Exercise and Chronic Pain: A Guide

It is well known that exercise is an extremely beneficial activity that can elicit substantial improvements in many different measures of health, well-being and fitness.

Exercise is a broad category, as there are many different types and manners in which exercise can be carried out. (See Movement, Physical Activity, & Exercise blog for more information.)

There are many factors to consider when determining what kind of exercise might be best for an individual. These individual considerations might include health conditions, fitness level and experience with exercise, injuries, goals, cultural factors, socioeconomic status, access to safe spaces to exercise, personality, and the existence of chronic pain. One size does not fit all when it comes to exercise.

At the Wellness Station, we provide holistic care based on the biopsychosocial model, which takes these differences into account to create individualized movement programs.

 Can Exercise Help with Pain?

Pain is an extremely complex, subjective experience, it is difficult to apply generalizations to this topic. That being said, exercise can be extremely helpful for individuals with chronic pain for several reasons.

  • However, individuals with chronic pain may become more physically inactive which may be due to fear-avoidant behavior (they may avoid movement for fear of triggering their pain), depression, or many other reasons.

  • Inactivity can make chronic pain worse, as the tissues of the body will become deconditioned, inflammatory processes may increase, and weakened tissues may become more likely to be irritated and strained from acute stressors.

  • Exercise, when performed appropriately, can have tremendous health benefits for all individuals, those with chronic pain included. Engaging in intentional exercise can help improve metabolic, cardiorespiratory, and musculoskeletal functioning, and also triggers the release of endogenous hormones (endorphins) that help us to feel good and decrease our sensitivity to pain.

  • Exercise can improve the confidence we have in ourselves and in our painful body parts, which can also help with our experience of pain. This confidence helps us feel empowered to make positive changes, and less limited by fear of movement.

  • Targeted exercise can help to nourish tissues with fresh blood and nutrients and  improve tissue strength and resilience.

It is clear that exercise is helpful for pain both directly and indirectly, but one must consider how exercise might be applied differently for someone experiencing chronic pain compared to an individual using exercise solely for fitness gains.

An Exercise Program with Chronic Pain: Factors to Consider

 The interventions chosen at the Wellness Station are highly individualized, as the intervention will depend on the unique characteristics of the individual.

  • The individual will be encouraged to be generally more active in physical activities that are enjoyable and do not trigger pain.

  • If the activities (such as walking) do trigger pain, it is a matter of changing the movement patterns involved in the activity. Often, people with chronic pain experience a pain pattern during specific activities because they have adopted compensatory, stressful and inefficient movement patterns. Unless these patterns of movement change, the pain cycle may continue. It is our job at the Wellness Station to identify these movement patterns and help you to change them.

  • In addition to changing movement patterns, we can also make changes in the parameters of the activity (including the frequency, intensity, or duration of the activity). For example, engaging in several shorter walks throughout the day rather than a longer walk, if long walks trigger pain.

  • The individual will learn not to push into pain, as this oftentimes will reinforce the pain pattern, contributing to flare ups. Rather than pushing into pain, the individual should learn how to listen and respond to the pain, as pain is your body’s way of communicating information to you. Contrary to the popular mentality of “no pain no gain”, “it’s got to hurt to be effective” when it comes to exercise, if you want exercise to be helpful for your pain you must take a different path.

  • The movement program should also include specific, intentional practices that directly and/or indirectly involve the affected body area. If low back pain is the problem, the movement program will most likely involve the low back, whether that is performing movements that improve mobility, strength and control of the low back, or perhaps improving the movement capacity of a related body area (e.g. mid back or hips) to help spread out the forces of movement over more of the body. Engaging with the involved body part in this way is helpful not just biomechanically, but also psychologically, as it will improve the confidence you have in this area.

  • The movement program for an individual with chronic pain will likely be progressive, meaning it will increase in complexity over time, but the progressions will often be much more gradual than a program that is more oriented towards fitness gains. The parameters of the program and the decision to progress will be based on evidence of neuromuscular learning, comfort, and effect on the pain pattern. By contrast, progressions for a program solely for fitness would likely be based more on the subjective challenge of the activity (e.g. it begins to feel too easy).

