Exercise for Pain: Trust the Process (the journey)? Or Trust the Progress (the outcome)?

Why not both equally? Or both but different ratios per individual?

Are we addressing pain? Or are we addressing function? Or function despite pain?

This is a very nuanced topic and it has been a controversial one because of the beliefs entwined within the professions that work with people in pain and recovery.

But do these beliefs hold up to research scrutiny? Do they hold up to real-life application scrutiny too?

First, let’s set some precedents.  

When I say exercise, I mean various forms of physical activity.  Exercise is not synonymous with the gym and they do not always mean the 7 movement patterns lifters rave about.

When we say exercise for pain, it also does not mean the corrective exercises you see in those sponsored marketing ads.  And when we talk exercise progression, it also does not always mean increasing load or weight.

It could mean better form, better awareness, the ability to go slow or fast or stop and resume where you left off. It could mean the ability to pay attention to what goes on around you as you perform a movement with a certain label of quality.  It could mean being able to do movements in sequence, describe them in sequence, do them in reverse sequence and even out of pattern and still process it.  Progression could mean a higher vertical jump or it could mean knowing which exercise comes next in a circuit of 5 in a workout.  

Walking is a great exercise for low back pain as supported by research and because of its simplicity and availability.

Progression here (walking in general and not just LBP) could be walking faster or farther, walking with better arm swing, walking without looking stiff, walking sideways, backwards, walking with a smile or even giving a correct answer to 2+2 and 4×4 without stopping (I did this for my client who trained with me after recovering from cerebral hypoxia or brain damage from lack of oxygen).

You see, exercise is just repetitive physical activity with varying objectives.  And these objectives would depend on the individual doing it.

More importantly, physical activity might be a biopsychosocial exercise.  Let me explain.

Any type of physical activity done often enough and progressed enough will cause the body to adapt in order to be tougher and more efficient in the task.  If you keep doing bicep curls, your biceps become bigger and you lift more weight and do more repetitions.  This is a physical adaptation. If you practice basketball and keep shooting hoops, your accuracy improves and you make more shots.  This adaptation is both physical and mental.  But if you have been practicing shooting by yourself, you will not necessarily make those shots in a game. 

You have to be specific.  Training is supposed to be specific.  But, real life involves uncertainty, moving variables and changing scenarios.  You have to practice shooting by yourself in a controlled environment where you focus only on yourself and your target.  Then you have to learn to do that in a game where your focus is not on yourself but on the basketball court, the basketball ring, the nine players on the court, the movement of the offense, the movement of the defense and where you are in relation to all these.  Then you make the shot.

Now if that doesn’t seem tricky enough, imagine not just taking shots but being pressured to make those shots by your coach and by your team.  More than that, you’re being watched by your significant other, your parents, a big crowd and potential recruiters.

So you take a shot.  A defender lunges after you.  You maintain mental focus to control your shot.  But in a split second, you remember that you had an ACL injury because a defender went after you a year ago and intentionally hurt you to take you out of the game.

How do you make those shots? How do you train yourself for that?  How do you train someone else for that?  Did I just go off topic to discuss basketball instead of exercise and pain?

No.  I was trying to paint the full picture of the things someone in pain is expected to go through and overcome but in an elaborate manner so it is easier to understand context.  Someone recovering from injury might have pain at some point in the journey to recovery, they might have no pain at all and they might have pain through it all.  But still, the road to recovery is filled with functional demands that take a toll not just on the physical, but also on the mental, emotional and social.

It doesn’t seem to me that we have been covering all of our bases.  We focus so much on the physical and leave the rest for our patients to figure out themselves.  Some of us even do physical things that don’t cause positive adaptations (passive therapies) and often makes things worse by using fear-based and marketing-driven language.  When we say “first, do no harm.”, we should understand that it involves the totality of the person (mental, emotional, social) and not just the physical.  If you harm a person’s belief that he can get better, you caused a significant level of harm that can be difficult to undo.  

Soft tissues heal in 4-6 weeks. Fractures, in 6-10.  And they heal on their own.  A damaged socio-emotional well-being and belief system? Who knows? Some people have years of professional help and still struggle.

Several years ago, I met a guy with a 10 year history of back pain.  At the onset, he was told he had disc bulges and that forward bending would be bad for him and must be avoided.  Back then, he could still touch the floor by bending forward in a standing position.  

When I met him, he moved like a robot, didn’t have arm swing and was afraid to even bring his head forward!  He had one overwhelming belief that trumped everything else: all spinal flexion was bad.  That made everything worse for him.  He continued to pursue various modes of treatment through the years because he was also driven by a fear of missing out on the growing years of his 2 daughters.  Now his pain interferes with every aspect of his life.

