Publication date and title: Exercise therapy for chronic musculoskeletal pain: Innovation by altering pain memories, Journal of Physiotherapy, Elsevier
Key learning points:
1- This article reviews exercise therapy as a potential desensitizing treatment for chronic musculoskeletal pain by integrating pain neuroscience education with exercise interventions.
2- In acute musculoskeletal pain, the main focus for treatment is to reduce the nociceptive trigger. However in chronic musculoskeletal pain conditions including OA, rheumatoid arthritis, whiplash, fibromyalgia, low back pain, pelvic pain and lateral epicondylitis, are often characterized by brain plasticity that leads to hyper excitability of the central nervous system (central sensitization) which means even though nociceptive pathology has often long subsided, the brain of patients with chronic musculoskeletal pain has typically acquired a protective (movement-related) pain memory.
3- MSK therapists can integrate pain neuroscience education with exercise interventions by following the below mentioned steps
- Step 1: Preparations to provide cognition-targeted exercise therapy: in which the pre-requisite is that the therapist should have an in-depth understanding of pain mechanism with a thorough understanding of the role of fear (of movement) in the development and sustainment of chronic pain, also the therapist should have the skill to communicate it effectively to the patient and should be familiar with current evidence-based pain management strategies including graded activity and a variety of exercise interventions, including neuromuscular training. This should be clearly explained to the patient in order to manage expectations of cognition-targeted exercise therapy.
- Step 2: Cognition-targeted exercise therapy for chronic musculoskeletal pain: Once the patient has adopted less threatening perceptions about pain, therapists can use cognition targeted exercise therapy for altering pain memories in patients with chronic MSK pain and central sensitization. ‘Cognition-targeted’ implies a time-contingent rather than symptom-contingent approach to exercise intervention. Setting SMART goals is central to this which will help in motivating the patient and address their perceptions about exercises
- Role of fear needs to be addressed by the therapist which is essential to retrain pain memories. It is important to discuss the fears thoroughly with the patient, and challenge the perceptions about negative consequences of performing the movement. In cases of irrational fears, graded exposure to exercise will help. Clinicians should be cautious of not using ‘inappropriate safety behaviour’ to convince the patients of their ability to successfully perform the exercise. The threat value of the exercise usually decreases after performance. Exposure of chronic pain patients to exercises or daily activities without danger to convince the brain of its error is crucial when applying cognition targeted exercise therapy.
Using stress for altering movement-related pain memories: Final progression should include exercising during physically demanding tasks, and also exposure to the feared movements or activities which were avoided for a long time, and exercising under cognitively and psychosocially stressful conditions, for example returning to driving the car following a whiplash trauma, especially in cases with post-traumatic stress symptoms. It should be a balance between enough stress to cause memory consolidation but not enough to increase central sensitization.
Application to practice:
- MSK therapists need to think and treat beyond muscles and joints while dealing with chronic MSK pain, it is crucial to consider the concept of central pain mechanisms including central sensitization which will help to alter pain memories in patients with chronic MSK pain.
- The goal of cognition-targeted exercise therapy is systematic desensitization, or graded, repeated exposure to generate a new memory of safety in the brain, replacing or bypassing the old and maladaptive movement-related pain memories.
- By addressing patients’ perceptions about exercises, therapists should try to decrease the anticipated threat of the exercises by challenging the nature of, and reasoning behind their fears, assuring the safety of the exercises, and increasing confidence in a successful accomplishment of the exercise.
- Time-contingent exercises are the main focus where therapist shouldn’t let pain determine the number of repetitions or exercise duration.
- Goal setting: It is important to let the patient define the treatment goals using SMART approach. Use the predefined goals to design the exercise program and to motivate patients.
- When progressing to a next level of (more difficult) exercises, a preparatory phase of motor imagery can be useful.
- In this way, exercise therapy will account for the current understanding of pain neuroscience, including the mechanisms of central sensitization especially in dealing with chronic pain.
Results from clinical trials have supported the use of several components of the treatment presented in the article. There is also some evidence that pain neuroscience education is the effective sole treatment for patients with chronic MSK pain. However more trials on direct clinical experience using the approach and subsequently more awareness among MSK therapists will be essential to support and establish this as gold standard for chronic MSK pain.