When exercise doesn't work

[Gil Haight]

Hi all,
Jon Neuman has suggested I start a new thread regarding a post I made yesterday on the super exercise discussion.
Jon, I think we have discussed the endogenous antinociceptive mechanism a lot at this site. However, I don't think we have discussed as much here or elsewhere in PT what to do when are treatments fail because these mechanisms are dysfunctional. I mentioned the idea of "attitudinal" because pretty much everywhere one looks the idea of stress/exercise/stimulus analgesia is always associated with effort. If during exercise one hurts to the point of necessitating termination it must be because one is not trying hard enough or because one is simply not tough enough. How about the idea that the mechanisms responsible are not working for what ever reason. I think there is a lot to discuss here.
I often think of something Feldenkrais said (paraphrased) you can not take credit for helping someone with a particular technique unless you can use this same explanation for all your failures.
Gil

[Frédéric]

Gil,

I think that the more dysfonctionnal will be the endogenous inhibitory system then the less your chances of being effective with any treatment will be. That also perhaps reflects the fact that most treatment are only of modest efficacy when we look at litterature reviews. If it's exs or MT I think we heavily rely on the judicious use of the top down endogenous inhibitory system when it gets to pain relief.

In a truly sensitized state with an important central sensitisation component, it is likely that our effect could be small at best.

Perhaps we have a greater chance of success if the neurophysiological changes are more fonctionnal than structural. Perhaps we'll have a greater chance of succeeding if the patient is aware of these changes in his conceptualisation of his painful condition.

[Jon Newman]

I watched the last in the Sapolsky series being promoted by Diane recently and thought it was relevant to this thread. It's titled Individual Differences.

[Diane]

I'm with Fred on the descending modulation point.

[Gil Haight]

I agree with Fred entirely and so do a lot of others. The description of pain in terms of biopsychosocial interactions clearly supports the idea of top down modulation. However, what is disappointing are the suggested remedies expected to change the situation. An example would be graded exercise and exposure to known pain provoking stimuli. It seems to me this testing of the system, expecting it to magically improve, is nothing new and is likely to be a perpetuating factor. Any thoughts?

[Diane]

Originally Posted by Gil Haight

I agree with Fred entirely and so do a lot of others. The description of pain in terms of biopsychosocial interactions clearly supports the idea of top down modulation. However, what is disappointing are the suggested remedies expected to change the situation. An example would be graded exercise and exposure to known pain provoking stimuli. It seems to me this testing of the system, expecting it to magically improve, is nothing new and is likely to be a perpetuating factor. Any thoughts?

At the moment, graded exposure is it..

[Jon Newman]

Originally Posted by Gil Haight

It seems to me this testing of the system, expecting it to magically improve, is nothing new and is likely to be a perpetuating factor. Any thoughts?

I think those methods have been promoted partly based on the fact that something like graded exposure does work for some sorts of things, such as phobias, for some people. Although, I don't think that graded exposure in those situations, done appropriately, is the same as "testing the system." Perhaps that is part of the attitudinal aspect to which you were referring? For example, I may feel differently when I'm practicing something than when I'm being tested even if the stimuli is the same.

Regardless, your question remains about what to do when the method you tried failed.

[Gil Haight]

I think you're right, Jon, when comparing the graded exercise routines to methods used for phobias. Please don't get me wrong, I'm not against graded exercise and often suggest its use clinically. What I'm calling into question is the position frequently taken on active exercise. Namely, it is always good. The American College of Rheumatology says the best treatment for fibromyalgia is active or conditioning exercise. I'm certain this is based on the concept of exercise induced analgesia. Yet, every patient with fibro says "exercise makes me worse". Conclusion: "you're not able to push through the pain to success". Another example is a stubborn TKA that worsens with passive stretching. Different issue but similar conundrum.
The movement that emerges with SC or with Functional Integration (Feldenkrais) is not effort based and often is quite effective for relieving pain sxs that are commonly provoked with effort-full routines, graded or not. Can we assume SC elicits endogenous analgesia in a much different way?
Gil

[Diane]

Gil, how does movement that is ideomotor differ from movement which is graded exposure? Really? To me they could mean exactly the same thing.
I think we need better definitions.
At the moment, I see way too many categorical assumptions about exercise in this profession but not much understanding about how to prime a patient properly to move a sufficient amount at his or her minimal painfree end of the line, then build on it.

[Gil Haight]

Diane,

"how does movement that is ideomotor differ from movement which is graded exposure?"

I think the difference involves planning or intention. With ideomotion the movement itself is not specifically sought. We could be splitting hairs especially when discussing graded movement as pain free. However, my suspicion is that intensional movement has a different origin than ideomotor activity. I am no expert on motor planning and hope someone could help resolve the point. If the movement associated with ideomotor activity does indeed come from a different region,(anterior cingulate for instance), we may have a new way to describe its (SC) analgesic consequences.

PS -could someone help me with the quote thing and the nice colored boxes everyone else uses. Thanks
Gil

[Frédéric]

Exercices probably «works» through many different mechanisms. The graded-exposure would work by changing both counscious and autonomous driven apprehensive behaviours thus changing the interpretation of afferent stimulations. This type of change can be slow and happen during the course of a year. Assimilation and understanding is needed on the part of the patient if we really want it to work. Moseley has shown the benefits of pain education might only be present after 6 months or more of juggling with the concepts by the patient.