Enhance your Fitness for a Better Life

Physical fitness can be described as the ability for all body systems to work together in order for us to maintain health, and perform daily tasks with ease. Strength, balance, agility, cardiorespiratory endurance, and body composition are all components of fitness. It is extremely important for all of us, including those of us with chronic pain, to maintain our fitness through exercise. As we age, it becomes harder to maintain our fitness, as our muscle mass and bone density begin to fade unless we regularly strengthen ourselves. Maintaining and enhancing our fitness will help us stay independent, active and involved in the activities we love, while helping us avoid falls, fractures, metabolic diseases, and more. Pain is often a huge barrier that discourages people from exercising, so addressing the pain as described above can contribute to improvements in fitness overtime.

At the Wellness Station, we use movement to empower people with and without chronic pain to take control in order to live happier, healthier lives.

Written by Jacob Tyson, DPT - Physical Therapist, Yoga Instructor and The Wellness Station Team

References:

  1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5461882/ 

  2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5491894/ 

Top-Down vs Bottom-Up Processing: Applications to Movement and Pain Science

Top-down and bottom-up processing are ways of interpreting stimuli

Top-down processing refers to the utilization of previous knowledge, beliefs and expectations (existing schemas) in the perception of incoming stimuli. The higher levels of our brain make judgments about what we are experiencing based on past experiences.

Bottom-up processing focuses on the incoming sensory informationin real time, and does not require prior experiences. It relies on raw data from our sensory organs, which then transmits information to our brain which perceives the information. 

In other words, in top-down processing our higher brain directs our body. Your higher brain creates a story, and can tell your body what to do. In bottom-up processing, the body is informing the higher brain, which has no reliance on our preconceived ideas.

How might these types of processing relate to the development of pain behaviors?


**We have written several articles related to the neuroscience and psychology of chronic pain. Please browse our previous blog posts for a deeper dive on this topic.** 


Consider an injury in which someone bends over, picks up a box, and injures their back.

  • During the injury and for a short time afterwards, bottom-up processing would contribute to the pain experience.

  • Nociceptors in the injured tissues would send signals to the brain, which we would experience as pain. From the bottom (body) up to the top (higher brain), we are receiving sensory information that we perceive as pain.

Now consider the top-down processing that might occur for hours, days, weeks and months following this injury.

  • The higher brain might begin to tell stories and our behavior might change accordingly. “Bending over is dangerous”. Based on the past experience of pain with bending over, this activity is now associated with pain and fear- therefore, we avoid it.

  •  “I am weak, and cannot pick up anything heavy”. The emotional circuits of the brain are engaged, and a story is created about core weakness, and further avoidance of activities that involve picking up objects is perpetuated.

  • “I should be lifting like this, not like that”. A superimposed idea of keeping the back straight and bending only from the legs leads to a change in movement patterns, which may or may not be beneficial for that individual.

  • Now, whenever the back is bent in the future, the movement is deeply associated with pain and fear. The tissues that were originally injured might be healed, but weakened. The top-down processing that occurred after the injury may contribute to the development of chronic pain and disability.

Our work at the Wellness Station involves recognizing these movement patterns and behaviors that are habitual, and may be dysfunctional, stressful, or inefficient. We help you relearn how to move safely, comfortably, without limitations from fear or less than optimal movement patterns.


How does this relate to movement and exercise?

Many clientele will ask questions or otherwise indicate that they are functioning primarily in a top-down state. This presents as trying to do the exercise “correctly”, focusing more on what someone might observe from the outside-in rather than from the inside-out.

In order to optimize biomechanically-efficient movement patterns, there must be an interplay between top-down and bottom-up processing.

During a movement, the person might explore based on instructions from the therapist, previous experiences, or trying out various options. The higher brain might be saying “now listen to what your glutes are telling you when your feet are placed that way, and then compare that with the sensations, from the bottom-up, when you place your feet in a different way.” 

