Exercise Induced Analgesia

Why does exercise make you feel good? The popular idea is that exercise gives you “endorphins,” and this explanation is actually not far from the mark. The word endorphin is short for endogenous morphine, which is an opioid “drug” that may start to flow when you move. In this post, I’ll provide a detailed discussion of various mechanisms for “exercise induced analgesia” including activation of the body’s pain inhibitory system. We need this system working well not just so we can get a runner’s high, but to help prevent chronic pain. Regular physical activity might be the best way to maintain its health and proper function.

Top Down Control Of Pain: Descending Inhibition

One key mechanism for exercise induced analgesia is descending inhibition of nociception, which occurs when certain brain areas suppress nociceptive signals in the spinal cord. This is called “top-down” control over pain, because the brain has an active say in whether pain occurs, as opposed to passively reflecting bottom-up signals from the body.

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For example, in an emergency, the brain might recognize that survival requires running, so it activates the descending inhibitory system to suppress nociception. (Interestingly, this suppression is selective, focused more on C fibers than fast acting A fibers, which means that “old news” about existing tissue damage is effectively tuned out, while the system remains alert to sensory information about new injuries  (Heinricher 2010).

The descending inhibitory system is generally activated by vigorous physical activity. During a marathon (which may be perceived as a minor emergency), the feet and knees may generate a lot of nociception, but much of it will be inhibited if higher brain centers determine that completing the marathon is a valuable goal. Not surprisingly, triathletes have supercharged descending inhibitory systems: they truly get high from running. People with chronic pain and fibromyalgia are at the opposite end of the spectrum – their descending inhibitory systems do not work very well at all, which is why they often feel worse not better during physical activity. Many experts believe that the behavior of the descending inhibitory system is a critical factor in explaining chronic pain (Ossipov 2012, 2015).

Key Anatomical Structures Involved In Descending Inhibition

The periaqueductal gray (PAG) was the first brain region shown to activate an endogenous pain inhibitory system, as its stimulation caused immediate pain relief (Kwon 2014). The PAG receives inputs from parts of the limbic system and brain areas involved in processing emotion, fear, and motivation. These connections are understood to be mechanisms by which thoughts and emotions can affect pain. For example, the PAG plays a role in the placebo response.

The PAG influences descending inhibition primarily through its connections to the rostral ventromedial medulla (RVM), which can also facilitate nociception. The decision about whether to facilitate or inhibit nociception is based on considerations by higher level brain areas about the meaning of the nociception and how to respond to it (Melzack and Wall 2014).

Just as suppression of pain could be advantageous in highly stressful or dangerous situations where other behaviors must pre-empt pain responses and recuperative behaviors in order to ensure survival, facilitation of pain could promote recuperative behaviors during illness, and enhance vigilance in situations where threat is possible, but not imminent.

(Heinricher 2009). Two types of neurons have been identified in the RVM as being responsible for pain modulation: on-cells and off-cells. Off-cells trigger descending inhibition, and on-cells create descending facilitation (Kwon 2014). The dynamic balance between on and off is dictated by behavioral priorities, fears, and other factors evaluated by higher structures in the brain (Heinricher 2009). It has been suggested that an imbalance toward facilitation may underlie pathological pain states (Ossipov 2012).

A primary target for descending modulation is the dorsal horn of the spine, which is the point where peripheral nerves connect to the spinal cord. The dorsal horn acts as a “gate” on nociception, because its sensitivity helps determine whether nociception moves from the body to the brain. Sensitivity is determined in part by ascending sensory information (the amount of nociception from the periphery), but also the descending modulation from the PAG-RVM system. Thus, inadequate inhibition can be an important cause of central sensitization and chronic pain states (Ossipov 2012).

There are a wide variety of chemical substances that act to inhibit nociception, including endogenous opioids, cannabinoids, serotonin, and catecholamines. For example, opiod peptides bind to opioid receptors on many parts of central and perisperhal nervous system, and this decreases the excitability of the nociceptors, causing them to fire less (Da Silva 2018).

