Guidelines on pain management for patients with chronic painall promote physical activity and exercise as part of treatment strategies. However, chronic pain is a very broad term and it encompasses many different populations. Each individual will have a different experience of their pain and will have different influencing factors. For example, guidelines on chronic low back pain such as the Belgian KCE guideline or the NICE guidelines advise to adhere to the physical activity guidelines as used in a healthy population. Likewise, in cancer survivors with chronic pain, guidelines written by the American College of Sports Medicine (ACSM) and the European Society of Medical Oncology (ESMO) also emphasize the importance of physical activity.
Great! Physical activity is an easy, low-cost, low-risk intervention that you even can do at home. Seems easy enough... However, any behavioral intervention is only going to work if that behavior is executed. Unfortunately, we see that adhering to physical activity is challenging. How come patients with chronic pain don’t engage in physical activity and how can we help to change this? Maybe they are not aware of the potential benefits? This is partially true, for example, a study in cancer survivors with pain showed that physical activity as part of treatment is often not discussed by their health care providers.
However, engaging in exercise is not as simple as knowing the benefits or knowing what to do and then just start doing it. As any behavior, it is quite complex. The blogpost of colleague Charbel Najem (April 22, 2021) provides a framework of behavior change. Go and take a look here!
There are many barriers thatchronic pain patients experience when it comes to exercise. On a physical level pain, functional limitations, fatigue or co-morbidities can hinder the activity. There could be psychological aspects such as fear, self-doubt, disturbed body image or feelings of depression and aspects on a social level as well, for example a lack of support from their social environment. Lastly, practical issues such as time, money, and the availability of materials and space are common barriers.
So no, it’s not just that easy to be active. How can we overcome the barriers and facilitate physical activity behavior? Luckily, no specific exercise or type of activity is proven to be superior. This gives us the option to really decide together with our patients how we can design their exercise plan.
Find something that your patient will enjoy doing and make sure your activity goal is feasible. We all have had bursts of motivation in which we declare that we will run half a marathon or climb mount Everest. Enthusiasm is great, but make sure that the plan you draw out is still realistic when your patient’s motivation takes a dip.
Find easy ways to move and remember that the most important part of physical activity is that you do it. For example, a 10-minute walk that gets done is always better than the 5-page exercise schedule that gets dismissed.
Lastly, talk strategy. Seek out strategies to facilitate and implement physical activity into their daily life. Don’t only discuss what type of exercise, how to do the exercise or how many reps, … but also talk about how they can incorporate activity in their daily life and identify possible pitfalls. What will they do if they experience a flare-up? Discuss the steps of action they can take and how they can adjust their plan.
Remember that our patients don’t exist in a vacuum. For example, if someone is very body conscious, this person might not feel comfortable going to a public gym or might even feel uneasy exercising outdoors. Think about how someone might feel if you ask them to perform exercises that they think are not safe for them. Imagine your own busy life and think how you would have to implement an extra 150-300 minutes of activity per week. So, ask these questions and ask them how confident they are in achieving the goals that you collectively decided on. “Do you find this a realistic plan? Do you see any aspects that might be difficult for you? How can we make this easier for you?”
Physical activity and exercise are undeniably essential aspects of chronic pain management. So, let’s make sure that we use this strategy in the most effective way and make room for these conversations with our patients.
Sophie Van Dijck
I am a physical therapist and PhD student. My clinical experience has showed me the complex problems of chronic pain. It pushed me to find solutions for problems like the challenge of physical activity. Check out the Pain-DetAct study, a study that looks at the determinants of physical activity in chronic pain: https://www.facebook.com/paindetact.
2022Pain in Motion
References and further reading:
Geneen LJ, Moore RA, Clarke C, Martin D, Colvin LA, Smith BH. Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2017. DOI: 10.1002/14651858.CD011279.pub2
Meade LB, Bearne LM, Godfrey EL. “It’s important to buy in to the new lifestyle”: barriers and facilitators of exercise adherence in a population with persistent musculoskeletal pain. Disability and Rehabilitation. 2021. https://dx.doi.org/10.1080/09638288.2019.1629700
Campbell KL, Winters-Stone K, Wiskemann J, May AM, Schwartz AL, Courneya KS, et al. Exercise guidelines for cancer survivors: consensus statement from international multidisciplinary roundtable. Medicine and science in sports and exercise. 2019
Fallon M, Giusti R, Aielli F, Hoskin P, Rolke R, Sharma M, et al. Management of cancer pain in adult patients: ESMO Clinical Practice Guidelines. Annals of Oncology. 2018. https://dx.doi.org/10.1093/annonc/mdy152
Clifford BK, Mizrahi D, Sandler CX, Barry BK, Simar D, Wakefield CE, et al. Barriers and facilitators of exercise experienced by cancer survivors: a mixed methods systematic review. Supportive Care in Cancer. 2018. https://dx.doi.org/10.1007/s00520-017-3964-5
Slade SC, Patel S, Underwood M, Keating JL. What Are Patient Beliefs and Perceptions About Exercise for Nonspecific Chronic Low Back Pain?: A Systematic Review of Qualitative Studies. The Clinical Journal of Pain. 2014. https://dx.doi.org/10.1186/s13012-019-0884-4
Jackson T, Wang Y, Wang Y, Fan H. Self-Efficacy and Chronic Pain Outcomes: A Meta-Analytic Review. The Journal of Pain. 2014; https://doi.org/10.1016/j.jpain.2014.05.002
Nyrop KA, Callahan LF, Rini C, Altpeter M, Hackney B, DePue A, Wilson A, Schechter A, Muss HB. Aromatase inhibitor associated arthralgia: the importance of oncology provider-patient communication about side effects and potential management through physical activity. Support Care Cancer. 2016. DOI: 10.1007/s00520-015-3065-2
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