Exercising with Persistent Pain

The guidance in this blog can be used for people with and without persistent pain.  Many people know exercise is essential for the health of body, mind and brain.  We get modulation of pain perception, known as exercise induced hypoalgesia, from a release of helpful chemicals like endorphins and dopamine.  However, for people with persistent pain the way this works can be different and commonly, at least to start with, the mechanisms of exercise induced hypoalgesia can be inhibited and instead pain and/or fatigue intensify.  When this happens it is understandable that people stop exercising, although not helpful in the long-term as it causes, such as: deconditioning, increases fear-avoidance of many activities, decreased functional ability, and it can sensitise already sensitized systems further.  The great news is this can change with understanding, regular practice, patience, time and modifying some variables.  I ended up losing a lot of exercise tolerance 7 years ago when I gradually stopped exercising following a back injury, I didn’t know then what I know now and it’s one of many reasons I am passionate about helping people with ongoing pain live well.  It took a lot of time, practice and patience to change and it was a gradual process

On a side note to exercising with ongoing pain we need to all remember to take regular movement breaks during the day.  Exercising or being active for an hour after sitting all day is not enough.  We lead much more sedentary lives than we used to thanks to, such as, advancing technology and more use of our cars.  With the pressures of modern living it is important we think of ways to add in more regular movement into each day, creating new movement habits with regular practice.  Maybe this could include walking to work, parking the car further away from work or getting off the bus a few stops earlier, going to speak to someone in the office instead of sending an email, doing some squats whilst the kettle boils, standing during a phone call and going lifting alternate heels, there are many possibilities!  During the day remember to take regular movement breaks, these little movement snacks will also help your concentration and attention as well as your body.

I have noticed some common questions from people with persistent pain, including:

1. What exercise is helpful?

When choosing the exercise consider:

  • Does it help you achieve your goals, maximize or maintain function?
  • Do you enjoy it?
  • Is it meaningful?
  • If there is a variety of the types of exercise (mix of cardiovascular, flexibility, strengthening)
  • Is the level achievable for you at present or do you need to modify some of the variables (see dosage tips below). Think of the Goldilocks rule – not too little, not too much, just right.
  • Do you feel confident in modifying the variables or do you need to explore this with a physiotherapist?
  • Do you understand your pain and have a toolkit that helps when you have a flare up?
  • Do you have an understanding of pain not necessarily being correlative of what’s happening in the tissues – hurt doesn’t equal harm?

2. How do I know what’s enough for me and how do I avoid pain flare-ups?

For ages 19-64 The World Health Organisation recommends 150 minutes a week (30 minutes a day) of moderate intensity aerobic exercise (e.g. brisk walk, cycling, slow swimming), or 75 minutes a week of high intensity/vigorous aerobic exercise (e.g. running, a game of tennis, fast swimming), and twice a week strengthening of all major muscle groups.  Moderate intensity and high intensity aerobic exercise can be mixed, it has been said 1 minute of vigorous/high intensity aerobic exercise equates to 2 minutes of moderate intensity.  This amount of exercise could be something for you to work towards.  For some people with long-term conditions it’s not achievable, which is ok as long as the level of exercise being done is enough for adaptability.

What’s enough for one person may be too little or too much for another so this needs exploration, if it’s not something you feel confident to do on your own a physiotherapist can guide you. Remember the goldilocks rule here – not too little, not too much, just right! The only way we find what’s best for us is by testing and exploring, we learn through experience.  It’s important to remember a little bit of pain flare-up with persistent pain is ok, by a little I mean that it settles within 24 hours and doesn’t affect your daily function.  We need enough challenge for adaptability of body and nervous system and this can mean a little flare-up, sometimes we initially aim for no flare-up to build confidence and calm things down, we need to remember to build things up.  Start where you are at, find your baseline, if you have persistent pain this baseline needs to be a level where you don’t have a big flare-up that lasts a few days or longer (in the traffic light system below that’s red).  Find a level that feels achievable and comfortable for you.


The traffic light system:

You mainly want to be exercising in the green, amber is ok yet either needs increased awareness, a little adjustment to proceed, or modulation to change to a green light.  An amber light can mean too much too fast and needs evaluation, red is stop and significantly modify what you are doing and possibly seek guidance from a physiotherapist if needed.

Red – there is a severe flare-up during the exercise, 7 or more on a 0-10 scale, you don’t feel safe/are worrying about causing more pain or damage.  The pain flare continues after exercise for between 3 days and several weeks and you have a significant loss of ability in your daily function.   You need to stop when in the red, seek advice from a physiotherapist if you are often in the red.