Immune System Changes

Physical activity can also affect pain by causing complex changes in the behavior of the immune system, both locally and globally (Petersen 2005; Sluka 2018). For example, exercise can modulate the phenotype of macrophages in muscle, making them more likely to release anti-inflammatory as opposed to pro-inflammatory cytokines. There is research indicating that regular exercise can reduce the level of circulating inflammatory cytokines in the bloodstream, in patients with fibromyalgia and healthy controls. Other research shows that regular exercise may reduce glial cell activation in the central nervous system, reduce inflammatory cytokines, and increase anti-inflammatory cytokines in the dorsal horn (Sluka 2018).

Conditioned Modulation

Another reason exercise may kill pain is through conditioned pain modulation or “CPM” (also referred to as diffuse noxious inhibitory control or counter-irritation). CPM describes the phenomenon whereby “pain inhibits pain.”

CPM has been studied for at least 70 years, because it’s fairly easy to study. Experiments usually look something like this: (1) a person receives a noxious stimulus (such as pressure) and reports pain level, and then (2) the person is exposed to a painful “conditioning stimulus”, such as cold water immersion of the hand, and then (3) the person receives another round of the initial noxious stimulus and reports pain level. Usually, the second round will feel less painful, and the degree of pain relief is considered a measure of how well the descending inhibitory system is functioning.

Here are some interesting facts about CPM:

  • CPM is the likely mechanism for pain reduction in a wide variety of manual therapies, including deep tissue massage, acupuncture, dry needling, instrument assisted soft tissue manipulation, and foam rolling. If any of these treatments help with your pain, it is likely that you can get the same effect from the right kind of exercise.

  • CPM is less effective in patients with IBS, TMJ, tension headache, fibromyalgia and depression (Yarntisky 2010).

  • Pre-operative CPM efficacy predicts post-operative pain levels, including which patients transition from acute to chronic pain (Yarnitksy 2010).

  • CPM efficiency predicts the strength of exercise induced analgesia, and they probably rely on at least some common mechanisms (Stolzman 2016).

  • People who frequently engage in vigorous activity have enhanced CPM compared to less active people (Sluka 2016).

Can We Improve Descending Inhibition Through Exercise?

We know that physical inactivity is a risk factor for chronic pain, that exercise stimulates the pain modulatory system, and that a healthy balance in the system is necessary for avoiding chronic pain. This raises the question of whether regular exercise is a way to maintain and recover the proper function of the pain inhibitory system. Sluka and colleagues propose that the answer is yes:

regular physical activity changes the state of central pain inhibitory pathways and the immune system to result in a protective effect against a peripheral insult.

The evidence in support of this contention is confusing and mixed, but there are some encouraging results. In addition to the research discussed above, it has been shown that regular aerobic exercise is an effective treatment for fibromyalgia, and can also increase tolerance to ischemic pain in healthy individuals (Sluka 2016; Ellingson 2016). On the other hand, it has been found that aerobic capacity does not predict pain level in response to a given stimulus, and several studies show that exercise can cause pain in fibromyalgia or lead to flareups (Ellingson 2016). In general, almost any kind of exercise seems to help with almost any kind of chronic pain, but the effect sizes tend to be small.

Closing Thoughts

Exercised induced analgesia is not just about getting some temporary feel-good chemicals from a jog or weightlifting session. It is about tuning up a system whose proper function is necessary to keep you feeling good all the time.

A word of caution about the physiology discussed here: it’s very interesting to learn about all of the individual micro-level players in the descending inhibitory system, but we must remember that they interact in highly dynamic and complex ways. Therefore, their collective effect may be very hard to predict by analyzing the separate parts. For example, serotonin inhibits pain in some contexts but facilitates it in others. This is why therapies aimed at very specific targets (especially drug therapies) may have unintended effects, or even cause the opposite of the intended effect.

In my view, the more practical perspective is to keep in mind the purpose for which the descending inhibitory system evolved, which is to help you perform personally valued movements in the face of potential physical danger. Descending inhibition is there to keep you moving even when the movements are generating some nociception, especially when those movements are meaningful and intrinsically motivating. To keep the system healthy, challenge it to perform this function at a goldilocks level of intensity as often as possible, and see if it adapts to get better at its job.

This is how we improve the function of all the different bodily systems that help us move around, including muscles, tendons, bones, and the cardiovascular system. When they are put under an appropriate level of challenge or stress to do their jobs, they get better at doing them. Perhaps something similar holds true for the descending inhibitory system. Find movements that make you feel good, or that at least give you a “good pain,” and do them frequently.


