Exercise for chronic musculoskeletal pain: A biopsychosocial approach
Chronic musculoskeletal pain (CMP) is a common condition affecting 1 in 5 adults worldwide. CMP encompasses a diverse range of conditions such as osteoarthritis, chronic low back pain (CLBP), fibromyalgia and chronic widespread pain, where ongoing pain is felt in the bones, joints and tissues.
Exercise is considered to be the primary treatment intervention for people with CMP; it is effective at reducing both pain and disability. It is widely believed that exercise leads to reduced pain and disability by improving physical function and performance (e.g., range of motion, strength, muscular endurance). However, the evidence supporting these mechanisms is lacking. For example, in CLBP, improvements in pain and disability during an exercise programme were unrelated to changes in physical function. This suggests that exercise might work through other mechanisms, such as improved psychological status and cognitions (e.g. reduction in fear, anxiety and catastrophisation, increased pain self‐efficacy), exercise‐induced analgesia (pain relief), and functional and structural adaptions in the brain. This might also explain why research to date has not shown any specific exercise to be superior to any other – it may be that psychological and/or neurophysiological factors that are common to all exercise approaches have the greatest effects on pain and disability. This reflects the modern conceptualisation of pain as a multidimensional experience with biological, psychological and social contributions – a biopsychosocial experience.
So how can exercise interventions better align with this modern conceptualisation of pain as a complex, biopsychosocial experience?
It is thought that exercise interventions that effectively target the biopsychosocial factors contributing to the individual’s pain and disability (e.g., unhelpful beliefs and cognitions, nervous system sensitisation), and that align with contemporary pain rehabilitation practices, may have a greater potential to improve patient outcomes beyond the specific effects of exercise alone. Although no type of exercise appears to be superior in treating pain, there is consensus that exercise should be individualised and monitored based on the individual’s presentation. Exercise should follow a comprehensive initial assessment and be aligned with patient goals and preference. Additionally, exercise should occur in an environment that is perceived as safe and non‐threatening to avoid fostering unhelpful associations between physical activity and pain.
In addition to exercise, an understanding of contemporary pain neuroscience concepts will help clinicians and patients engage in meaningful and positive pain dialogue to better help the patient understand their pain problem. Learning for patients involves changing from ‘pain as a sign of structural damage or pathology’ to ‘pain as a protective mechanism modulated by all credible evidence of tissue damage and safety’. Failure to do so may leave a patient confused as to why a biopsychosocial approach is required for what is usually previously considered to be a structural–pathology‐based problem.
It is important to note that in some instances, irrespective of exercise, simply engaging with the individual, developing their confidence with movement, assisting them to become more active and gradually pace up their daily activities also have the potential to reduce the impact of pain and improve quality of life.
The ideas in this blog are discussed in greater detail in a recent clinical update on exercise and chronic musculoskeletal pain (Booth et al., 2017).