IS EXERCISE AN “ALTERNATIVE” TO PHARMACOLOGICAL TREATMENT OF CHRONIC PAIN

Chronic pain conditions can be divided into two dominant tiers. First ones can be of objective pathogenic, genetic or biologic origin and can easily relate to symptom while second ones are those with unknown origin. Arthritis, systemic inflammatory rheumatic diseases, connective tissue diseases, post-herpetic neuralgia, and peripheral neuropathy, fall under the first category and are typically diagnosed via objective biologic or inflammatory markers, radiologic evidence or other identifiable symptoms. Chronic pain conditions of idiopathic origin conditions include fibromyalgia (FM), complex regional pain syndrome (CRPS), chronic widespread pain (CWP), subsets of chronic low back pain (LBP), and chronic pelvic pain (CPP). These syndromes incessant pain and many other health conditions such as fatigue, sleep disturbance, cognitive deficits and depression.

Chronic pain is a serious public health concern that indiscriminately affects vulnerable populations, such as the elderly, children, and those who are already having compromised immunity due to other health conditions. 

Recent estimates suggest that chronic pain affects almost 1.5 billion people worldwide, figures that are steadily rising. According to the Australian Institute of Health and Welfare (AIHW), one in every 5 Australians aged 45 and over are living with chronic pain conditions which can be disabling and stressful. This report also states that more people are seeing their general practitioner (GP) for chronic pain and patient encounters have risen by 67% over ten years. A total of 105,000 hospitalizations were reported in 2018 and chronic pain cost reached an estimated $139 billion in Australia.

Arthritis is one of the chronic pain conditions which is highly prevalent. Low physical inactivity is another factor which may contribute to the rise in chronic diseases. World Health Organization suggests insufficient physical activity as a leading risk contributor to rising non-communicable diseases and death worldwide. Physical inactivity or sedentary behavior is common in all ages, manifesting many chronic diseases both in older populations and younger age groups.

With no cure for many chronic pain conditions, physical exercise, or physical treatments address symptoms such as pain, reduced functional capacity, poor sleep, fatigue, joint immobility, cognitive dysfunction, depression and anxiety. Non-pharmacological therapies are an increasingly important ingredient for chronic pain management. Cognitive-behavioral therapy is a classic example, which uses behavior correctional strategies to effectively reduce pain and fatigue, improve sleep, and overall physical function. Therapies once considered “alternative” such as acupuncture, mindfulness meditation, yoga and relaxation have now become accepted forms of chronic pain management with clinical trials demonstrating efficacy for pain and physical function.

Increasing evidence favors physical activity as beneficial for many chronic illnesses including cardiovascular disease, type 2 diabetes, obesity, and cancer. It has also been observed that physical exercise tends to reduce the mental and behavioural impact of chronic illness through improvements in overall wellbeing and independence. Reduced pharmacological healthcare-seeking and workplace absenteeism are the socio-economic factors which have seen improvements due to the increase in approach to treatment involving physical activity. Overall health benefits are undeniable, regardless of whether physical activity is accomplished via lower intensity exercise or activities of daily living, movement therapies, or higher intensity exercise associated with cardiovascular fitness gains. It’s hard to say that a single model can provide staggering symptom relief for chronic pain patients; rather, multimodal treatment approach including pharmacological and non-pharmacological management strategies appear to be most effective.

Historically, favourable evidence for physical activity varies with the quality of randomized trials. However, results from these trials have supported physical activity as a beneficial treatment model for chronic pain, physical function, sleep, cognitive function and overall health and well-being. Aerobics is one of the ancient physical exercises that have long been studied as a treatment for chronic pain. Aerobics includes both land-based exercise, such as walking and stationary cycling, and aquatic exercise. 

Several studies have explored the economic impact of physiological treatment of chronic pain. Allied health and community-based exercise programs which require special facilities, assistive technology equipment and professionally trained instructors, can be costly and inaccessible financially for some patients, consequently failing to provide outcomes significantly better than pharmacological treatment. Alternatively, self-directed physical activity can be inexpensive, requiring minimal resources such as walking, cycling, and swimming but higher cost remains a problem for individuals who have conditions which restrict them from even such simple exercise routines. Making community-based exercise models more feasible, less costly, and more attainable with guidelines that promote user-friendly interface, more safety, and educating patients can positively improve the impacts of physiological treatment.