Consider the pelvic clock: Lying on back with knees bent, roll your pelvis towards 12 o clock (towards your head). Do this several times. Notice if you are pushing down through your feet as you go to 12. If not, try pushing down through your feet. Now bring your hands to your glutes (buttock muscles). When pushing down through your feet, observe that your glutes will contract. When not pushing down through your feet, observe that your glutes will not contract as much. The instructions “engage your glutes” would be top-down, and the instructions “observe what you feel in your glutes when you press through your feet” would be bottom-up. You could also observe differences in how your glutes are engaging when you place your feet closer or further from your bottom, or closer or further from each other.

Guide to Structuring Your Home Exercise Program

Throughout engagement in the process of physical therapy, many individuals struggle with parameters of their home program. How often should I do the exercises? How many sets and reps should I do? Should I feel pain or stay away from pain completely?

Notice what all of these questions have in common: “Should”

Traditional physical therapy tends to be very prescriptive. Pre-filled templates with “3 sets of 10” of this, “2 sets of 20” of that. For many individuals, this cut and dry prescription makes sense, and creates a clear structure for engagement with the exercises at home. However, consider what this rigid structure deprives you of.

By the therapist deciding on the exact parameters of your home program, agency may be removed from the individual. The performance of the home program becomes less about facilitating a positive engagement with one’s body, and more about what you should be doing- a task to check off the to-do list.

Okay, so… there shouldn’t be any structure to my home program?

Our lives are a constant dance between rigidity and chaos. Too much structure, we have rigidity, close-mindedness, decreased spontaneity, and limited options. Not enough structure, we have chaos, confusion, and a loss of direction. How do we find a healthy balance?

The structure of one’s home program is highly individualized based on person, environment, and goals. What works for one person may not work for another. What works for you today may not work for you tomorrow.

Sometimes life is busy. Sometimes our environment is not conducive to completing our home program. Sometimes we don’t feel good. Rather than seeing the completion of your home program as all or nothing, how can you modify it to fit into your day regardless of what is going on in your life?

Consider creating a loose structure, with room for adding and subtracting 

 Perhaps practicing the whole series of movements in your routine can only happen three times this week. However, what about five minutes here and five minutes there to engage with the movements in a way that fits in with the rhythms of your day?

  • You find yourself lying in bed for a few extra minutes and you try bringing your knees to your chest, or rotating from side to side. 

  • You are standing in the kitchen waiting for the water to boil, and you find your hips gliding. 

  • You are getting up and down from a chair, and you decide to practice three additional sit to stands with awareness of your body mechanics.

Questions to ask yourself

Learning how to direct your own care is ultimately what we aim to teach you at the Wellness Station. Consider asking yourself the following questions to enhance this ability-

If I were my therapist, what might I want to know more information about?

Consider a situation in which you are engaging with physical therapy, but you feel that you “aren’t getting better”, or the exercises aren’t “working”. If you were your own therapist, what would you want to know more about?

How often do I spend time with the movements? 

When our home program is a to-do list item, it can be very easy to rush through it and let it slip through the cracks. If you are spending no more than 10 minutes total each day engaging with yourself through mindful movement, and wonder why the therapy is not more effective, then the answer may be that you are not spending enough time with it. If you want to learn the language of your body more fluently, you have to practice.

  • It may be helpful to have a goal of how long you would like to engage in the movements, perhaps at a specific time each day. For example, 20 minutes in the morning before breakfast. 

  • To further enhance the therapeutic effects, take 10 minutes here, five minutes there, two minutes here, five minutes there, to re-engage with the movements throughout the day. 

Am I working “on” my body, or working “with” my body?

We could spend all the time in the world on our home programs, but if we are not doing the movements as intended, they will have little therapeutic benefit. If the way you are engaging in your movements is to accomplish a task, push through pain, or to just do what you think you’re supposed to be doing, then the intention is missed. The completion of the movements is less important than the manner in which they are performed.

The intention of the movements are to be able to pick up on the signals from your body with greater sensitivity, bring stimulation and change into your tissues, and grant agency to know how to respond to pain and discomfort. Keep asking yourself as you perform the movements… “Am I working on my body, or learning how to work with my body?”

In addition to a designated time for my home program, how am I implementing what I’ve learned into what I’m already doing throughout the day?

We live in our bodies 24/7, and we are already moving our bodies throughout the day, whether we are mindful about that or not. This grants us the ability to be engaging mindfully with our bodies pretty much all the time.

