When Exercising Through Pain Helps Make It Better
Reading Time: 6 minutesHow to Know When to Exercise Through Pain—and When to Rest, Movement can help us tap into an ‘inner pharmacy’ of opioids that can be more effective than pills., When to exercise through pain, and when to rest
This is an installment of Good Fit, a column about exercise.
They call it a ‘runner’s high’ for a reason. You leave for a run feeling lethargic, foggy, and achy from hours of sitting at a desk. At first, you might question your decision to even set foot outside—you’re sweaty and out of breath, your legs feel stiff and heavy. What could possibly be enjoyable about pounding your feet on pavement over and over again?
Then, 20 minutes into the run, your thoughts start to purr. The color of the sky and the sound of the birds are more vivid; your strides quicken and you feel invisible. And, maybe, a persistent ache in your knee fades into background noise.
You’ve heard of endorphins, the happy chemicals your body produces in response to exercise and other forms of stress. What you may not know is that endorphins are opioids. They bind to the same receptors as drugs like Vicodin and oxycodone, and have the same pain-relieving effects. Working out floods the body with natural opioids and anti-inflammatory chemicals.
These opioids are mood-boosting, and can act as an antidepressant. They also make exercise a powerful tool for recovery from chronic pain (which is distinct from acute pain, which signals that there’s an injury). It allows us to tap into ‘our internal pain medicine,’ said Akiko Okifuji, an anesthesiologist in the Division of Pain Medicine at the University of Utah. These effects go far beyond the euphoria you experience right when you get home from the gym. In the long term, exercise may even train your brain to send fewer pain signals.
Pain is your brain’s way of protecting you from physical damage. Nerves in your tissues relay information to the brain in response to stimuli, from the tickle of a light breeze to the burn of a hot stove. The brain produces pain signals when it interprets this information as indicating danger. When you sprain your ankle, the jolt of pain you experience upon taking a step is your brain warning you that you’re risking further damage to those ligaments.
But the brain is an unreliable narrator. In many cases of chronic pain, negative sensations brought on by an injury outlast physical damage to the body. ‘The same way that we can learn to ride a bike, our brain can actually learn to experience pain in certain areas of your body,’ said Daniella Deutsch, a psychotherapist and trainer at the Pain Reprocessing Therapy Center, which trains health care providers in chronic pain science. Ankle pain, for example, might worsen and even spread long after torn muscles stitch themselves back together. Other times, chronic pain appears seemingly out of nowhere. Emotions like fear, certain chemicals the body produces, and a host of other factors can sensitize the nervous system to innocuous stimuli, so that even benign sensations like muscle fatigue or the weight of your body on a perfectly healthy joint feel like white-hot pain. This pain is just as real as what you experience immediately when you get injured; it’s just no longer helpful. That’s when exercise becomes an important tool.
In one study, published in the journal Pain in 2020, researchers had 38 participants with chronic low-back pain complete three 30-minute cardio sessions per week for six weeks, involving the exercise of their choice: bike, elliptical, treadmill, or stair machine. Before and after the full exercise program was completed, all the participants completed a ‘heat pain task’ in which they sat while wearing a metal device that grew progressively hotter until they couldn’t tolerate it anymore. Each time, the participants were given a different injection: either naloxone, a drug that blocks opioid receptors, making it so that endorphins can’t exert their pain-relieving effects, or saline, which does nothing. (Participants didn’t know which injection they were getting.)
The researchers then compared how each participant rated their pain when they received saline versus naloxone. Forty-four percent of participants enrolled in the exercise program experienced a substantial drop in pain when they received saline compared to when they received naloxone—that is, their bodies were giving them painkillers, and when the naloxone prevented those painkillers from working, the participants noticed the ill effects. The more vigorously the participants in the exercise group tended to exercise, the greater the difference in pain. The researchers also did all of this with a control group, who were not given a regimen of movement; only 9 percent of participants in the control group experienced the drop in pain with the saline injection. The non-exercisers, on balance, didn’t have that abundance of natural painkillers. It’s important to note that the exercisers didn’t complete the heat pain task immediately after a workout, so the study wasn’t measuring that post-workout high. Instead, it suggested that a consistent exercise routine increases the opioids circulating in the body in general.
