If you haven’t heard about the health benefits of exercise in the last 10 years or longer, then you’ve probably been a hermit! Exercise can do all these wonderful things – help you lose weight, reduce heart disease, moderate insulin and blood glucose levels, improve your mental health, and yes! reduce pain and disability when you’re sore. (check this list out)
The claims sound suspiciously similar to the claims made by old snake oil merchants – or the amazing White Cross Electric Vibrator!
Well perhaps there’s a little more research supporting claims for exercise… but are those claims being inflated just a little? When it comes to pain, particularly persistent pain, perhaps so…
But before I launch into some of the problems with exercise research, I have another problem with “exercise” – and that’s the word itself.
According to Wikipedia (and no, it’s not an academic reference!!) “Exercise is any bodily activity that enhances or maintains physical fitness and overall health and wellness.” Winter and Fowler (2009) in an interesting paper looking at definitions of exercise, found that “exercise” and “physical activity” are essentially the same and differ only in terms of motivation/intent, finally arriving at this definition: “A potential disruption to homeostasis by muscle activity that is either exclusively or in combination, concentric, isometric or eccentric.” Whew! Glad we’ve got this sorted.
But given the sticky nature of our minds, and that very few of us are inclined to spend hours debating the technical details, the word “exercise” has picked up quite a few other meanings. For me it conjures up images of sweaty, lycra-clad blokes grunting in front of enormous mirrors while they heave on lumps of metal to the pumping rhythm of loud music (and the eyes that follow my every move). It also raises the spectre of school sports where I was inevitably the last person chosen for any sports team, the last to come in after every run, the person who got hit in the face by the ball, who got her thumb smacked by the hockey stick the week before my piano exams…
I’m not alone in my distaste for “exercise”. Qualitative researchers have often investigated how people with pain view exercise: “I get the comments that “It is not dangerous” and that “you are not going to be worse.” I do not believe it is dangerous … but actually it happens that I become worse after .… I know that the pain will increase. And they … talk to me about pain that is not like my pain.” (Karlsson, Gerdle, Takala, Andersson & Larsson, 2018)
Boutevillain, Dupeyron, Rouch, Riuchard & Coudeyre (2017) in another qualitative study, found that people with low back pain firstly identified that pain intensity interfered “any minimal physical activity, standing still in one spot, is torture” (line 1683); “if my back hurts, I don’t do any activity that’s for sure, I am not going to the garden and do some digging, that is out of the question! I have two children, if I am in pain and they want to play, my back hurts and I can’t play with them. My back hurts I can’t do it. It’s not that I don’t want to it is just that I cannot. I am unable to” (line 29). In turn, motivation for exercise was reduced “I don’t have any desire to exercise. A lack of motivation, even apprehension” (line 390); “there needs to be this spark to get motivated, and I just don’t have it” (line 1335). Along with the lack of perceived benefits for some: “Sometimes I try to exercise and then I’m in pain, looking back had I known it would hurt I would probably not have done it” (line 2037) “It can be harmful, I give you an example: I have a colleague with low back problems, similar to mine, and she loves to take step classes, but each time she exercises too much, she is in pain but continues. I think she should stop, it is quite dangerous for her” (line 378).
A systematic review by Slade, Patel, Underwood and Keating (2014) found that “Individuals were more likely to engage within programs that were fun and had variety than ones that were boring, unchallenging, or onerous because they disrupted daily activities.” They added that “Difficulties with exercise adherence and not seeing benefits of exercise were frequently attributed to lack of time and fit into daily life.” Quotes drawn from the studies included in this review show that lack of confidence, negative experiences at the time, and poor “fit” between the exercises selected and individual preferences influence whether exercise was carried out consistently.
At the same time as these negative views, many participants in qualitative studies report that they use “movement” as a key strategy for their daily management. Whether movement looked like “exercise” as prescribed by PTs or trainers is a little less clear – people use the word “exercise” to mean many different things, hence Karlsson and colleagues (2018) combined the term “physical activity and exercise”.
Now one very important point about exercise, and one that’s rarely mentioned, is how little exercise actually reduces pain – and disability. A systematic review of systematic reviews from the Cochrane collaboration found that most studies included people with mild-to-moderate pain (less than 30/100 on a VAS) but the results showed pain reduction of around 10mm on a 0 – 100mm scale. In terms of physical function, significant improvements were identified but these were small to moderate in size.
And let’s not talk about the quality of those studies! Sadly, methodological problems plague studies into exercise, particularly sample size. Most studies are quite small, which can lead to over-estimating the benefits, while biases associated with randomisation, blinding and attrition rate/drop-outs, adherence and adverse effects.