  • Getting out of bed or out of a chair- think about your body mechanics. 

  • Standing in the kitchen- turn it into a dance. 

  • Walking to and from rooms- what is that light from your chest doing? 

  • Picking up a box from the floor- send your bottom back and tuck your pelvis when you come up.

By considering these concepts, your home program will likely become more rewarding, enjoyable, and instrumental in moving towards success in your therapeutic journey.

At the Wellness Station, we will guide you to creating an adaptable structuring that empowers you to direct your care and enhance your wellness, fitness and beyond.

Written by Jacob Tyson, DPT - Physical Therapist, Yoga Instructor and The Wellness Station Team

Mindful Movement Part II: Yoga and Feldenkrais

Our last blog discussed the importance of mindful movement as a way to recognize and change patterns of strain, become more connected to our bodies, and to find a flow state. Moving in this way will support a healthy enjoyment of movement and exercise, which will encourage us to stay active for longer. Below, we discuss two mindful movement practices that can be integrated into your lifestyle. 

Restorative Yoga

There are many organized movement practices that focus on cultivating mindful presence. Some styles of yoga, which integrate mind, body, and spirit can help improve the awareness that we have of our movement. Vinyasa styles of yoga such as power yoga are more focused on the physical challenge of the practice, aimed at building strength and working up a sweat. If we are new to yoga, a better option would be a slow flow, restorative yoga, or yin yoga class. These slowed-down practices allow us to tune in on a deeper level.

If we want to truly feel what is happening in the present moment and be able to learn from it, our nervous system respectfully requests that we slow ourselves down.

To practice yoga more mindfully, become aware of where your attention is drawn. Is it drawn to the teacher? Trying to emulate the shape of the flexible person in front of you? Wishing time would pass so you can finish all the items on the to-do list? 

Rather than focusing on doing, or achieving some yoga pose or transition, shift to an internal focus of what is happening right now.

What can you feel and sense in your muscles? What parts of you are connected to the ground? How does your mind respond to a physical challenge? Does the pattern of your breathing change when you are changing the shape of your body?

Feldenkrais Method

The Feldenkrais Method uses somatic education and gentle movement sequences to help people learn new and more efficient ways of moving their bodies. It is based on principles of whole body/whole brain learning. Feldenkrais practices integrate the mind, body, and spirit while bolstering self-awareness and supporting positive changes of habitual movement patterns.

For example, a person with shoulder issues can learn to reach overhead comfortably by engaging proper use of the pelvis and spine – See “pelvic clock lesson“ below.

This method can be performed in one-on-one sessions by a practitioner, and there are also group movement classes known as Awareness Through Movement.

A classic Feldenkrais lesson is known as the pelvic clock. By imagining that you are  sitting or lying on a clock, we can become more aware of our posture and the natural movements of the spine.

Try this now: Lie comfortably on the floor or in bed with your knees bent. Imagine there is a small clock under the back of your pelvis. 12 o clock would point towards your head, 6 towards your feet.

Now, how would you go about rolling your pelvis between 12 and 6? How does this influence the shape of your spine as you move between 12 and 6?

If you had a light shining from your chest bone onto the ceiling, would this light move? Does moving in this way have any influence on your breathing? What sensations can you detect as you move in this way?

What is the experience of reaching an arm up to the ceiling while engaging in the pelvic clock? How does your arm want to move along with your pelvis and chest bone? 

Follow along with this video to get a better sense of the pelvic clock in a sitting position.


The Wellness Station is a somatic physical therapy practice that integrates principles of traditional physical therapy, therapeutic yoga, and the Feldenkrais Method. Our gentle approach is aimed at helping our clientele improve their lives through movement-based interventions. 

We help you to identify the obstacles that are preventing you from being active, and guide you on the path towards enhanced health and well-being.

You might find that through our guidance and your participation in mindful movement practices, your love of movement will increase, and you will naturally find yourself moving more throughout the day. With this comes the excellent health benefits of exercise, enhanced bodily comfort, and a greater ability to participate actively in your life, FOR life.


