​Even though nociceptive pathology has often long subsided, the brain of patients with chronic musculoskeletal pain has typically acquired a protective (movement-related) pain memory. Exercise therapy for patients with chronic musculoskeletal pain is often hampered by such pain memories. Physiotherapists can actually alter pain memories in patients with chronic musculoskeletal pain. This can be done by integrating pain neuroscience education with exercise interventions. The latter includes applying graded exposure in vivo principles during exercise therapy, for targeting the brain circuitries orchestrated by the amygdala (the memory of fear centre in the brain). 

Before initiating such exercise therapy, a preparatory phase of intensive pain neuroscience education is required. For reading more about therapeutic pain neuroscience education, use the following link: http://www.paininmotion.be/EN/news-2014-therapist-explaining-pain.html. Next, exercise therapy can address movement-related pain memories by applying the ‘exposure without danger’ principle. By addressing patients’ perceptions about exercises, therapists should try to decrease the anticipated danger (threat level) of the exercises by challenging the nature of, and reasoning behind their fears, assuring the safety of the exercises, and increasing confidence in a successful accomplishment of the exercise. This way, exercise therapy accounts for the current understanding of pain neuroscience, including the mechanisms of central sensitization. 

For illustrating such an approach to exercise therapy in chronic pain patients, you can find an example here: http://www.paininmotion.be/EN/RetrainingPainMemoriesEnglish.html. The example entails a therapist discussing the patient’s perceptions about exercises before and after performing them for the first time.

Reference & further reading: 

http://www.ncbi.nlm.nih.gov/pubmed/25090974 

Jo Nijs

2014 © Pain in Motion