Thanks for reading the 58th edition of my newsletter. This newsletter tracks my work on lumbar nerve root syndromes. So far there are two books - one here, on CES and another being re-published - and one zine.
With a newborn to look after, it’s been very hard to do any new research or writing. So, for this edition, I’ve improved and updated an old post from elsewhere.
This piece is for non-clincians. Do print and share it with your patients!
Exercising When It Hurts
This post is for people who have muscle, joint and/or nerve pain that has gone on for a long time and doesn’t seem to be going away. It is meant to help you to become more fit and active, so that your body and mind are as healthy, happy and capable as they can be, despite your pain.
Why exercise?
We are always being told about the benefits of exercise. For example, improved cardiovascular health, stronger bones and muscles, lower rates of depression, longer life expectancy, and so on. I prefer to think of the benefits as more individual to each person. Perhaps it means you are able to go to the shops without needing help, pick up your grandchildren without fear, or do a shift at work without feeling exhausted at the end of the day. In other words, exercise increases your capacity to do things that are important to you.
Step 1: Ask The Key Question
I encourage everyone to visit a doctor or physiotherapist and ask The Key Question:
“Am I safe to move?”
Usually we ask a medical professional for a diagnosis, medications or advice about the best treatment. It is important that you do that, but I’m assuming that people who are reading this post already have, and are still in pain and not where they want to be.
To exercise, what you want to know from your doctor or physiotherapist is whether you have a condition that means you should avoid exercise and movement. There are really surprisingly few of these.
In fact, for most muscle, joint and nerve pain, exercise is not only safe but strongly recommended by health professionals. This includes joint pain like hip and knee arthritis, and neck and back pain, including spondylosis, sciatica and disc problems.
Step 2: Understand that “hurt doesn’t necessarily equal harm”
For most of our lives, pain is a useful thing that protects our body. If I touch a hot stove, I feel pain and I quickly withdraw my hand. Pain is like an alarm that warns me of danger.
Unfortunately, persistent pain is much less useful. It is often well out of proportion to any damage going on in the body, and people can feel terrible pain when moving even when it is not dangerous. The alarm that is usually so useful can become “over-protective”.
This means that if there is a particular movement you do that causes you pain, and has done for some time, it is quite possible that the pain is not indicating you are doing any harm. In other words, you are sore, but safe. This is important to understand because otherwise the idea of exercising makes no sense, and you will just be miserable!
Another way to think of this is like a lowering of the pain threshold. A certain part of the body - or many parts - becomes over-sensitive to movement and feels more painful than it needs to be.
This is why step 1 is seeing your doctor or physio and asking, “Am I safe to move?”. You are asking a professional whether you are sore and need to rest, or sore but safe to move.
Step 3: Decide which exercise
The best exercise is one you enjoy, because you’re more likely to stick to it. So, think about something you’ve liked in the past or something you’ve always wanted to try. If you’ve never enjoyed exercise and it’s just not your thing, try to recall a time when even if you didn’t like the exercise it at least made you feel a bit better after!
Exercise doesn’t have to be a sport or the gym. For our purposes, exercise is anything that’s more demanding than your usual day to day life. For some people, this could be walking, swimming, dancing, lifting and carrying...
Preferably, whatever you’re doing should make you feel a bit out of breath, sweat a little, or make your muscles feel tired. That said, this might not be possible if you’re starting from a low level or your pain is particularly bad.
Avoid the trap of choosing something you think you “should” do. If you have back pain, you don’t have to do pilates. If you have knee pain, don’t think you have to do exercise in the swimming pool. They are both good options, but only if you actually want to do them.
Make sure there is going to be as little “resistance” as possible to your choice. If you choose to go swimming regularly with a friend but the pool is a long drive away and your friend is very busy and likely to cancel, you might be setting yourself up for failure. On the other hand, if the pool is near your house and your friend is reliable, that would be a perfect situation. So, try to choose something that will fit in as easily as possible with your existing routine.
Here’s some ideas:
Walking
Running, for example Couch to 5k or Parkrun
Cycling or an exercise bike
Lifting weights at the gym
Walking up and down the stairs
Carrying heavy bags
Racquet sports
Dance classes
Gardening
Home stretches or yoga
Exercise class at your local health centre
Rock climbing
Escape Pain app or local class
Youtube/DVD workouts, or NHS fitness studio
Youtube/DVD dance tutorials
Home strength exercises
For more tips about approaching exercise I recommend this great list of “common sense exercise and movement guidelines”.
Step 4: Get started and get into the swing of it
When you have decided what you want to do, decide when you want to do it. Aim for three or four times per week. More than that is okay if the exercise is quite easy. But if you are working hard it is often best to give your body a day off in between workouts so it has time to recover and adapt.