Before anyone starts getting crabby about this blog post, here are my key points (and why I’ve taken this topic on!):
- Over-stating the effects of exercise won’t win you friends. It creates an atmosphere where those who don’t obtain pain reduction can feel pretty badly about it. Let’s be honest that effects on pain reduction and disability are not all that wonderful. There are other reasons to move!
- Exercise and physical activity can be done in a myriad of wonderful ways, research studies use what’s measurable and controllable – but chasing a puppy at the beach, dancing the salsa, cycling to work, vacuuming the house, three hours of gardening and walking around the shopping mall are all movement opportunities up for grabs. Don’t resort to boring stuff! Get creative (need help with that? Talk to your occupational therapists!).
- The reasons for doing exercise are enormously variable. I move because I love the feeling of my body in rhythm with the music, the wrench of those weeds as they get ripped from my garden, the stretch of my stride as I walk across the park, the ridiculousness of my dog hurtling after a ball… And because I am a total fidget and always have been. Exercise might be “corrective”, to increase cardiovascular fitness, because it’s part of someone’s self-concept, to gain confidence for everyday activities, to beat a record or as part of being a good role model. Whatever the reason, tapping into that is more important than the form of the exercise.
- Without some carryover into daily life (unless the exercise is intrinsically pleasurable), exercise is a waste of time. So if you’re not enjoying the 3 sets of 10 you’ve been given (or you’ve prescribed to someone), think about how it might translate into everyday life. It might be time to change the narrative about movement away from repetitive, boring exercises “for the good of your heart/diabetes/back” and towards whatever larger, values-based orientation switches the “on” switch for this person. And if you’re the person – find some movement options that you like. Exercise snacks through the day. Jiggles to the music (boogie down). Gardening. Swimming. Flying a kite. Don’t be limited by what is the current fashion for lycra and sweaty people lifting heavy things with that loud music pumping in the background.
Boutevillain, L., Dupeyron, A., Rouch, C., Richard, E., & Coudeyre, E. (2017). Facilitators and barriers to physical activity in people with chronic low back pain: A qualitative study. PLoS One, 12(7), e0179826. doi: 10.1371/journal.pone.0179826
Edward M. Winter & Neil Fowler (2009) Exercise defined and quantified
according to the Système International d’Unités, Journal of Sports Sciences, 27:5, 447-460, DOI: 10.1080/02640410802658461
Geneen, L. J., Moore, R. A., Clarke, C., Martin, D., Colvin, L. A., & Smith, B. H. (2017). Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database Syst Rev, 4, CD011279. doi: 10.1002/14651858.CD011279.pub3
Karlsson, L., Gerdle, B., Takala, E. P., Andersson, G., & Larsson, B. (2018). Experiences and attitudes about physical activity and exercise in patients with chronic pain: a qualitative interview study. J Pain Res, 11, 133-144. doi: 10.2147/JPR.S149826
HealthSkills Blog 
I love this post! I can’t agree more. I have been in the fitness industry since 198… long asstimeago. And even then, in my 20’s I felt like the industry had it all wrong. That “exercise” wasn’t the way to go, that somehow as an industry we were missing the point! And leaving way too many people behind to sit on the couch because “exercise” didn’t work for them. And so I started teaching yoga…. well it was better but in the early 90’s not by much. in the west it became another mode of “exercise” and an even bigger point was getting lost. And so I started teaching movement, using all different kinds of movement and it might look like “exercise” or yoga to pilates or aerobics or stretching ( I don’t call it stretching anymore wither but that’s for another time) and breath work along with meditation and wow! how it has changed the way my students and clients think of …dare I say it “exercise”…. and now that I am older and God help me a bit wiser I hope I can see the wisdom of just getting people to move, to stop sitting quite so much. Thank you for a great post!
Yay!! At least one personal trainer who gets what I’m on about!! I know you’re not alone in thinking that we’ve made movement boring… let’s bring back variety and fun and enjoyment outside of the One Way To Do Exercise because humans were made to move!
Spoken as a true OT. Bronnie! I find it interesting that some people go to the gym 5 x week with a full set of exercise but it’s not translating much into valued and enjoyable activity, and not much is changing in their lives. The physio I work with advises the patients in our clinic that exercise is only the first step to explore how to move their bodies again before they progress on to doing the things that add value to their lives..
YES!! And occupational therapists have almost handed over the “engaging” and “participating” aspects of movement to other professions without so much as a murmur. We can also do movement with the people we hope to help!
An important element that is rarely mentioned is people with FMS have lower levels of circulating dopamine, which affects appetitive behaviours and therefore reduces both reward and affects mood and ultimately withdrawal.
Michelle Craskes work on Positive Affect Treatment using positive psychology techniques like savouring, gratitude, loving kindness had a marked affect on anxiety and depression.
