A flare up in chronic pain is an increase in pain beyond the usual level. Flares ups can be both frustrating and scary. Although exercise is a powerful tool in managing chronic pain, there are a few ways exercise can increase pain.
Too much activity
If you haven’t exercised for a while, you may have exceeded your current tolerance level. Tolerance can depend on the physical fitness of tissues, your beliefs and fear around movement, or a combination of both. Tolerance can also vary based on factors such as stress and fatigue.
It is helpful to remember two things:
- Tolerance is different from the actual threshold for tissue injury, which means pain usually comes on before any injury occurs. So, although an increase in pain can be alarming, it is unlikely to indicate more injury.
- The human body is extremely adaptable and thrives off challenge. This adaptability is what allows the body to get stronger. Only in rare circumstances are the body’s muscles, joints and ligaments unable to adapt. Going over your tolerance, even though painful, actually acts as a strong stimulus for tissue strengthening.
Placebo and nocebo effects of exercise
The placebo effect is a phenomenon shown in experimental studies where individuals experience positive changes in health after receiving a fake intervention. "Placebo thinking" refers to having positive beliefs and expectations, which can lead to real improvements in health. The placebo effect has been repeatedly shown in research to be a significant factor in treatment outcomes. In fact, new treatments are often best compared to a placebo to measure their true effectiveness.
Vice versa, “nocebo thinking” refers to having negative beliefs and expectations, which can lead to harmful effects on health. Just as positive expectations can promote recovery, negative expectations can contribute to worsening symptoms or increased pain.
A great example of placebo and nocebo thinking was demonstrated in a study by Bingel et al.(2011). Healthy participants were exposed to heat pain and then given an opioid painkiller three times. Before each opioid administration, they were told that the drug would: 1) be effective, 2) have no effect, or 3) worsen their pain. When participants expected the drug to be effective, they experienced twice as much pain relief compared to when they expected it to have no effect. In contrast, when they were told the drug would worsen their pain, they reported no pain relief at all.
So, although pain is a very physical experience, our beliefs and expectations are incredibly powerful in triggering real, physical responses. If you believe you are in danger and exercise is bad for you, you are more likely to feel pain. Learning more about pain and how the body works can update your understanding of the condition and help you feel safer.
Fear or worry
Fear or worry about certain movements causing further injury, or the stress of experiencing the discomfort of pain itself can unfortunately increase pain. Fear, worry, and stress stimulate biochemical processes that speed up nerve sensitivity and communication.
Humans are the original AI
A part of learning is through association, which doesn’t require conscious thought. It is very easy to develop unconscious associations with pain, including pairing an experience of pain with a certain movement or exercise. To break this association, we have to use our conscious thoughts to re-wire the unconscious associations while gradually increasing the activity.
Changes in the nervous system
Some people have altered features in the peripheral nervous system which result in increased sensory information.
In addition, chronic stress and persisting pain can modify processing in the central nervous system resulting in many normal senses being automatically interpreted as pain.
Our nervous systems do adapt, so there is a lot of potential to downregulate these pathways. However, it takes time and effort to learn new thoughts and behaviours.
Tension and protection
Most of the above factors can lead to protective movements and behaviours that actually increase pain. Increased muscle tension from holding and bracing can activate nerves and signal to the brain that more protection is needed, which, in turn, generates more pain.
To avoid this, try to relax through movements and make sure you continue to breathe – don’t hold your breath!
Remember
- A small increase in pain is safe, especially if it’s a movement you don’t do often or if you are already tense and worried.
- Some pain is normal and can even be a sign of beneficial adaptation.
- Try not to worry about pain as it only increases the pain volume.
- Consider how other aspects of your life such as stress, mood, sleep, and diet might be affecting your pain- not just the most recent exercise.
- Bingel, U., Wanigasekera, V., Wiech, K., Ni Mhuircheartaigh, R., Lee, M. C., Ploner, M., & Tracey, I. (2011). The effect of treatment expectation on drug efficacy: imaging the analgesic benefit of the opioid remifentanil. Science Translational Medicine, 3(70), 70ra14. https://doi.org/10.1126/scitranslmed.3001244
- Nielsen, L. A., & Henriksson, K. G. (2007). Pathophysiological mechanisms in chronic musculoskeletal pain (fibromyalgia): the role of central and peripheral sensitization and pain disinhibition. Best Practice & Research Clinical Rheumatology, 21(3), 465–480. https://doi.org/10.1016/j.berh.2007.03.007