What is the role of movement in the treatment and management of pain?
We know physiotherapists have long time incorporated exercise(s) into their practice, but now osteopaths, chiropractors and other remedial therapists have started introducing exercise and movement as part of their treatment approach to pain.
Does this improve outcomes for people in pain?
As someone who has an exercise background, and a practice based in a gym (with a large number of patients who are active themselves), I’m a big proponent of empowering people with active management strategies to both help manage pain and improve health and fitness.
Large scale research projects have confirmed that an active, movement based approach is superior to a passive treatment approach for the management and treatment of many pain conditions.
Whilst the many benefits of exercise and movement are commonly known and widely promoted, the message can be misconstrued when context is not provided.
To understand the role of movement in the treatment of pain requires an understanding of pain.
Unfortunately, many people do not learn about pain when they seek treatment for pain, which leads to incorrect ideas and beliefs, that can make their pain worse.
The Dark Side of Exercise Therapy for Pain
In general, encouraging people to take an active role in their recovery from pain is a good thing.
Problems arise when exercise and movement is billed as being the treatment or “fix” for pain.
Unfortunately, nothing can “fix” pain, not manual therapy, not exercise, not medication, not surgery.
The reason being, pain is not a thing, pain is an experience, an active process. All of those methods create a change within your body and brain, so that your brain can resolve things.
So, as always, the context in which anything, including movement, is performed to help with pain is paramount.
What’s the big deal?
Many times, I have seen people who have been told to stand/walk/move in a certain way, because if they don’t “their pain will get worse”.
Others, rightly or wrongly, interpret their failure to improve as their fault, if they have been made to believe that exercise is what is needed to fix their pain, due to poor compliance. I often view poor compliance as not as the fault of the client, but of the therapist.
If someone can’t do something, then what has been given to them is too much for them at that point in time.
And yes, people still need to take responsibility for their actions, but the job of a health practitioner is to show the path in actionable steps, not unload a volume of information onto their patients (they could use google for that).
What’s In A Name?
Throughout this post, I have used “movement” and “exercise” interchangeably.
Whilst it is true that exercise is movement, it is also true that not all movement is exercise.
Exercise is purposeful physical exertion/activity performed to create a physical adaptation.
Movement is a preferred term, because it doesn’t have the connotations to exertion.
You shouldn’t need to exert yourself (physically) to overcome pain.
Mechanisms of Movement in the Treatment of Pain
We don’t actually know exactly what happens when pain resolves.
To clarify, we know that pain is an emergent property, that is, it has biological, psychological and social/environmental components, but it is not any one of these, nor does 1+1 = 2.
This means, that treatments for pain can be specific only up to a certain point.
Why does spinal surgery improve outcomes for some people, but not all? If pain were only physical, then surgery would always work, but we are not bodies, but people, and this needs to be considered in the treatment of pain.
That’s not to say we have no idea what helps pain, we do, generally, but what helps pain for any specific person at any specific time is going to vary.
One thing we do know, is that “all pain is neurogenic”, that is, all pain originates in the nervous system.
So for any intervention to help in the resolution of pain, it must have some effect on the nervous system.
Thankfully, we know that movement has a great effect on the nervous system.
Our brains crave novel sensory input. It is why we are generally attracted to “new and shiny”.
When we experience pain, it is an output of the brain, based on all the current sensory inputs from both the body and the brain itself (confusing? read this).
In theory, by providing novel sensory inputs, we can alter the outputs, including pain.
With movement, if we can “show” the brain a different way, then sometimes that is what is needed to “teach” it how to produce the desired output.
For example, let’s say you experienced low back pain that hurt when you bent forward.
If we change the context of your bending by having your feet in a split position and bending to the side, that might be enough of a different sensory input to change the output of pain.
Our body is in our brain. We have a “map” of our body within our brain, such that when certain peripheral nerves are stimulated, a corresponding brain area is activated.
Conversely, stimulating that brain area with electrodes will cause a vague sensation in that region of the body.
When we have pain, we know that our “body map” is impaired. That is, we can’t clearly recognise our affected body parts like we can the unaffected ones.
Deliberate movement can help with cortical mapping, once again, by increasing the amount of information coming from an affected area.
Touch can help, but we seem to have a better response to active movement, likely because more brain areas are involved, resulting in a more pronounced stimulus.
This is little bit easier to understand for many people, because it is more of a direct mechanical effect.
Nerves are everywhere in our body. We have km’s of them.
They pass through “tunnels” of soft tissue all over the body.
They can get stuck or deformed.
When they are stuck of deformed, they will fire more rapidly and strongly.
Movement, can either directly, or indirectly mobilise the nervous system, freeing up your nerves to slide and glide freely, which is exactly what they want to do.
Our brains are pretty cool.
In addition to being able to recognise a bunch of pixels lit up on a screen into shapes (letters) as meaningful, they can produce a whole host of chemicals that can block pain at the level of the spine.
Aside: there are 3 levels where you can block pain. Peripheral, spinal and brain.
Movement can facilitate the production of pain relieveing chemicals, like endogenous opoidids. Much better than buying them at the pharmacy, because your brain is never going to get the dose wrong.
There is a correlation between mood disorders like anxierty and depression and pain.
Regular and meaningful movement is correlated with improved moods, as is exercise.
You can probably see where I’m going with this.
So Movement is Medicine After All?
But just as taking the right medication, in the right dose for the right problem is paramount, using movement as an intervention for pain is the same.
More is not better if all you are doing is reinforcing the same behaviours that lead to or maintain your pain.
Think of it like this: there is the skill to perform a movement, and the capacity to perform it. If you have the skill, but limited capacity, you need to improve your capacity and vice versa.
Movement is important in treatment of mechanical pain.
Active movement is superior to passive movement in most cases.
The mechanisms of how movement affects pain are not specifically known, but there are plausible ideas, all of which must involve the nervous system.
These effects are what would be called “non-specific effects”. Whilst there are potentially “specific effects” occurring as well, we don’t know enough as yet to harness these more precisely.
In terms of pain: inputs + processing = output (pain).
To change pain, we are attempting to change our inputs, be it movement, education, cognitive behavioural therapy, manual therapy or something else.
Whatever it takes to get a change is what “works” for that person, in that moment.
This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.
This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.