Mindful Movement Part I: Practices for Healthful Aging

It is well-known that exercise has tremendous benefits for all aspects of health. Exercise is extremely protective for cardiopulmonary and metabolic fitness, mobility, balance, muscle and bone strength, cognitive and psychological health, and much more. 

What if we are having trouble exercising because of the very things we are trying to protect? Our shortness of breath is preventing us from walking greater distances. Pain in our joints is preventing us from lifting weights or getting up and down from the floor in a yoga class. Our imbalance and fear of falling is contributing to sedentary behavior. 

These kinds of limitations in physical activity will ultimately contribute to the functional decline that so often occurs with aging, which will further discourage people from participating in traditional exercise routines. 

When it comes to society’s messages about exercise, we are taught that more is good. 

Put in more effort for greater benefits. We often hear “no pain no gain”. On the contrary, for people who are actually experiencing chronic pain and mobility issues, these messages are not inclusive and can further dissuade people from exercising. It changes the way that we think about movement- rather than relating to movement as a privilege that is empowering, movement is seen as “work”, a task to complete, an activity that is associated with pain.

If we want to improve our relationship with movement, it has to work well for our bodies, and we must enjoy it. When you observe children in a playground, you can feel how they love to run, climb, and try what is challenging  – pause, imagine those kids for a moment, can you feel the joy in your own body? 

Improving your relationship with movement will be a gift that keeps on giving!

  • You will begin to understand your limits more clearly, knowing when to put in more effort and when to scale it back.

  • You will become more aware of how your body moves, so you can move in a way that feels good to you.

This will make movement more intrinsically rewarding, as it is with children. The enjoyment of movement will support healthy levels of physical activity and fitness.

What is mindful movement?

In order to find more enjoyment in our movement practice, we must maintain mindful presence while we move. Our bodies are always present, but where is our mind? Mindfulness is simply bringing one’s attention to the present moment without judgment. We can not truly enjoy anything unless we are there for it. 

Many of us are used to sitting and meditating, drawing our attention to our breath, sounds, and thoughts. By applying this same mindful presence to physical movements, we can become more aware of how we move. This foundational awareness gives us a greater sense of connection to our bodies, and the ability  to change habitual movement patterns that may be placing unwanted stress on the joints and tissues.

Decreasing strain, improving comfort

For example, think about the movement required to follow the upward flight of a bird. If we are only moving from our neck, this may be a pattern that puts additional strain on our neck. If we find that your chest can participate in this movement, we can bring more ease to our tissues during bird watching.

Bring your hand to the back of your neck. Now, look up towards the sky. Does the back of your neck stay long, or does it compress? Now, practice looking up again, but this time put your hand on your chest bone. Does your chest bone rise, or does it stay where it is? Does allowing your chest bone to rise, thereby keeping length in the back of your neck improve the ease and comfort of looking up?

If we are able to change our patterns in ways that improve the efficiency of our movement, we can take strain off our tissues and feel a greater sense of comfort, ease, and enjoyment in our movement practices- as well as the rest of our lives!

The ability to move mindfully will support flow, a positive mental state in which we are fully immersed in what we are doing.

Moving in a state of flow brings intrinsic enjoyment because we are present, engaged, challenged but not too challenged. Consider this the next time you are engaging in movement or exercise- how can you find a state of flow, an embodied presence in what you are doing?

Written by Jacob Tyson, DPT - Physical Therapist, Yoga Instructor and The Wellness Station Team

Images: 

  1. https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.thirtythousanddays.org%2F2017%2F06%2Fseven-factors-that-predict-healthy-aging%2F&psig=AOvVaw1_n376b_mdhLa_vO8Hr0m4&ust=1679328220136000&source=images&cd=vfe&ved=0CA8QjRxqFwoTCLDnuqKv6P0CFQAAAAAdAAAAABAE 

  2. https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.pexels.com%2Fphoto%2Fbird-looking-up-6026823%2F&psig=AOvVaw1ABOzYFDAOdYp--V8kw3Hg&ust=1679840752025000&source=images&cd=vfe&ved=0CA8QjRxqFwoTCICTzMyk9_0CFQAAAAAdAAAAABAE