It would seem this should be the starting point of treatment for FMS ( and likely general chronic pain states) as it seems logical that if appetite/ reward is boosted then people will more likely improve mood and feel the sense of reward or an appetite for exercise.
https://www.intechopen.com/online-first/chronic-pain-dopamine-and-depression-insights-from-research-on-fibromyalgia
Hmmm, ok. I’m gonna play devil’s advocate and say there is some “exercise” I will do simply because of the way my body feel AFTER I’ve done it (yah- I know, personal experience). If I can manage to run 1-2 miles, my body is simply floating- does it hurt? maybe. Do I sleep better? yes. Do I recover and continue to feel better the next few days? yes. If I dance for 45 minutes to great music I love and enjoy every minute of it, am I sore the next day? Hell, yes! Do I get that same high and feel like my body is part of the universe and my surroundings? yes.
My point- if you read this far- is that sometimes the activity may not be the most enjoyable, but dang it if the after high isn’t one of the best! Is there research to support this? of course.
Now, being an overactive child that could not sit still if you tied me down was most likely helpful, but teaching and showing people this principle is encouraging for me.
If you can find something you enjoy- that doesn’t hurt so much- even better! But as has been said above (trainer, OT, PT, coaches- everyone who likes to move) we are meant to move and when you stop- it hurts. I don’t think principles of movement are discipline specific- I think we are humans trying to survive abnormal circumstance and get out of our heads and back into out bodies….
For sure – you’re prepared to do things that hurt in the moment for the benefits afterwards. Nothing in what I’ve written suggests that (a) movement must be pleasurable (though it’s a bonus if it is); (b) movement must be pain-free (though it’s a bonus if it is); (c) movement doesn’t have benefits (but only if they’re meaningful to the person).
The points I’m making are that many clinicians fail to recognise that exercise is often a dirty word to people who experience pain and who had the kinds of experiences I had throughout school and afterwards, furthermore that many clinicians prescribe forms of movement that are unpalatable – in fact, I’d call it lazy.
Some clinicians fail to recognise the challenges faced by people living with pain, particularly women, where movement practices can take up precious time that’s not available and clinicians “prescribe” movements that won’t fit in to the person’s life even in the short-term let alone the long-term. It’s not commonly acknowledged that people with fibromyalgia just don’t get the post-exertional hypoalgesia OR the endorphin high from movement AND we get a two-week DOMS experience.
Let’s think about meeting where people are at, working with them, at their pace, nudging towards a more movement-filled life for LIFE, not just a rehabilitation programme.
Thank you so much for this post and acknowledging the real issues. I am a chronic pain patient. As I tell a lot of people who see me do some fairly strenuous activities for a person with a visible physical impairment: “Yes, this hurts. But any movement I am going to do is going to hurt, and the stress relief and the boost of mental energy I get from it is well worth it”. Yet the “snake oil” aspect of this can be extremely damaging. One of the lowest points in my life came 10 years ago when I was dealing with new, then-undiagnosed, acute pain issue. But I was funneled in the “chronic pain person that got more unexplained pain” route. One of my doctors told to me: “Just look at the impact of your decisions: you stopped exercising, which you say you enjoyed, and the pain is still there, you need to reconsider”. I am a woman and this is the one and only time in my life I though “I wish I could hit you to get you to listen”. I just started crying instead because at that point any attempt to exercise led to immediate and severe exacerbations: I would do my favourite activity for 15 minutes and then would not be able to sleep the night for the severe pain it caused.
I am ever grateful to the PT who recognized what was happening, diagnosed the issue, got me to stop and rest until the inflammation went down, and then helped me build up strength to be able to exercise again. She had a very explicit approach, too: “We don’t want you doing random movements for sake of exercising, we want you to be functional, engaged and life and doing the activities that you enjoy. So let’s find the physical activity that you like and therefore can sustain for the long term, start small and I will help you solve problems along the way”. This attitude really served me well since! I have a complex condition and I have needed other treatments since, but now when the next doctor proposes that I could do his “favourite” exercise or PT I ask: why would this be better than the regular exercise that I already do? What are the specific benefits and the evidence of effectiveness? How long will I need to do it and will it enable me to keep up with the activities I actually enjoy? Sadly, there seems to be a lot doctors who are convinced that “exercise is the cure” and I must be doing something wrong (or maybe misrepresenting my physical activity level?) and my problems will magically go away if I just do yoga(or reformer pilates, or…). Yet they are unable to point out to any concrete evidence that these would be beneficial compared to other regular physical activity. I learned to walk away from those, even if I get labelled “noncompliant”, because taking up things that I don’t enjoy tends to reduce the stress management benefits but doesn’t make any difference in my pain levels.
I love that you’ve found a way through this! And saddened that it takes so much energy to get listened to. I hope the more nuanced approach to movement becomes the norm – though the shouting matches on social media don’t fill me with a lot of hope…We need to keep reminding people that our lives are what matters – OUR lives, not theirs!