to do exercise. Let’s make movement practices varied and based on preferences. Let’s have plenty of options for movement through the day, through the week, through years. Let’s give people confidence to try new movement practices, rather than locking them in to the forms of movement that are easiest to regulate. Let’s give opportunities for people to try many forms of movement during their rehabilitation – dance, gardening, cycling, walking the dog, fishing along a river, walking on the beach, cold water swimming, climbing to the top of hill, building fences, kayaking… Let’s make sure older people don’t lose the opportunity to do movement practices they enjoy. Let’s ensure parents with young children have options that work in their lives. Let’s make it so teachers and retail assistants and mechanics and librarians and lab technicians can all have ways to get movement into their lives throughout the day and week. For goodness’ sake let’s not tell people they shouldn’t be doing the movement practices they most enjoy ‘because of pain’!
Cashin and colleagues (2022) suggesting this flowchart for decision-making. It’s a good start though based on LBP. I’d suggest going further – why not look at what the person is having trouble doing in their daily life, and simply use those activities as therapy? Or is that getting a little close to occupational therapy…?
Cashin, A. G., Booth, J., McAuley, J. H., Jones, M. D., Hubscher, M., Traeger, A. C., Fried, K., & Moseley, G. L. (2022). Making exercise count: Considerations for the role of exercise in back pain treatment. Musculoskeletal Care, 20(2), 259-270. https://doi.org/10.1002/msc.1597
Caspersen, C. J., Powell, K. E., & Christenson, G. M. (1985). Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public health reports (Washington, D.C. : 1974), 100(2), 126–131.
Mary Reilly, (1974). Play as exploratory learning: studies of curiosity behavior. Sage Publications
Wang, Y., & Ashokan, K. (2021). Physical Exercise: An Overview of Benefits From Psychological Level to Genetics and Beyond. Front Physiol, 12, 731858. https://doi.org/10.3389/fphys.2021.731858