Amber – pain flares during activity of 4-7 on 0-10 scale, yet you know you are safe.  This is a pause and proceed with awareness light, notice what happens as you continue and if things are settling or not continuing to intensify continue for few repetitions or 1-2 minutes. Afterwards pain persists by up to 3 numbers above your baseline and settles back to baseline within 24-48 hours, and only minimal effect on daily function.  If the after affects are longer or function is more affected make sure the next time you are in amber you modulate to green.  You may need to use some tools from your pain flare toolkit to help things settle.

Green – pain flares during activity 0-4 on 0-10 scale and settles in less than 24 hours with no loss of function.

When you know your baseline work there for a week, with a green traffic light, and if you feel confident to increase this the following week add a small amount more e.g. 5 more minutes duration or a 1-5% increase.  Remember hurt doesn’t equal harm, yet with ongoing pain when the body and nervous system are sensitive we need to calm things down, so working in green is the most helpful place to be.  We need enough challenge for adaption which may mean a little flare up, as the green shows.


Dosage variables you need to consider and can modify:

(Think Goldilocks here!)

  • Frequency – how often you exercise each week
  • Intensity – exertion level or amount of weight lifting
  • Duration – how long each session is
  • Type – cardiovascular, strength, flexibility/mobility
  • Load – all the things that affect your homeostatic balance (e.g. sleep & stress)

If every day is too much for moderate intensity exercise start with every other day or even twice a week, it doesn’t matter where you start, remember it is more important that you know your baseline and make a start.  You could split the duration into two 15 minute moderate intensity aerobic exercise sessions rather than one 30 minute one to start with.  Make sure you do a mixture of exercise to include cardiovascular, strengthening and flexibility/mobility.

3. What to do if you have a flare up

  • If you have a big flare up it can be a result of a combination of factors, rather than just exercise, for example imagine you have slept badly for few days, have more stress at work (increased load on your systems affecting homeostatic balance) and you do your usual level of exercise and experience a big flare-up and instead of being in green on the traffic light system you are in amber tipping into red or maybe you are in the red.  When this happens reflection on all the factors affecting you is important, modulate what you can and seek help when needed.
  • What traffic light are you using, make sure you are in the green and re-evaluate your baseline.
  • What tools do you have in your toolkit to help (e.g modulate activity, a little more rest between activities, meditation, hot bath).
  • If having repeated flare-ups that you are struggling to manage seek help from a physiotherapist.

A few tips for awareness & modulation of mind & body when exercising with persistent pain:

  • Notice what you are thinking – do you feel safe or are you worrying about a pain flare? If you don’t feel safe, make some adjustments so you do and then re-evaluate.  If you are worrying about making pain worse it usually does as systems are already on high alert.
  • How are you feeling? Do you feel confident and safe or do you feel unsure and anxious?  If it’s the latter what can you do to change it, what do you need to know or feel to feel more confident and safe to exercise?
  • Notice what happens to your breathing, are you holding your breath? If so can you soften your breath. Remember your breathing will change with moderate intensity exercise.
  • Are you holding more body tension than is needed? Can you modulate it? If not change what you are doing to make it a bit easier & re-evaluate.


Tips for sticking to your exercise routine:

  • Know your strongest motivators.  I talk to people about peeling back the layers like removing layers on an onion until you get to the core.
  • Exercise with a friend or family member.
  • Make sure the exercise you choose is enjoyable and/or meaningful to you.  Have fun, play, and be creative.

  • Vary your exercise, maybe every 4-6 weeks, even a small change is helpful.  This is helpful for physical adaption as well as mentally.
  • Set aside some time each day, if something else gets in the way that’s ok you can adjust your timetable.   If it is commonly being replaced by other things look at why: maybe you haven’t yet revealed your deepest motivators, maybe you are anxious about causing more pain, maybe you don’t enjoy the exercise you are doing, maybe you are not seeing changes and are wondering if it’s really helpful (you may need to seek help if this is happening or you may be able to explore and make changes yourself).
  • Keep a record of what you have done each day you exercise.  Reflect on this at the end of each week and then plan next week’s exercise.



In summary, understand: what exercise you enjoy and what exercise is meaningful to you, your motivators, where your baseline is and think green traffic light; that there are different variables you can modulate in the dosage.  Remember hurt doesn’t equal harm and change is always possible.  Make regular movement snacks part of your daily routine. Seek help from a physiotherapist if needed.

Freedom from pain & energy

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