As someone with persistent pain (and a few traits that predispose me to pain) and a therapist for 20 years I am a proponent of resuming meaningful activities and exercise even when its painful…sometimes. I think that for a lot of people with persistent pain it is not only safe but its actually the thing that could help them most with recovery. This article is a case for poking the bear.

As this is what I teach to both patients and other therapists I’m often asked a question that is surprisingly complex and informed about pain. I’ve had patients and therapists very well-read on pain mechanisms and they’ve asked whether pushing into pain will lead to something called Central Sensitization (CS). It’s a really good question. They are aware that persistent pain sometimes involves an overly sensitive nervous system and are rightly concerned that doing painful activities will make that sensitive nervous system even more sensitive. Before we try to answer this question let’s talk about Central Sensitization (CS).

The formal definition is:

“increased responsiveness of nociceptive neurons in the central nervous system to their normal or subthreshold afferent input…Certain signs and symptoms, such as allodynia (pain felt with non-painful stimulus) and widespread hyperalgesia, may suggest its presence” (Reference HERE).

The concept is pretty helpful in understanding how pain and suffering can actually have very little to do with the state of the tissue (i.e. huge amounts of pain very little tissue issues). The main implication being that after we have pain for a while we might:

- experience pain doing an activity that would normally be non-painful and

- have a lot of pain during activities that were previously only slightly painful activities

CS kind of cranks everything up. It might also be responsible for migraines, headaches, restless legs and stomach issues as it suggests this is system wide problem.

Some of the original laboratory studies suggested (link here) that if you apply a painful stimulus to a person (we assume this creates nociception) you will get an elevated pain response over the course of hours and up to 24 hours. It’s this simple idea that pain makes us better at having pain.

Because of that it is pretty logical to think that we need to avoid pain to try to avoid central sensitization or not make existing central sensitization worse.

I’m going to surprise you and say that is probably wrong in most instances and in fact we actually need to sometimes persist into painful activities to recover in those without CS and even in those with CS.

Let’s take a look at a number of different research areas with a number of different pain presentations where poking into discomfort and choosing painful activities was both acceptable and perhaps beneficial.

1. Exercise is an analgesic:

If I poke you with something painful exercise will decrease that pain in the short term. This is called Exercise Induced Hypoalgesia. The problem is that this ability is more often seen in those without chronic pain. Once you have chronic pain (fibromyalgia for example) this ability can be blunted (References Here and Here). Thats kind of BS, since the people who need the pain relief are the ones that lose this ability. But wait, there is hope. This is just a short term phenomenon. Exercise and activity are still helpful in the long term when you have chronic pain - you just won’t get that short term “runner’s high”. So when people tell you how fantastic they feel after working out and you look at them with daggers in your eyes because you don’t get that elation don’t worry. You’re the normal one. You shouldn’t expect to have less pain during the activity, you might even have more pain but in the long term you are capable of adaptation (Reference here and here).

Conclusion - poking into pain with activity might be unavoidable in the short term but beneficial in the long term.

2. Just because activity hurts doesn’t mean you are even creating nociception.

Remember at the start when we it was suggested that painful activities would create nociception (the tissues sends “danger” or “irritation” signals to the spinal cord and maybe the brain) and ultimately Central Sensitization. Well, you have no idea if nociception is occurring when you do something that is painful. Other variables can cause pain that have nothing to do with increased nociception. Pain is that complex. Beliefs, fear, anxiety, learning can all influence the pain you feel and this has nothing to do with nociception (Reference Here). This is kind of the issue with persistent pain. After awhile, innocuous movements or postures can cause pain and it doesn’t mean that you’ve created some problem at the level of the tissue.

3. You can have nociception and not develop Central Sensitization

Have you ever done an exceedingly painful activity before you had chronic pain? I guarantee you have. Athletes do this on a regular basis and it doesn’t lead to CS. Reference - life (Particularly my Wednesday night old man 25 km brewery bike ride where my saddle hates me).