Da Silva Santos R, Galdino G. Endogenous systems involved in exercise-induced analgesia. J Physiol Pharmacol. 2018;69(1):3-13. doi:10.26402/jpp.2018.1.01

Kwon M, Altin M, Duenas H, Alev L. The role of descending inhibitory pathways on chronic pain modulation and clinical implications. Pain Pract. 2014;14(7):656-667. doi:10.1111/papr.12145

M.M. Heinricher, Tavares I, Leith JL, Lumb BM. Descending control of nociception. 2010;60(1):214-225. doi:10.1016/j.brainresrev.2008.12.009.Descending

Ossipov, Morimura. Descending pain modulation and chronicification of pain. Curr Opin Support Palliat Care. 2015;9(1):38-39. doi:10.1097/SPC.0000000000000055

Petersen AMW, Pedersen BK. The anti-inflammatory effect of exercise. J Appl Physiol. 2005;98(4):1154-1162. doi:10.1152/japplphysiol.00164.2004

Polaski AM, Phelps AL, Kostek MC, Szucs KA, Kolber BJ. Exercise-induced hypoalgesia: A meta-analysis of exercise dosing for the treatment of chronic pain. PLoS One. 2019;14(1):1-29. doi:10.1371/journal.pone.021041

Price TJ, Ray PR. Recent advances toward understanding the mysteries of the acute to chronic pain transition. Curr Opin Physiol. 2019;11:42-50. doi:10.1016/J.COPHYS.2019.05.015

Sluka KA, Frey-Law L, Hoeger Bement M. Exercise-induced pain and analgesia? Underlying mechanisms and clinical translation. Pain. 2018;159(9):S91-S97. doi:10.1097/j.pain.0000000000001235

Ellingson LD, Stegner AJ, Schwabacher IJ, Koltyn KF, Cook DB. Exercise strengthens central nervous system modulation of pain in fibromyalgia. Brain Sci. 2016;6(1):13. doi:10.3390/brainsci6010008

Melzack and Wall. Textbook of Pain Ed. 6.

Zhuo M. Descending facilitation: From basic science to the treatment of chronic pain. Mol Pain. 2017;13:1-12. doi:10.1177/1744806917699212

Yarnitsky D. Conditioned pain modulation (the diffuse noxious inhibitory control-like effect): Its relevance for acute and chronic pain states. Curr Opin Anaesthesiol. 2010;23(5):611-615. doi:10.1097/ACO.0b013e32833c348b

Alsouhibani A, Vaegter HB, Bement MH. Systemic exercise-induced hypoalgesia following isometric exercise reduces conditioned pain modulation. Pain Med (United States). 2019;20(1):180-190. doi:10.1093/pm/pny057

Stolzman S, Bement M. Does exercise decrease pain via conditioned pain modulation in adolescents?”. Pediatr Phys Ther. 2016;28(4):474. doi:10.1097/PEP.0000000000000313

Ossipov MH. The Perception and Endogenous Modulation of Pain. Scientifica (Cairo). 2012;2012:1-25. doi:10.6064/2012/561761

Yamamotová A. Mechanisms of exercise-induced hypoalgesia. Psychiatrie. 2018;22(1):33-38. doi:10.1016/j.jpain.2014.09.006.Mechanisms

Amazing Low Back Exercises to Try Right Now.

Sometimes coming up with exercises in your clinic room can be difficult. Even more difficult is finding some that you can recommend as good home care.

Last week we went over how to do a great exercise called the “Dead Bug”.

This week we’re basically going to flip that over and progress the exercise to something called the “Bird Dog”.

What I love about these, is you can do it right on your table, and they’re easy for a patient to do at home.

Once your patient is confident with doing this exercise on top of the swiss ball, we can make things more difficult by removing the swiss ball.

This can still be easily done on your table in your clinic room, but it’s just a bit more difficult and will build a bit more confidence than when you’re using the swiss ball.


Now we can ramp things up just a bit more after your patient is confident with these movements.

By using an exercise band we can make things just a little more difficult and still build more confidence in movement with our patients.

Give these a try.

Doing movements like these will reinforce everything you did with your hands on the table and bring about greater outcomes with your patients.