Exercise doesn’t just produce opioids, it also acts as an anti-inflammatory—which has the same ultimate effect of decreasing pain at the source, said Kathleen Sluka, a professor of physical therapy and pain researcher at the University of Iowa. The body becomes inflamed when the immune system kicks into gear in response to pathogens, injuries, and other stressors. This response aids healing in the short term. But in people with chronic pain, inflammation often overstays its welcome. Inflammatory molecules released by white blood cells, called cytokines, can actually excite nerve cells and make them more sensitive to stimulation, causing them to send more messages of alarm to the brain.
Exercise tamps down this response. In one study, scientists measured the quantity of inflammatory markers in the blood of 47 participants before and after exercise. The results, published in 2017 in the journal Brain, Behavior, and Immunity, found that on average, participants experienced a 5 percent drop in inflammatory cytokines after just 20 minutes of brisk walking on a treadmill.
‘I like to say, you can take five pills or you can just exercise and get these systems activated,’ Sluka said. A 2022 analysis of 13 different studies found that exercise is associated with a larger decrease in pain than nonsteroid anti-inflammatories (a category of drugs that includes ibuprofen) and ranked exercise above both opioids and NSAIDs. The difference described in the paper was small, but the study noted that exercise has a lower upfront cost and risk of side effects and complications. Plus, exercise comes with other benefits, like lower blood pressure, improved memory and learning, and just feeling good—benefits you can’t reap from ibuprofen.
If you are dealing with acute pain from a sports injury, what your body may very well need is rest, or exercises provided by a physical therapist that support recovery. It’s a good idea to begin an exercise program with a professional who understands chronic pain and can ensure movement won’t worsen any damage. Assuming your body is structurally sound, symptoms tend to decrease after several weeks of physical activity, Sluka said.
Of course, starting an exercise program when you’re in pain can still feel counterintuitive and scary—especially if your chronic pain began with a sports injury. For years, I dealt with chronic pain stemming from old running injuries. Jumping back into a workout program was the last thing I wanted to do; I was terrified it would delay my recovery further or make the pain worse. So I diligently rested, iced, and waited for the pain to go away. I didn’t know that I needed to get moving before I could jumpstart that recovery.
What I also didn’t know back then is that beginning exercise can hurt at first—and that’s OK. As long as the pain mainly occurs during the exercise, and doesn’t worsen afterwards, it’s not harmful to feel some discomfort, Sluka said. ‘That pain during activity will eventually go down, and so will your overall pain,’ she explained.
It doesn’t really matter what type of physical activity you do, Deutsch said. The most important thing is that it’s something you enjoy that feels sustainable. However, there is stronger evidence for the benefits of cardio—anything that gets your blood pumping, from walking to running to tai chi—over strengthening exercises, Okifuji said.
Whatever activity you choose, it is important to start slowly. When you’re dealing with chronic pain, an important element of reintroducing exercise is convincing your brain that you’re safe, Okifuji said. That’s because when you learn to associate movement with pain, the anxiety you experience around physical activity and the expectation that it will trigger a flare-up can actually amplify pain signals—a phenomenon pain researchers call the nocebo effect, aka the ‘evil twin’ of the placebo effect. Take baby steps. Estimate your capacity, activity-wise, then do much less, Okifuji said: ‘It might be a five-minute walk. Or walking to the mailbox. It could be very minor. But you need to be consistent.’ Once that activity becomes tolerable, you can slowly increase the volume and intensity, she added.
Finally, understand that you will experience setbacks. ‘Usually the improvement is not linear,’ Okifuji said. ‘It takes time and is labor-intensive.’ Listen to your body. If you’re not feeling well, it’s OK to reduce the intensity, Okifuji said. ‘You can do shorter and less intensity.
Just do something. Commit yourself, even if it’s just three minutes.’
Read more installments of Good Fit.
Reference: https://slate.com/technology/2023/02/exercise-chronic-pain-opioids-painkiller.html
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