When you know what you want to do and when you want to do it… do it! And for now, don’t worry about anything more than just doing it. The details don’t matter; keep it simple at this stage. The key is to “just show up” - at the gym, in the park, in front of your TV with an exercise DVD on, or wherever. Build the habit.
Explore the movements involved in whatever you are doing. Get used to how your body feels, see how it reacts, see how your pain reacts. Be curious about moving your body. Don’t feel you have to work yourself to exhaustion.
If you miss a workout, don’t beat yourself up. Just try again next time.
What about the pain? The golden rule
On the one hand, we know that pain can be like an “over-sensitive alarm” and doesn’t necessarily mean you are doing damage, which means you don’t need to avoid pain (assuming your doctor or physio or chiropractor has confirmed this). And, some pain - or at least discomfort - might even be necessary to get a good workout. But, you don’t want too much pain because pain… is still pain! Especially nasty is the kind of pain that ‘flares up’ after exercise and stops you from working and sleeping properly.
To solve this conundrum, I recommend sticking to the golden rule of exercise and pain. The golden rule is this:
Exercise within tolerable pain, that plateaus during exercise and does not continue to rise significantly, and gradually decreases once you have finished.
[If you’re curious about the research behind this ‘golden rule’, please see here, here, here and here.]
“Tolerable pain” is a funny phrase. It’s very individual. For some it will be a mild discomfort, for others it will be more. Another way of thinking of tolerable pain is that it’s ‘something you can cope with and feel is manageable’. It should not feel frightening and you should feel in control.
It will take some trial and error to find this level. At first, you might do too much and flare up your pain. Take time to let it ease off then try again, doing a little less. Think of a flare up as part of the learning process - you now know what is “too much” for you, at the moment. As you continue to exercise, it is likely that what was once too much will become achievable.
Be ready for DOMS!
Everyone, regardless of whether they have a painful condition, is likely to feel sore for the next day or two after trying something new. This is called DOMS - Delayed Onset Muscle Soreness. So, if you do feel worse after your first session, consider that this might not be a flare up of ‘your’ pain but normal muscle soreness that will diminish over time.
Congratulations!
If you’ve got started and got into the swing of it, you’ve made a huge (and hopefully enjoyable) positive change.
Stages 4 and 5 are about doing more, on top of what you’re already doing. These are optimal for fitness, but they’re not necessary for the good life. In other words, you don’t really have to do them. If you’re up and moving and a bit out of breath most days of the week, things are looking good. A little goes a long way!
If you do want to go a bit further, read on…
Step 5: Push on for more benefit
Once you have had a few weeks in a row of “showing up” and doing your exercises, no matter how little, and you have worked out the Golden Rule, it is time to start pushing on to get the most benefit from your time and effort that you can.
[Please note that there are some conditions like Long Covid and Chronic Fatigue Syndrome where ‘pushing on’ and doing more exercise over time is sometimes not possible. Please speak to your doctor about this, it is not my area of expertise.]
Once you are in the habit of exercise, you might find that you end up doing the same thing each time. For example, walking the same route, lifting the same weights, dancing along to the same DVDs. This is great and should be seen as a huge achievement! You could stop here, especially if you’re enjoying it. Or, you could try to do something more or something different. Getting out of your “comfort zone”, a little bit at a time, will help you to get the most from your exercise.
For example, try to walk a bit further, or do the same distance in a shorter time. If you are doing home exercise or weights at the gym, try to do a few more “repetitions” or lift heavier weights.
Give yourself some tough love. Are you out of breath? Sweating? Are your muscles tired? If not, you may not be getting the benefit you want.
Earlier, I said the best exercise is one that you enjoy, because you will stick to it. This is true, but it is also true that part of your exercise should be quite hard. Now, I’m not saying is that you have to Be Totally Extreme or ‘leave it all in the gym’. But every now and then you should challenge yourself to do a bit more than you’re used to.
A good rule of thumb is:
“What doesn’t challenge you, won’t change you”.
Step 6 and beyond: becoming an exercise expert
By now, your confidence will be high. It’s time to try new things. For example, if you mostly do things like walking and swimming, you would benefit from adding in some strength training - shorter, more difficult movements often using weights. It’s good to have a variety of endurance, strengthening and mobility exercises, if you can.
It might even be a good idea to flip the “best exercise is the one you enjoy” rule and actively try things that you are worried about. If you are worried about something then it is likely a weakness of yours that you might benefit from confronting. You might surprise yourself!
That concludes my six step guide to exercising when it hurts. It can be a tough road, with setbacks along the way, but it’s always worth it!
Finally, here’s a little poster made by one of my patients who benefited from this approach :)