Chronic pain affects a large number of individuals. Some of the more common chronic pain syndromes affecting individuals include degenerative spine disease, knee and hip osteoarthritis, and rotator cuff pathology. Although certain exercise modalities can help these conditions, it can be very difficult for individuals to engage in fitness because of the pain associated with each. This article contrasts acute and chronic pain, as well as the basics related to the treatment of such problems. Degenerative spine disease, knee and hip osteoarthritis, and rotator cuff disease will be highlighted as examples of chronic pain commonly seen by physicians, therapists, and fitness trainers. Suggestions will be made related to fitness and chronic pain, as well as activity modifications for these specific conditions.
ACUTE INJURY CARE AND RELATED PAIN
Acute pain is relatively easy to understand, and we, as a sports medicine and therapy profession, do a good job treating this. Examples would include a sprained ankle or broken bone. The old adage RIICE (Rest, Ice, Immobilization, Compression, Elevation) treatment plan applies well to many acute injuries. The injured area typically is rested for a period, initially, when pain is severe. In sports medicine, we often use the term “relative rest” for most injuries that are not severe. Individuals may be able to ride a bike instead of jogging or swim instead of playing a sport to allow for continued activity without stressing the injured area. Ice or cold compresses can help a great deal with swelling, inflammation, and the pain associated with acute injuries. This can be applied for 20 minutes every few hours. It is important to have a protective barrier between the skin and the ice. Sometimes immobilization is necessary in a splint, cast, or sling. Compression and elevation can help prevent and treat unnecessary swelling associated with the injury. The pain associated with acute injuries often is managed with acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs). Acute pain disorders respond to these modalities within a 1- to 2-month period and with little residual problems for the individual.
ACUTE PAIN VERSUS CHRONIC PAIN
Chronic pain is a completely different animal. When pain is present for 2 to 3 months or longer, it is termed “chronic.” Unlike acute pain that serves to protect the injured body part from further damage, chronic pain serves no known helpful purpose. Also, as opposed to the treatment of acute pain, treatment of chronic pain is much more challenging for patients and caregivers and often less successful in terms of outcomes. Common examples of chronic pain include headaches, shingles, neuropathy, degenerative spine disorders, and osteoarthritis. Chronic pain is very common, with an incidence of approximately 100 million Americans affected. More individuals report chronic pain than diabetes, coronary artery disease, stroke, and cancer combined. Chronic pain syndromes also differ from acute pain in terms of the burden on other aspects of one’s life. Social interactions, personal relationships, productivity in society, and physical and emotional health are affected negatively by chronic pain. Individuals with chronic pain often have comorbid depression and anxiety disorders. As a result of the pain and other mentioned factors, fitness levels are often poor in individuals with chronic pain. The treatment of chronic pain is a huge burden on the health care system.
CHRONIC PAIN TREATMENT
Chronic pain is quite a challenging disorder to treat for health care providers. Pain medicine is a specialty of its own. Pain medicine providers typically have a background in anesthesia, physiatry, neurology, and/or psychology. Sports medicine providers can be involved in the case of patients with chronic pain when the disorder affects the musculoskeletal system, in particular, the spine and joints. Chronic pain is best treated using a combination of modalities. Certain medications can at times help with pain syndromes. Antiseizure and antidepressant medications are common examples. These medications often help with neuropathic pain, and antidepressants in particular can help with comorbid depression and anxiety. Pain medications such as acetaminophen and NSAIDs help with milder pain. More significant pain may require intermittent or regular opioid use. All of these medications have a number of negative side effects. Behavioral coping strategies also have been shown to help with chronic pain syndromes. Physical therapy can help with musculoskeletal problems contributing to chronic pain. Patients are encouraged to follow a healthy nutrition plan that provides plenty of antioxidants, adequate protein, and is low in refined sugars. Sleep cycles are often disrupted in chronic pain and may require specific treatment.
CHRONIC PAIN AND FITNESS
Exercise has been shown to help with chronic pain syndromes. It is well established that regular exercise can help with disorders such as fibromyalgia, chronic low-back pain, and arthritic conditions. That being said, it can be very difficult to convince patients with chronic pain that fitness actually will help their pain. The typical response is “I can’t exercise, it hurts too much.” Fitness plans for these individuals should take into consideration their specific problem, baseline fitness level, and ultimately their specific goals. Gentle aerobic conditioning is a good place to start, with subsequent strength training for larger muscle groups in particular. Core training can help most musculoskeletal conditions causing chronic pain. These fitness basics can be introduced in physical therapy for the painful condition. Fitness trainers can play a pivotal role, emphasizing home fitness plans after patients have graduated from physical therapy. Newer fitness strategies emphasizing training to fatigue, high-intensity training, and plyometrics may not be appropriate for individuals with chronic pain.
Sports can be an excellent method to encourage lifelong fitness. However, it is important to point out that sports also can be a cause for acute injuries that could contribute to chronic pain. Individuals with degenerative spine disease, knee and hip arthritis, and chronic rotator cuff pathology often have muscle weakness that may predispose to injuries. These conditions can be made worse with repetitive minor trauma. It is critical that these individuals have a reasonable baseline fitness level if they choose to engage in sports.
DEGENERATIVE SPINE DISORDERS
Low-back pain is the leading cause of disability in Americans younger than 45 years. Over the age of 55 years, many individuals have chronic low-back pain as a result of a combination of issues, which in sum are termed a “degenerative spine.” The anatomical changes include the following:
- The intervertebral discs are often narrowed in height, bulging, and “dehydrated.”