We also know that we regularly experience nociception as a protective measure. When you are sitting down in a hard chair you will naturally shift and move. This is probably nociception causing you to move to protect your butt tissue from developing an ulcer. Nociception is protective and ongoing in this case (Reference - here)

4. Even when there is tissue damage it is safe to poke into pain.

When people tear their hamstrings they are able to engage in painful exercises as part of the rehab program. Clinician researchers explicitly choose exercises for the hamstrings, to help heal them and make them stronger, that are painful. This does not lead to more pain and is associated with slightly increased function (Reference here). We also see the same thing when people have tendinopathy. They are able to poke into discomfort, perform their meaningful activity and see no detrimental effects (Reference here)/.

Does this mean you just hammer away and completely ignore what you feel? No, you slowly build up your tolerance, feel comfortable and safe (i.e. you have to KNOW that you aren’t damaging yourself) and monitor your response over 24 hours. If your pain isn’t increasing over the next few days then you can probably be confident in poking into discomfort.

5. You can even poke into neuropathic pain.

The title of this paper includes “expose or protect”. And guess what? When you expose into painful, avoided, feared BUT meaningful activities it can be helpful (Reference here)

6. We can habituate to painful activities.

Habituation means you can do something that is painful and slowly get comfortable with it over time (others might call this sensory adaptation). You’ve seen this everyday. Think of cooks getting comfortable with hot water splatters, you getting used to a hot shower, rock climbers having their fingers get used to sharp edges, Martial artists breaking bricks or cyclists not complaining about their groins.

The neat thing about habituation is that you can have more pain at the start of the painful stimulus (called within session Sensitization) but over the course of days you have less pain (Reference here).And guess what? If you are told that poking into pain will make things worse and you believe that - it it will actually come true. You can lose your habituation response if you are lead to believe sensitization will occur!!! (Reference here). So be Movement Optimist - trust the process and your amazing ability to adapt. You are wonderfully plastic.

Caveats

There are definitely times to back off, deload and change what we are doing (If we have to label a subset of people who might need to back off they would be called Endurance Copers - Ref Here).

And there are certainly those in pain who might have tissue driven symptoms where we need to protect as we heal (e.g stress fractures in runners). But if you work with someone where you both have an understanding of your pain problem then exposure and activity resumption could be the right thing for you. Speaking of runners in pain sometimes you can use running as rehab (details here)

Exposure is probably better for those who have been avoiding meaningful activities and have put themselves into a box (or had a therapist suggest that box) that is getting smaller and smaller. Very simply, our beliefs, fears and worries end up stopping us from doing the things that might be most helpful. And those same beliefs, fears and worries can actually make the healthy things you should be doing more painful. It’s a pretty vicious cycle. You essentially stop being you (called Biographical Suspension - Reference here) and stop doing the things that could help you recover. So, is it time that you got out of the box?

Wrapping up and going forward

When we are in pain we often put ourselves in movement prison - a tiny shack that just gets smaller and smaller. We think too much about what we can or can’t do, obey arbitrary and unhelpful rules about what movements are safe, listen to movement gurus that tell us that certain movements are bad for us and will cause long term damage and ultimately we stop trusting our body. We become movement pessimists and live our life in a tiny shack of allowable activity governed by a warden with unhelpful rules. And when you live your life in a closed off shack it gets harder and harder to get out. So resuming fearless and confident movements and activities is sometimes the best thing we can do even though it can be terrifying. If we always wait to be pain-free before we start living we just won’t start living again.

Resuming meaningful and avoided activities is a way that you can build a case for your own resiliency - to convince that deep, irrational and overly protective part of yourself that drives your sensitivity and pain that you are in fact safe and amazingly adaptable. In some ways you are proving to yourself what you are still capable of. It will be scary. It can be painful. There will be good days and there will be bad days. But you will build a mountain built on success that will ultimately dwarf that little shack that was your movement prison.

With many things this sounds simple in theory but can still be difficult in execution. A number of health professionals can help you on your road to recovery and resuming meaningful and avoided activities should be a part of most good programs. Good luck.

Is it safe to do activities that are painful: exploring the expose versus protect debate