If you’d like to learn more on how to incorporate more things like this into your treatments, and generate greater outcomes, register for our newest online course “Clinical Applications Of Pain Management Using Therapeutic Movement” by clicking HERE

4 Ways to Bring These Low Back Exercises to the Next Level

The dead bug is one of the more popular exercises to help strengthen the low back. However, there are mutliple variations you can use in order to help your patients rehab a low back injury, or even non-specific low back pain.

Here are just a few variations you can use, starting with the simplest version.

Once your patient is really comfortable doing this simple version, and can do it with minimal discomfort for how ever many reps and sets you decide, then you can start to make it more difficult.

This next version is good as you’re more involved in the exercise with them. 

Just grab an exercise band and give them some tension while the use the band to stabilize the shoulders and strictly use the lower body for the movement.


This next version is only providing some stabilization through one shoulder, while the other shoulder and opposite leg do the work. 

If you don’t have a dumbbell or weight in your clinic, you can stand to the side with an exercise band and provide tension similar to how you did it in version #2.

This final version also involves an exercise band and makes the exercise just a bit more difficult, and a bit more coordinated.

If your patient is able to do all of the above variations this is a great option to continue increasing the difficulty and helping your patient with their low back strengthening.

As always your reps and sets will be up to your clinical decision making along with combined goal setting with the patient. Doing therapeutic movement with your patients doesn’t have to be complicated and most of what you need to do can be done right in your treatment room.

We just have to instil the confidence in patients that they are capable of doing it, while working together with them in their goal setting. Be confident and try doing some more exercises and movement with your patients. It will not only benefit them, but your practice as well. 

3 Exercises To Help Patients With Back Pain

As you know, we’re big advocates for therapeutic exercise around here.

This is one of those occasions where I’ve had to do some self care to help a little pain spot I deal with. On the left side of my mid to lower back I get this one little spot that flares up once in a while. so I went to a friend of mine to get a little work done in the area.

They recommended doing some back extensions on a machine at the gym, however, most of us don’t have access to a gym in our clincs.

So, I figured out a way that any of us could do some effective therapeutic exercise right in our treatment rooms just using a theraband, and here’s what I came up with.

Here’s how to do an Isometric, Concentric, and Eccentric load for extension.


Here’s some ideas for rotation.

Another great exercise for rotation is the Palloff Press (also one of the exercises my friend recommended for me). This is usually done with a cable machine at the gym but can easily be done with a theraband as well.


  • Communication with your patient regarding comfort level for length of time and repetitions are key.
  • Start with isometrics, then move on to concentric, then eccentric.
  • Remember, a bit of discomfort is okay, just don’t cause pain with the exercise.
  • Make sure your patient is comfortable doing the eccentric portion as it may cause more muscle soreness.

What Kind of Exercise is Healthiest?

Physical activity is now considered one of the “big four” lifestyle factors (along with smoking, nutrition, and drug abuse) that have major effects on health. In 2015, the Academy of Medical Royal Colleges put out a report summarizing the benefits of exercise, calling it both a “miracle cure” and a “wonder drug.” [1] The report observes that regular exercise can prevent dementia, type 2 diabetes, some cancers, depression, heart disease, and other common serious conditions — reducing the risk of each by at least 30%. This is better than many drugs.

A recent analysis of data from more than 60,000 respondents found that people exercising 1-2 times per week had a 30% reduction in all-cause mortality compared to those who got no exercise. There was a 35% reduction for people who exercised 3-5 times. [2] Similar studies have concluded that a sedentary lifestyle is a primary cause of 36 diseases, and that exercise is an effective treatment to prevent them. [3, 4] Numerous experts have observed that if exercise came in a pill, it would be the most effective and widely prescribed medicine ever developed.

While the evidence supporting the health benefits of exercise is undeniable, I don’t find the metaphor of it being “medicine” totally appealing. First, medicine is something most people would rather not take, so the marketing is not very good. Second, the term medicine suggests cure of a particular disease, which is misleading.

Physical activity can improve your health in many different ways, just as light, water and soil will nurture a plant. But it’s not a targeted intervention that “fixes” a specific problem.