Outcomes of physical activity

Pain: For most chronic pain patients, participating in physical activity is beneficial to reduce pain. It has been observed in recent studies that exercise programs that include a range of activity such as aerobic, resistance, and flexibility exercises, are more effective at significantly reducing pain in patients with Fibromyalgia (FM), Chronic Lower Back Pain (CLBP), and Rheumatic Arthritis. In Fibromyalgia patients, low to moderate intensity warm-water pool exercises performed twice per week, had an immediate positive effect on pain. Also, strength training resulted in significant improvements in pain in FM patients. According to an experimental study, eight weeks of yoga consisting of 2 hours of supervised sessions per week and a little extra home practice, improved pain in 22 FM patients.

Functionality: Improving physical function is nearly as important as reducing pain for patients with chronic disease. Similar to pain, physical activity program based on combination of various exercises such as aerobic, strengthening and flexibility exercises can improve physical function significantly. Movement therapies such as Tai Chi and yoga improve strength, balance and mobility as well decrease anxiety and depression, which subsequently yield improvements in physical function for patients with chronic health condition.

Sleep and fatigue: Sleep disturbance and fatigue is common among individuals with chronic pain conditions. Fibromyalgia patients frequently suffer from non-restorative sleep and it is reported often by patients making it one of the most complained effects behind pain and fatigue. Chronic pain patients specifically experience difficulty falling asleep, restlessness upon awakening and difficulty starting the day. Pain, stiffness, fatigue, and attention deficits are often associated with poor sleep quality and quantity in chronic pain patients. While it is evident that engaging in physical activity improves sleep, the effect is reciprocal. Findings from various studies emphasize the importance of improving or maintaining good sleep for reducing fatigue, staying active and enjoy healthy lifestyle.

Depression, anxiety and mood: Depression and anxiety are also common among chronic pain patients with highest number of Fibromyalgia patients reporting depressive symptoms. Furthermore, poor muscle strength leads to increased inactivity, hence increased depression, anxiety and reduced quality of life. Depression can be a great challenge for maintaining physical exercise routine especially when social or psychological support is lacking. As physical activity is commonly believed to elevate mood and mental health in the general population, the effect equally extends to chronic pain patients. It has been observed that patients who participate in active pain management programs also had significantly less depression than those who did not engage in these exercises. A wide variety of activities appear to improve depression, including aerobic exercise, muscle strengthening, and movement therapies.

Inflammation and related outcomes: Individuals with chronic pain conditions sometimes exhibit systemic inflammation as a result of their condition. Physical exercise is known to mitigate cellular inflammation. Many researchers have suggested that higher frequency of physical activity incur a greater effect on systemic inflammation. According to health specialists, after following 4 months of twice weekly aquatic exercise, inflammatory condition can immensely improve. Evidence from past studies also supports the importance of consistency of physical activity maintained throughout the week. Peripheral Neuropathy patients have shown promising improvements in nerve function and reduced pain and sensory disorder, by performing flexibility exercises such as Aerobics.

Patients’ efforts to adopt and maintain physical activity and to achieve successful outcomes are often barred by psychological and social issues. Fear of injury, avoiding social interactions and certain beliefs and behaviors are common barriers to increasing physical activity. Fear of falling is a main contributor to sedentary behavior in musculoskeletal pain patients and fear of increased pain is a barrier to activity among patients with Fibromyalgia and Chronic Fatigue Syndrome.

Individuals suffering from chronic pain usually have varying level of self-efficacy.  It is normal for these patients to doubt their own ability to complete tasks or reach health related goals. Inadequate disbelief in exercise is undoubtedly a considerable barrier to increasing physical activity. In patients with RA, physical activity time is not related to pain but with self-efficacy for physical activity. Middle-aged to older adults prone to sedentary behavior require more support, monitoring of adherence, and individual tailoring of exercise programs to promote self-efficacy and exercise routine maintenance.

 Combination of pain, poor sleep, depression, anxiety, fear-avoidance beliefs, and poor self-efficacy for physical activity can negatively impact motivation. Developing custom tailor-made exercise packages which best suit an individual’s condition can significantly contribute to patients’ motivation, self-confidence and adherence. Celebrating patients’ “success”, symptom reduction, and verbally encouraging them induces motivation for physical exercise. It cannot be denied that physical exercise can be a great way to treat individuals with chronic pain. However, combined with pharmacological treatment options, and working to elevate morale and boost self confidence of the patient, amusing results can be achieved.