- Without these discs serving as shock absorbers and providing stability in the spine, the forces are transferred to the vertebral bodies, which often leads to compression deformities and osteophytes (bone spurs).
- The facet joints that bind each vertebral body to one another show signs of arthritis as well with bony enlargement.
- The spinal nerves frequently are compressed between the discs anteriorly and ligaments and joints posteriorly. This is termed spinal stenosis.
These degenerative changes (arthritis and stenosis) in the spine can hinder an individual’s attempts at exercise greatly. The arthritic changes in the spine limit spinal mobility and the spine’s ability to absorb stress. Spinal stenosis causes pain in the back or legs when patients are standing or walking. Patients can then develop stiffness and core and leg weakness, which only worsen their underlying pain. This degenerative pain cycle can be difficult to stop. Treatment is aimed at maintaining strength and flexibility in the core muscles, as well as having strategies to reduce painful episodes in terms of intensity and duration. Some patients may go on and have interventional procedures (lumbar epidural steroid injections, for example) or surgery for their pain; however, there is no cure for degenerative spine disorders.
KNEE AND HIP OSTEOARTHRITIS
Osteoarthritis is the number 1 joint disorder worldwide. In America, the prevalence of osteoarthritis of all joints affected nearly 27 million individuals in 2005 and this number is increasing consistently. Symptomatic knee and hip osteoarthritis affects 16% and 4.4%, respectively, of adults older than 45 years. Knee and hip osteoarthritis tends to affect females more than males, especially over the age of 50 years. Common risk factors for knee and hip osteoarthritis include obesity, sports participation, trauma, occupational hazards, genetics, and developmental disorders. The pathology involved with arthritis includes thinning of the hyaline cartilage, bony enlargement, osteophyte development, joint instability, and soft tissue inflammation.
Knee and hip osteoarthritis is a common source of chronic pain and interferes with fitness because of joint immobility, secondary muscle weakness, and simply the pain itself. Nonsurgical evidence-based treatment of these conditions recently was reviewed and outlined by organizations including the American Academy of Orthopaedic Surgeons (AAOS) and the American College of Rheumatology (ACR). Some suggestions include the following:
- Self-management education programs (sources include the CDC, Arthritis Foundation)
- Activity modification
- Weight loss if appropriate
- Medications including acetaminophen, NSAIDs (oral and topical), and pain medications (opioids) for more significant pain
- Steroid injections for pain flares
- Hyaluronic acid injections for mild to moderate knee osteoarthritis
It is worth noting that both the AAOS and ACR recommended against the use of glucosamine and chondroitin supplements because of their lack of current evidence. As opposed to degenerative spine disorders, joint replacement is an option for patients with severe disease and significant pain.
CHRONIC ROTATOR CUFF TEARS
The rotator cuff muscles in the shoulder function to help perform certain motions (elevation, internal and external rotation) and provide a secondary restraint securing the ball in the socket. Rotator cuff tears are very common, with a prevalence of about 20% of 60-year-old individuals. This prevalence increases with age. Risk factors for rotator cuff injuries include a history of trauma, male gender, and the dominant arm. For the most part, the standard of care for acute rotator cuff tears is surgical repair. Chronic tears, on the other hand, do not fair as well with surgical intervention. When the rotator cuff is not functioning, the ball can ride up in the socket, which can result in impingement. This will cause pain when individuals raise their arm more than 90 degrees. Common complaints are pain and difficulties with sleep. It is important to point out that degenerative rotator cuff tears frequently can be asymptomatic. Fortunately, there is good compensation for chronic rotator cuff tears and many patients with associated pain respond well to therapy interventions. Pain flares can be managed with activity modification, ice treatments, and intermittent pain medications.
EXERCISE MODIFICATIONS FOR CERTAIN CONDITIONS
Degenerative Spine Disease
- Water activities (water walking, water aerobics)
- Stationary or outdoor bike
- Emphasize gentle range of motion in the spine
- Strength training for the legs
- Balance training/exercises
Knee and Hip Osteoarthritis
- Water activities (water walking, water aerobics)
- Stationary or outdoor bike
- Shorter, more frequent walking episodes
- Avoid deep knee bends (flexion past 90 degrees)
- Avoid or modify knee extension machines (terminal extension allowed)
- Emphasize quadriceps strength, especially with women
- Certain fitness methods may not be appropriate for individuals with knee and hip osteoarthritis (i.e., plyometrics)
Chronic Rotator Cuff Tears
- Emphasize upper body posture (head high, shoulders back)
- Exercise the rotator cuff and scapula-stabilizing muscles, emphasize technique
- Avoid exercises that can strain the shoulders (deep bench press or push ups, chest flies, full dips). Keeping your hands where you can see them is a good strategy.
- Use caution with upper body strength training to fatigue, maximum lifts
Chronic pain syndromes pose a significant challenge for all health care providers. Exercise has been shown to help with the pain associated with many pain syndromes. Comorbid conditions associated with chronic pain such as depression, anxiety, obesity, and poor sleep also can be helped with regular exercise. Certified fitness trainers can play an important role in emphasizing safe and effective physical activity for individuals with chronic pain caused by degenerative spine disorders, arthritis of the knee and hip, and chronic rotator cuff pathology. Individuals with these conditions should have an understanding of the problem, correct modifiable factors leading to the problem, and have a game plan for pain flares related to the condition. Exercise and proper nutrition should be considered just as important as medications, injections, or surgery for such chronic pain syndromes.