I think a better metaphor for the benefits of physical activity is one recommended by Katy Bowman and Nick Tuminello: movement is like food. This analogy works on many different levels. First, nutrients in food are beneficial when consumed in some goldilocks amount — not too much and not too little. For example, you need a minimum dose of iron to avoid anemia, but too much is toxic. Many kinds of inputs to the body follow this pattern, even water. With physical activity, some minimum amount is essential, too much is toxic, and there is a broad range of happy mediums.

Another analogy between food and movement is that you need a well-balanced diet of many different nutrients, all of which have a different optimum dose. If you have a deficiency in Vitamin A, it won’t help to double up on Vitamin B. The same is true of physical activity. The bench press is a fine exercise, but if that’s all you ever did, you would become deficient in other areas of physical function.

If movement is like food, how do you eat a balanced diet? Part of the answer is that … it depends. A twenty-year-old athlete will need a different diet of movement than a 65-year-old with knee pain. In fact, two 65-year-olds with knee pain might benefit from completely different programs. To find what works best for an individual, you will need to explore a wide landscape of different options. The good news is that some parts of the landscape are more worth exploring than others. To get a rough idea where they are, we can look to two sources of data: (1) formal recommendations from government health groups; and (2) research analyzing the physical activity of hunter-gatherers living in natural environments. I think of these guidelines as major landmarks for orientation on the movement landscape. Fortunately, they both point in the same basic direction.

Recommendations From Health Groups

Numerous governmental agencies, including the World Health Organization, the U.S. Department of Health Services, and the National Health Service in the U.K., have published physical activity guidelines. [5, 6] They are based on expert analysis of the voluminous research looking at physical activity, fitness, and health. Here is a brief summary of their advice, which is almost the same for each source.

The Amount

The guidelines suggest at least 150 minutes per week of “moderate” physical activity or half as much “vigorous” activity. (See below for definitions.) But this is just the minimum, and a better goal would be 300 minutes of moderate activity per week. Adding more exercise may continue to reduce mortality until as much as 750 minutes per week, after which point the health benefits of physical activity seem to flatline. [7]

“Moderate” Activity Defined

Moderate activities are usually light aerobic exercise — continuous cyclic movements done at an easy pace. Examples include:

  • brisk walking

  • hiking

  • gardening or yard work

  • jogging, cycling, or swimming at an easy pace

Moderate exertion feels like you are working, but not in a way that is unpleasant or difficult to continue. Heart rate is about 60-80% of maximum, and breathing rate is elevated to a point where it would be difficult to sing, but easy to talk. You may break a light sweat but will not become significantly overheated. After finishing a session of moderate physical activity, you could probably complete another one if necessary.

“Vigorous” Activity Defined

Vigorous activity is higher intensity work that can be either continuous or intermittent. Examples include:

  • resistance training with weights, machines, bands, or bodyweight

  • sprinting or high-intensity interval training on a cycle or rowing machine

  • continuous running, cycling, swimming, or rowing at a challenging pace

  • heavy manual labor

During continuous vigorous activity such as running or cycling, you are approaching the fastest pace you can sustain for twenty or more minutes. Your breathing rate is high enough that you cannot have a conversation. Intermittent activities like weight lifting, sports or sprinting cannot be performed continuously, but only in intervals. Vigorous physical activity feels hard and requires willpower to continue. When you are finished, you will probably want to rest at least a day before completing a similarly tough workout.

Movements That Challenge Strength

Most guidelines recommend that the above weekly totals should include at least two sessions that maintain or build strength in all major muscle groups. Although the majority of research on physical activity relates to aerobic exercise, there is a large and growing number of studies showing equally impressive health gains from strength training. Some of these benefits are not available with aerobic exercise, especially preservation of muscle mass, which declines with age, often to a point where function is significantly compromised. [8]

Movements That Challenge Mobility And Basic Coordination

Some popular guidelines, but not all, recommend inclusion of movements that maintain functional ranges of motion, and basic movement skills like squatting or single-leg balance. This doesn’t mean you need exercises specifically devoted to this purpose, such as stretching or corrective exercise. Many common activities challenge mobility and functional movement skills, including dancing, swimming, martial arts, gymnastics, climbing, calisthenics, or classic compound strength exercises like pushups, pull-ups, rows, presses, squats and lunges. On the other hand, if all you do is bike or run, you will not be challenging your mobility or coordination very much.

