Exercise as a Treatment for Chronic Pain

Abstract

INTRODUCTIONChronic pain can be a risk factor for compromised self-care and physical functioning, morbidity, and reduced quality of life (1) and is one of the most common reasons adults seek medical care (2). In 2016, approximately 20% of adults in the United States had chronic pain (approximately 50 million) and 8% of U.S. adults (approximately 20 million) had high-impact chronic pain (3). The National Academy of Medicine, formerly the Institute of Medicine, reported that chronic pain contributes to an estimated cost of $560 to $635 billion for direct medical interventions, lost productivity, and disability (4). PURPOSE Health and fitness professionals understand the benefits of exercise in the prevention and treatment of numerous health conditions and that exercise testing and prescription should be included as part of health care (5). The purposes of this Clinical Applications column are to provide definitions and describe the prevalence of chronic pain, describe the need for nonopioid treatments for chronic pain, provide examples of research conducted with exercise as a treatment for addressing chronic pain, and provide examples of initiatives supporting exercise for addressing chronic pain. CHRONIC PAIN DEFINITIONS Chronic pain can be defined as pain that lasts longer than 3 months or beyond the time of typical healing, it is not typically attributed to a single etiology, and is thought to be the result of both physical and psychological causes (6). High-impact chronic pain can be defined as persistent pain with substantial restriction of life activities lasting 6 months or more (3,7). The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience that is associated with actual or potential tissue damage or described in such terms” (8). It must be noted that medical and psychological experts debate extensively when defining the word pain, as there is no consensus as to a consistent and comprehensive definition of pain (9,10). Chronic nonspecified neck pain and chronic nonspecified lower back pain are the most common sites at which people report experiencing chronic pain. Chronic nonspecified neck pain and chronic nonspecified lower back pain are the most common sites at which people report experiencing chronic pain.ADDRESSING CHRONIC PAIN — NEED FOR NONOPIOID TREATMENTS One fifth of patients with noncancer acute or chronic pain are written an opioid prescription from their physicians (11), even though opioid prescriptions, while potentially effective for treatment of acute pain experienced after injury, illness, or medical procedure, do not appear to be effective for long-term pain management and should be used as a “last resort” (12,13). In 2017, 17.4% of the U.S. population received one or more opioid prescriptions, with the average person receiving 3.4 prescriptions (14). Approximately 2 million people in the United States are addicted to prescription opioids (15). Deaths from opioid overdose have been declared a national public health emergency, are epidemic, and are the leading cause of unintentional injury death in the United States (16–19,20). Results from a recent study published in the Journal of the American Medical Association (JAMA) did not support prescribing opioids as a treatment for chronic pain (21). In the randomized control trial, 240 patients from Veterans Affairs with chronic back, hip, or knee pain were placed into an opioid treatment or nonopioid (acetaminophen or a nonsteroidal anti-inflammatory medication) treatment group and were assessed for pain intensity, medication-related adverse effects, and pain-related function. After 1 year, patients in the nonopioid treatment group reported less intense pain. The opioid treatment group had more adverse effects, and both groups compared similarly regarding pain-related function. Expert recommendations from agencies such as the U.S. Centers for Disease Control and Prevention (CDC), National Academies for Science, Engineering, and Medicine, and the Work Group on the Prevention of Acute and Chronic Pain of the Federal Pain Research Strategy have released guidance for medical, health, and fitness professionals regarding nonopioid and nonpharmacologic treatments (including exercise, physical therapy, and cognitive-behavioral therapy) to address chronic pain (6,14,20,22,23). Expert recommendations from agencies such as the U.S. Centers for Disease Control and Prevention (CDC), National Academies for Science, Engineering, and Medicine, and the Work Group on the Prevention of Acute and Chronic Pain of the Federal Pain Research Strategy have released guidance for medical, health, and fitness professionals regarding nonopioid and nonpharmacologic treatments (including exercise, physical therapy, and cognitive-behavioral therapy) to address chronic pain (6,14,20,22,23). RESEARCH INCLUDING EXERCISE INTERVENTIONS Empirically validated exercise interventions have amassed in the scientific literature as effective treatment for chronic pain. The table provides several examples of empirical, systematic, and meta-analysis research studies (Table 1). For example, exercise interventions were found to reduce pain in patients with low back pain (24), and older adults with chronic pain seemed to be less active than asymptomatic controls (25). In addition to exercise, nonopioid pharmacological, psychological, and complementary and alternative interventions may contribute to chronic pain treatment as well (1,26).TABLE 1: Examples of Exercise and Chronic Pain ResearchAlthough research findings support the use of exercise as a treatment for chronic pain, significant barriers to implementing exercise as a treatment still exist. Older adults, women, individuals with preexisting conditions, individuals who are from an ethnic or racial minority group, individuals living in rural areas, and socioeconomically disadvantaged communities are at a greater risk of being in appropriately prescribed opioid prescriptions (23,27). Future interventions and research should focus on addressing social determinants, clearly defining type of pain and severity, clearly defining the intervention, and improving access to physical activity and exercise opportunities, programs, and facilities (26,28). INITIATIVES TO PROMOTE EXERCISE AS TREATMENT Clinical recommendations for primary care clinicians who treat adult patients for chronic pain have been published in JAMA and promoted on the CDC web site (23). The recommendations are intended to improve physicians’ confidence about how to manage chronic pain and to promote safer and more effective options for pain management using nonopioid treatments including exercise, physical therapy, nonopioid medications, and cognitive behavioral therapy. The American College of Sports Medicine’s Exercise is Medicine® (EIM) initiative is a global health initiative encouraging primary care physicians and other health care providers to include physical activity when designing treatment plans and to refer patients to evidence-based exercise programs and qualified exercise professionals (5). The initiative recommends that health care providers communicate with their patients about their exercise habits and to incorporate an exercise “prescription” during visits, increase access to physical activity and exercise resources, and refer patients for exercise guidance by qualified exercise professionals or allied health care staff. An EIM credential is available for health and fitness professionals to demonstrate their ability to safely and effectively develop, implement, and lead exercise programs for patients, work in collaboration with health care providers, and help create sustained lifestyle and behavioral changes for people with acute and chronic diseases. Another example of a professional organization dedicated to promoting safer alternatives to opioid prescriptions for addressing chronic pain is the American Physical Therapy Association (APTA). Their “#choosePT” campaign encourages health care professionals to discuss the risks related to the use of opioid medications and to promote physical therapy as treatment for pain management (29). The APTA has organized its efforts to advocate to medical professionals, legislators, and other decision-makers the importance of prescribing physical therapy as a safer alternative to opioid prescriptions. CONCLUSIONS Given the broad definition of chronic pain, it is recognized that although exercise may not be the sole intervention to address the condition, exercise has fewer severe consequences than opioids, can be individualized and modified based upon individual needs, and is clearly within the scope of practice of health and fitness professionals. Health and fitness professionals are in the ideal profession to organize and mobilize themselves and community members to advocate to health care providers for exercise as a treatment for chronic pain (30). Given the broad definition of chronic pain, it is recognized that although exercise may not be the sole intervention to address the condition, exercise has fewer severe consequences than opioids, can be individualized and modified based upon individual needs, and is clearly within the scope of practice of health and fitness professionals. Note: This Clinical Applications column has been based on a published review of the literature regarding chronic pain, opioids, and exercise by Estill O and King KM. Addressing chronic pain: opioids or exercise as a treatment? Kentucky Association for Health, Physical Education, Recreation, and Dance (KAHPERD) Journal. 2018; 56(1):17-23 (31).