Here was a man whose injury may have started purely physical.  But with time and the various advice he had received that was purely biomedical and bio mechanical: discs, forward bending, fascia, trigger points, william’s flexion, McKenzie extension, transversus abdominis, core, deadlifts, squats; his problem turned into one big biopsychosocial predicament!   That surely was never the intention.  But ignoring the totality of the person as we guide them through betterment leaves loopholes that gets filled up with wrong notions, bad advice and negative language.  It is up to us to do better.

I had him lie down flat on the bed.  Gave him a pillow under his head. Waited for him to be comfortable.  Another pillow.  Another one later on until he eventually had four pillows under his head.  Told him that he now is in a slight forward bending position and confirmed that he was fine with it.  Then I told him to bend his knees and bring his heels close to his butt.  Then I repeated the same process of adding pillows but this time under his feet.  And he was fine with it.  I got him to hug one knee and pull it towards his chest.  Then the other knee.  Now both knees.  I put my weight on his shins so he can let go with his arms and fully enjoy the feeling of absolute spinal flexion and be fine with it.

The whole process took 2 hours.  I was calibrating my progressions based on his reactions, comfort level and belief system.  I was trying to influence his belief system ultimately.  The physical activity progressions we did on this day was more than he ever had for a significant amount of time.  Within those 2 hours we talked about a lot of things: what he thought, what he felt, what he believed, my contentions on those things he said and how much sense we can make out of it.  It was important for me to know which of the new information I presented was agreeable for him and which of the disagreeable ones we can work on in the future.

We talked about how hurt does not equal harm, how discs can heal, how research has shown people with disc pathology having no pain, how disc bulges are still significant, how the pain has affected his work and relationships, how committed he is to getting improvement and how much effort and time he can put into getting better.  We also talked about his goals and what he wanted to achieve out of this, how recovery is non-linear in nature and how he can further improve his lifestyle to help his recovery.

On his next session, I had him sit and slouch.  Next I had him put his hands on his knees, then his elbows, then hands on the floor touching it, then hands on the floor pushing it.  The whole process took an hour with appropriate breaks in between while recapping the things we talked about previously and discussing the things he noticed in between our two sessions and any other clarifications he might have.

The things we do in our sessions, I had him repeat frequently at home as an exercise program.  Notice that we were doing progressions but it is not the typical exercises you encounter.  Notice also that we are communicating well all through out.  Pain science doesn’t tell us to explain pain to our patients and present research to them.  Pain science is just one part of the biopsychosocial framework that we are supposed to apply.  Every person we counter in the clinic has a different biopsychosocial ratio and proportion to their pain, symptoms, experience, treatment challenges, and recovery.  I also gave him sources to study on his own so he can decide if our course of action is agreeable to him and is in line with his desired goals.

Every session, I give him a glimpse of the next by explaining to him the progressions we can do if he feels better and he is up for it.  This is how I set and manage expectations.  Of course I also tell him what we would do if things don’t turn out to be too favorable.  So every time he comes in, he knows what to report and what to expect.

We eventually did gym workouts and deadlifts.  But that was his choice and came as a result of natural progression.  I never implied that we should do it for pain.  I merely stated that it was a very good way to keep getting better and stronger but it is no guarantee to being pain-free.

Now the thing I love most when people in pain get stronger is their ability to self-manage.  Confidence levels and expectations are now different because they know they are tougher and the knowledge they now possess about themselves and their symptoms allow them to make very well-informed decisions on how to continue with their functions.

I wouldn’t say that strength made the difference in pain although it could make a difference in terms of function.  But I would say that the process of getting to a particular level of strength imparts knowledge of self-management, control and resilience to the individual.  

It is my opinion that strength per se is not what ultimately helps but rather, the process of recovering and then working for that improvement in strength.  Not to say that strength isn’t helpful all in all, but that it’s effect insofar as pain alone is concerned is not groundbreaking.

Now notice in my story how much set up I actually had to do to get the person moving in the first place and initiate momentum for progression.  That is what I meant when I said earlier that physical activity can be a  biopsychosocial exercise.  It depends on the person doing it and the context upon which the activity is going to be performed.  I hope that much is now clear.

This discussion wouldn’t be complete without me stating the obvious: pain is biopsychosocial in nature.  We have to accept it in all its glorious complexity and be comfortable in our uncertainty.  Why? Because for each person that you see, you won’t be able to measure how much of their pain is contributed to by biological factors just as much as you can’t say how much psychological and social factors have affected their pain experience.  It’s different for everyone.

To navigate through the confusion, let me share this with you.  It is not your job to find out, nor is it your job it fix each component separately.  The person in front of you is the totality of that embodied experience so you work with him while acknowledging that totality.  Keep in mind that in your interactions with people in pain, you are not a healer or a fixer.  You are a guide, a facilitator and a motivator.  Your role is to help them take the wheel and steer.  Don’t be a backseat driver.  Be a helpful passenger.  You’re just coming along for the ride.  The journey of recovery and betterment is theirs all along.