Physical Activity Levels Of Hunter-Gatherers

Another way to approach the question of how to move is to consider the physical activity levels of humans living in more natural environments. This is the same logic you would apply to analyzing the health needs of any other animal. If you had a pet cheetah and wanted to know how much running she should do to maintain good health, you would try to learn something about how much cheetahs run in the wild. If you had a pet chimp, you would take him to the climbing gym, not the swimming pool.

Anthropologists who study hunter-gatherer cultures observe that they generally enjoy excellent health and fitness, and have low to non-existent rates of chronic diseases associated with a sedentary lifestyle. [9] They engage in high levels of physical activity, but certainly do not consider it to be exercise or medicine. [10] Movement is simply inseparable from almost every meaningful event in their lives. Although each hunter-gatherer culture has a different lifestyle, there are some general patterns and averages that are informative.


Men usually spend the day hunting, which requires lots of walking, occasional jogging, and the odd sprint. They sometimes climb trees, dig to find tubers, and carry food back to camp, which must be butchered. Women generally spend their days gathering plants and also caring for young children, who often must be carried. Back at camp, men and women engage in toolmaking, and food preparation. Downtime is spent sitting on the ground in positions like squats that challenge lower body mobility. [9]

Although they are moving all day, the pace is not grueling. Recent studies on the Hadza tribe in Tanzania show that they do about 135 minutes per day of moderate to vigorous physical activity. [11] That’s about 900 minutes of activity a week, just a bit past the point at which recent studies have found that adding more exercise stops providing any significant additional health benefits in terms of reduced mortality.

Some days involve hard work, but they are usually followed by easy days. Presumably, some days will involve maximum intensity effort, such as sprinting or carrying a heavy load. Interestingly, activity levels do not decline much with age. The 65-year-old elders keep up just fine with the young adults. A good percentage of the total workload is walking 5-10 miles per day. If you think in terms of steps, this is about 10 to 20,000.

How does this organic, all-natural program for fitness compare to the standard-issue government cheese? There are some obvious similarities. The majority of the work is moderate continuous movement like brisk walking. Vigorous activity is a smaller percentage of the whole and includes work that challenges strength (climbing, digging, carrying, butchering) or power (sprinting).

Many of the activities require mobility, coordination, and balance, such as walking over uneven terrain, climbing, and scrambling, digging, lifting and carrying odd-shaped items, throwing, and sitting on the ground. One major difference is that hunter-gatherers do a higher volume of low-intensity work, even compared to highly active modern humans. They are not doing more bench presses, but they are getting in more steps.

Interestingly, walking is exactly the type of physical activity that modern humans would probably like to do quite a bit more, if only they had the time. Paddy Ekkekakis studies motivation to exercise and observes that although high-intensity exercise is quite effective at delivering health benefits quickly, most people don’t do it because … (prepare to be shocked) … they don’t like it. But people tend to enjoy walking. Under the right circumstances, say being with a friend in a nice environment, they do not consider it to be exercise at all, but an enjoyable and invigorating experience that delivers immediate rewards.

Another notable feature of walking is that it provides health benefits with only a minimal risk of injury. More intense exercise (e.g., a set of barbell squats) offers a relatively narrow window between too much and not enough. The difference between a good workout and an injury might be just a few extra reps or plates on the bar. But the margin of error with walking is huge. After a healthy dose of walking, most people could double it and recover easily.

It makes sense that walking delivers the highest bang for your buck because this is the movement we are best adapted to perform. Like any other animal, our primary physical function is locomotion, and walking is the most energetically efficient way to get the job done. If you did nothing else but walk a lot, you’d be in better shape than most Americans.

A Quick Summary

If you want to “play” with fitness as a way to improve general health, here are some “rules of the game” to keep in mind. Have as much fun as possible within these basic constraints:

  • Aim for at least half an hour and up to two hours of physical activity almost every day.

  • Movement should be varied in terms of volume, intensity, and type. Most activity can be fairly light. Walking is the most natural and beneficial movement for human beings.

  • Every few days, include some high-intensity work that significantly challenges your strength, power, and/or capacity to sustain high energy output for a short period of time. Climbing, running and resistance training are logical choices.

  • Include movements that challenge coordination, balance, and range of motion.

Or to put this in even simpler terms:

  • Move around a lot at a slow easy pace.

