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The earliest surviving surgical text, from 1500 BC, describes the best treatment for back pain:
“Thou shouldst place him prostrate on his back.. .”
The treatments have varied wildly since then. The Dark Ages, between the 5th and 14th centuries, were a fun time to be alive: in some parts of Scotland, mothers who had a breech birth were believed to have special power in their feet to cure back pain, while in parts of England the cure for sciatica was to smoke the patient’s legs in a fire of ferns.
Physical activity, not bed rest, can help to relieve pain, but why?Credit: iStock
Still, throughout the ages bed rest remained a common recommendation.
That was until somewhat recently when doctors realised that though aches and pains are as old as humans, bed rest was making the problem worse. And it’s a problem that is estimated will affect more than 800 million people by 2050, according to a new paper.
Today, being physically active and maintaining a structured exercise program, are considered among the best practices for managing chronic back pain, something that one in five Australians live with.
The prevalence of pain tends to be lower among people who exercise regularly and a large, new study has explored a possible reason why: boosting physical activity levels could help treat chronic pain by changing people’s pain tolerance.
Previous research had suggested that physical activity might alter our perception of pain, and it is known that athletes tend to have higher pain tolerance than others, but the data was limited and conflicting.
So for the new analysis, published in the journal PLOS ONE, researchers looked at the activity levels of 10,000 Norwegian adults over the course of seven years and their levels of pain tolerance, which was measured by a test in which they placed their hand in icy water.
The researchers found that participants who reported moving more regularly had higher pain tolerance than participants who were sedentary. The more active the person was, the higher their tolerance.
The two questions these findings raise are: Why does physical activity have this effect? And could the pain-reducing effects of a ‘hand in ice’ study be generalised out to other conditions?
The lead author of the study, Anders Årnes of the University Hospital of North Norway, says there are many possible reasons why exercise might affect our experience of pain.
“Engaging in activity releases substances in our nervous system that trigger pain-inhibiting pathways,” he says. “In fact, these are the same pain-inhibiting pathways that opioids and cannabinoids use, and so in some respects the effect of physical activity is the “baby brother” of those substances.”
Professor James McAuley, a senior research scientist at Neuroscience Research Australia and the UNSW School of Health Sciences, adds that activating the brain’s endogenous opioid pathways, via exercise, may protect people from the suffering part of pain, so they might still have pain but don’t suffer from it as much.
Physical activity also influences markers of inflammation in the body, which can sensitise us to pain.
Then there are the psychological effects that can influence how the brain processes pain. Physical activity can regulate stress and anxiety, help us to focus our attention, and lower the likelihood of catastrophising pain.
Being active can also improve our confidence, says McAuley: “If you can increase someone’s confidence, it does improve their pain and disability.”
Though he says it is a “great paper” with a large dataset, he adds that there might be other explanations for the relationship between physical activity and pain tolerance. It might be that people who choose to do more physical activity naturally have a personality that is more tolerant of pain or have adjusted to the experience of pain by pushing themselves and having muscle soreness from exercise.
“It would be great to tease out,” says McCauley, explaining that what is unclear is whether prescribing exercise to people who are not already active will reduce their pain or make them more tolerant.
Can physical activity improve chronic pain?
Arnes acknowledges that chronic pain is “quite a different beast” to the pain of putting your hand in icy water.
“We do not fully understand what causes pain to persist in this way. However, some theories point towards this individual ability to process pain signals as a possible contributing reason,” he says. “Since physical activity also appears to be a useful tool for preventing and treating chronic pain, we are trying to ascertain whether this effect on pain sensitivity might have something to do with that.”
Professor Manuela Ferreira from Sydney Musculoskeletal Health and the University of Sydney says exercise is “the way forward” for preventing and treating chronic back pain.
“Our spine was made for movement,” she says.
By maintaining physical activity in the acute phase of pain (the first six weeks), albeit at a reduced level, and having a physiotherapist or exercise physiologist design an exercise program if the pain becomes chronic (longer than 12 weeks), it can help in a multitude of ways.
Exercise increases the blood flow and nutrients to the soft tissues in the back, improving the healing process and reducing stiffness that can result in back pain. It also strengthens the muscles around our spine.
“It provides stability to our internal organs and the trunk,” she explains.
Yet, the first thing many people do when they have back pain is stop moving, Ferreira says: “That will actually trigger other problems with the muscles and the joints … putting more load on structures that cannot really support that load. More load on small joints instead of the muscles.”
And not moving decreases a person’s confidence in their ability to move freely, she adds.
How much and what type of physical activity works best is still being understood, but Ferreira, who was the lead author of the paper predicting the surge in back pain numbers by 2050, believes we can prevent it and treat it.
“Most of that [estimate] is driven by the ageing population and population growth… we can’t change that,” she says. “But, we haven’t invested in preventative strategies and making sure people know it’s OK to move. Exercise and physical activity is safe. We need to change people’s opinions and knowledge around back pain. If we do that we can reduce the numbers.”
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