Retirees trying their hand at a “towel exercise”. Growing evidence suggests that an exercise prescription – a specific plan of fitness-related activities designed for an individual – could help lower the severity of chronic pain and improve quality of life.
SINGAPORE – A single physiotherapy session was all it took to convince general practitioner Colin Lim, 53, that the right exercises could help to alleviate the aches and pains in his knee.
An avid futsal player for almost two decades, Dr Lim suffers from osteoarthritis, a condition that occurs when cartilage or cushioning between joints breaks down, leading to joint pain, stiffness and swelling.
He started experiencing pain in his left knee about two years ago. It also led to aches and pain in other parts of the body, such as the glutes, when he inadvertently started using other joints and muscles to compensate for the affected knee.
As part of his treatment, Dr Lim was referred to a physiotherapist who prescribed a series of exercises, such as wall sits and lying clamshell. He was surprised that the exercises, though simple, effectively staved off his knee pain.
“I have a certificate in fitness training and used to despise some of the exercises prescribed because I found them too easy. I did not expect such a great reduction of pain after doing them. In fact, I felt so ‘light’ I wanted to go out and play football,” he said.
Exercising may seem counterintuitive for people suffering from chronic pain. But growing evidence suggests that an exercise prescription – a specific plan of fitness-related activities designed for an individual – could help lower the severity of pain and improve quality of life.
An estimated 60 to 80 per cent of chronic pain patients seen at the Singapore General Hospital (SGH), which runs a pain management centre, are referred to a physiotherapist for assessment and suitability for an exercise prescription, said Dr Diana Chan, a consultant at SGH’s department of anaesthesiology.
This is part of its multidisciplinary, holistic approach to managing chronic pain, which includes other treatments such as an individualised medication regimen, patient education and psychotherapy for self-management of pain.
SGH, which has extended its pain management services to Sengkang General Hospital (SKH), sees more than 6,000 patients with chronic pain each year. Among the most commonly seen types of chronic pain are low back pain, neck pain, headaches and nerve-related pain such as painful diabetic neuropathy.
“Medications and surgery are only a part of the treatment regimen for chronic pain and one should not solely rely on these. An exercise prescription, in addition to medical treatment, could increase the effectiveness and cost-effectiveness of pain management,” said Dr Chan.
Dr Darren Leong, a senior staff registrar at Changi Sports Medicine Centre at Changi General Hospital, usually prescribes exercise for patients with fibromyalgia (a medical condition characterised by chronic widespread pain and a heightened pain response), osteoarthritis, chronic neck and back pain.
A NATURAL PAINKILLER
Natural painkillers known as endorphins are produced by the body with exercise, said Dr Leong.
“The (pain-relieving) effects can actually be felt on the same day. After a bout of exercise, pain tolerance increases for up to an hour, depending on the exercise activity,” said Dr Leong.
Endorphins also help improve mood and emotion, and reduce stress. These mood-lifting effects are particularly useful in patients with tension headaches, migraines and fibromyalgia, said Dr Chan.
While medication helps in situations when pain is inflammatory – for example when there is a flare of osteoarthritis or in autoimmune conditions – exercise could help some patients with chronic pain cut down on painkillers, said Adjunct Assistant Professor Ivy Lim, a consultant at Changi Sports Medicine Centre.
For instance, in osteoarthritis and other joint pains, weight loss that occurs with exercise and addressing modifiable factors such as muscle weakness, inflexibility or imbalance, may help reduce abnormal loading of a joint. This in turns reduces pain and the need for painkillers, said Adj Assistant Professor Lim.
Adj Assistant Prof Lim and Dr Leong will be presenting topics on tailored exercise programmes for patients at the Medicine and Sports Conference at the Medical Fair Asia next Wednesday (Aug 29).
Every patient is different. When prescribing exercise, factors such as specific exercises that may aggravate pain, the patient’s current fitness and physical activity levels, personal preferences are considered when tailoring an exercise prescription, said Adj Assistant Prof Lim.
“For example, someone with knee osteoarthritis may be able to cycle but for someone with back pain that is aggravated by back flexion (forward bending of the spine), he may not be able to tolerate prolonged sitting on the bicycle,” said Adj Assistant Prof Lim.
“If we can address the patient’s ideas, concerns and expectations toward exercise, it would help get them listen to us and, hopefully, start becoming more active,” she said.
VICIOUS CYCLE OF PAIN AND INACTIVITY
Despite the numerous benefits of exercise, people with chronic pain often avoid physical activity. This fear-avoidance phenomenon is not uncommon among this group of patients, especially in those who tend to worry or have underlying anxiety issues, said Dr Chan.
“Some patients with chronic pain may feel that exerting themselves might increase pain. Those who have attempted exercise at higher intensities and suffered more pain, might not be comfortable returning to physical activity,” said Dr Leong.
When patients report pain with exercise, some doctors may not have the relevant expertise to evaluate the pain, and thus err on the side of caution by advising patients to avoid the activity, said Adj Assistant Prof Lim.
But inactivity could worsen pain, leading to a vicious pain cycle.
While “resting” may be helpful in acute pain conditions, patients need to realise that when pain becomes chronic, the pain signal transmitted to the brain is no longer a useful protective response to injury, said Dr Chan.
“For instance, when you touch a hot stove, you feel pain – this pain is acute and useful as it protects you from harm. Chronic pain, however, does not prevent any further harm. It just hurts,” she said.
Remaining active can help break the pain cycle, and patients who do suitable exercises tend to have a better treatment outcome than those who are sedentary and have a fear-avoidance attitude towards activity, said Dr Chan.
BEFORE YOU PUT ON YOUR RUNNING SHOES…
Managing chronic pain begins with patient education and understanding that it is not a result of further harm or damage caused by activity, said Dr Chan.
The doctors said it is normal for patients to experience discomfort when they become more active. The general rule of thumb is to “start slow, go slow” – this allows the body to adapt to cope with the exercise, said Dr Chan.
An exercise plan for a chronic pain patient usually starts with low intensity exercises, and builds up progressively. The exercise intensity is capped at a 10 per cent increment every three to five weeks, said Dr Chan.
Dr Leong said those who have never exercised should be assessed using the Physical Activity Readiness Questionnaire (PAR-Q). It comprises seven questions related to one’s health status.
“If you answer yes to any of the questions, you should seek clearance from your doctor before starting exercise,” he said.
When exercising with chronic pain, the motto is “know pain or no gain”, as opposed to “no pain, no gain”, said Dr Leong.
Adj Assistant Prof Lim said it is important for patients with chronic pain to have their pain baseline assessed by healthcare professionals, and to learn to differentiate between “good” pain (such as muscle soreness from muscle strengthening) and “bad” pain (an aggravation of their current injury or a sign of a new injury).
“Once patients have a better understanding of their pain, and learn to discern the type of pain that is okay to exercise with or needs further evaluation and management, they are often able to continue exercising and reap the benefits despite their chronic pain,” she said.
For now, Dr Lim is continuing with his futsal sessions but has learnt “not to chiong all the way” to avoid aggravating his knee. He has also continued to do his prescribed exercises diligently to control the pain.
“I’ve added some additional exercise moves of my own. It is said that doctors make the worst patients but I think I’ve been pretty good and have been doing the exercises,” said Dr Lim with a laugh.