  • Frequently move with some urgency or pick up something heavy.

  • Every once in a while, move like your life depends on it.

And have fun!

Physical activity isn’t like taking medicine, you know.

PlayingWithMovement_Cvr_5.2.19evensmaller copy.jpeg

The preceding was an adapted excerpt from my new book called Playing With Movement: How to Explore the Many Dimensions of Physical Health and Performance.

In Defence Of The Advice To Remain Active For Back Pain

There has recently been some discussion around a lack of evidence for the advice to remain active during back pain. I personally believe there is a lot of value in the advice to stay active and here is why!

Firstly this HERE is from the folks over at Cochrane.

“Moderate quality evidence shows that patients with acute LBP may experience small improvements in pain relief and ability to perform everyday activities if they receive advice to stay active compared to advice to rest in bed. However, patients with sciatica experience little or no difference between the two approaches”

It is important to highlight the current state of play with regards to the evidence base, that there is MODERATE evidence of a SMALL relief for pain and this pretty much is in line with most other current recommendations/treatments that we have for back pain at this point.

Now I am going to give you a bit of my opinion as well!

Being active, IMO : ),  is NOT a treatment. It’s about being a human being and getting on with your life even though you have this very normal part of the human condition…..back pain.

It’s About Belief

Certainly, we don’t want to demonize the idea of resting or taking it easy if things are too painful, that is not evidence-based either, but we also know that the dominant view of back pain seems to be that we should rest it out and that for quite a few people the belief is that activity can be problematic for back pain.

This is highlighted in the two papers below that look at people’s opinions around what affects pain in the positive AND negative.

Darlow 2014 – Beliefs about back pain: The confluence of client, clinician and community.

Setchell 2019 What decreases low back pain? A qualitative study of patient perspectives

We also have two recent papers that form an interesting pairing when viewed together. Firstly we have a self-reported perspective of what triggers back pain flares from anyone who had had back pain at any previous time point (so maybe more a test of perceptions?). Here they found that physical activities and movements dominated the vast majority of the cited reasons for flare-ups

Costa 2019 – What Triggers an LBP Flare? A Content Analysis of Individuals’ Perspectives

Then we have a paper that looked at the same subject but asked the people to report it in a different way (longitudinally), at 3-7 day intervals over 6 weeks, and they found that physical activities were not so related to flares of back pain.

Suri 2018 – Do Physical Activities Trigger Flare-ups During an Acute Low Back Pain Episode?

The implication might be that when we ask people to remember what triggered their back pain it is a simple ‘go-to’ blame physical activities (especially when other things are not considered), but when the flare-up is more recent, 3-7 days, and presented with different reporting options the association between physical activity and flare-ups seems to decrease.

This highlights for me societal beliefs around the back and its relationships with activity and that we should be counteracting this idea in healthcare as much as possible!

It’s About Positive Messages

Overcoming some of the negative beliefs that we have around the body, pain and physical activity should be a goal of healthcare interactions. There are SO many NEGATIVE messages that we need some positive ones too.

I think the advice to remain active is such a message. Trust your body, get on with things, you will be OK! This is a strong, simple, and important message from my perspective.

There is the very real potential that there is not that much that can be done in the short term for acute back pain with advice and reassurance being pretty much all we have.

But could our short term attitudes impact on the longer term?

Short Vs Longer Term

What we do seem to have some data on is that having low pain self-efficacy, or the ability to go about our lives WITH back pain, does appear to have some relationship with outcomes of back pain in the longer term (this also seems to be apparent in other MSK conditions). In this paper HERE from Foster – 2010, we see that low pain self-efficacy is related to worse disability outcomes at 6 months.

The question is how do our own attitudes, and other people’s attitudes as well, towards our backs influence our behaviours? Food for thought perhaps?

Key Messages From Advice To Remain Active

Hurt does not equal harm – It’s OK to function with some pain, especially if it is not worsening and within tolerable levels. Pain does not give a reliable indicator of what’s happening within our bodies.

Rest is not the best treatment – Resting the back is unlikely to simply make it better and not much is likely to significantly change how the back responds in the short term.

Activity is not bad – Activity is not simply related to pain or damage. In fact limiting activities you enjoy might actually make the impact of back pain on your life worse.