Exs also can decrease pain with a top-down endogenous mechanism à la placebo or through a specific mechanism. It can also be via a mechanism unrelated to the endogenous path. For instance via the release of intra and peri articular interlukin-10 (a anti-inflamm. cytokine) when doing resisted exs. But then again, if there is no inflammation to start with it might not be so helpfull to release these cytokine.

So exs might not always be helpful, and that's for a number of reasons.

[Diane]

Hi Gil,
In your first post you said,

How about the idea that the mechanisms responsible are not working for what ever reason.

OK, can we start with what mechanisms you had in mind? Also, what thoughts you have about them?

[Barrett Dorko]

I may be oversimplifying it, but I've always understood that ideomotion (like excito and sensory motor movement) was instinctive. This identifies it as intended, active and volitional but beginning in areas of the brain not normally expressed after overt planning or instruction by another.

Graded exposure promotes careful, well-planned, often subtle movement with a definite purpose in mind - learning and desensitization. We notice when we're doing it and exert control. It's ballet.

Ideomotion, to my knowledge, is corrective in nature. It reduces neural irritation by changing the biomechanics and thus promotes blood flow/oxigination naturally and is a movement inherent to life, often amplified and/or reduced by context. It's improvisational dance.

[Diane]

Seems to me that this thread (Pain and Children) should be linked here.

I've always understood that ideomotion (like excito and sensory motor movement) was instinctive. This identifies it as intended, active and volitional but beginning in areas of the brain not normally expressed after overt planning or instruction by another.

Graded exposure promotes careful, well-planned, often subtle movement with a definite purpose in mind - learning and desensitization. We notice when we're doing it and exert control. It's ballet.

So, which parts of the brain, and how do you readily tell them apart other than conceptually? (In your own intrinsic categorizing system Barrett.) E.g., seems to me that Feldenkrais movement and learning could easily encompass both.

[Gil Haight]

My statement about mechanisms not working refers to those associated the bottom up aspects of exercise induced analgesia. These, as we know, involve baroceptors and chemocreceptors in the heart, lungs and carotids. I believe this information is first reported to the NTS and from there I'm uncertain. My point in all this is that since we do not know for sure why these mechanisms are not working we shouldn't assume there is a psychological underpinning responsible. Diane, I certainly realize you are not.

Barrett, Isn't it possible that in addition to the reduction of neural irritation there exist a central elevation in threshold or in other words endogenous analgesia?

Gil

[Jon Newman]

I think there are lots of reasons to encourage exercise because it's good for general health regardless of it's influence on a pain experience. As far as exercise induced analgesia is concerned, this is the most recent review available at PubMed. Also, the SS Forum Moderators' Current Consensus on Pain issues a cautionary note in point number 10

10. Conditioning for the purposes of fitness and function or to promote general circulation or exercise-induced analgesia can be performed concurrently but points 6 and 9 above should remain salient.

I was thinking that since there are quite a few new moderators, perhaps an updated consensus might be appropriate.

Originally Posted by Gil Haight

My point in all this is that since we do not know for sure why these mechanisms are not working we shouldn't assume there is a psychological underpinning responsible.

It seems to me that psychological issues are usually the story telling portion of our biology. Regardless, it isn't an either/or situation. That is, it probably isn't helpful to assume either the presence or absence of psychological elements. For example, here's Cory reporting on some research conducted by Steven George about how the two can combine to amplify a pain experience. And here is a link to a little more about the MET-MET COMT condition. The link is to Google Books' copy of Fibromyalgia and Other Central Pain.

[Barrett Dorko]

Wonderful points in the last two posts especially.

Gil, I thnk it's certainly possible but I haven't any literature to point to in the way of research on the matter. It's probably out there somewhere.

I can't help but think of how much unfamiliar, novel movement engages the brain and how the reflexive effect, learning and changing that accompanies that alters the amount of threat present. I don't employ Simple Contact unless I sense that my presence is perceived as nonthreatening to the person I'm handling. In this way I'm like a pick-pocket, if you know what I mean.

When ideomotion doesn't relieve pain immediately yet generates the characteristics of correction (and pain relief is not one of these) I assume that the work will simply take some time. If after a while there is no improvement I assume I can blame many other factors. I know this is convenient, but that doesn't mean I'm wrong.

What I have to focus on is doing my job. In the places I work my boss and colleagues really don't know what I think that is.

But the patients figure it out.

[Gil Haight]

Barrett,

Thanks for reminding us of the "Characteristics Of Correction". Freud's point on surprise is particularly interesting. Who is surprised during aerobic exercise? When exercise doesn't work, perhaps a method seeking the experience of surprise is the best alternative. What does SC or any other method based on the characteristics of correction share with active aerobic exercise? We know they can both relieve pain.
Gil

[zimney3pt]

Who is surprised during aerobic exercise?

Well I have some patients that seemed suprised after I have them try and walk on the treadmill or ride the exercise bike and they "think" they are in okay condition, only to become short of breath and have to stop after 3-4 minutes of continuous movement at a moderate pace. They are surprised how limited their conditioning is.

But I don't think this is the sort of surprise you are referring to Gil.

[Jon Newman]

In addition to Kory's anecdote, I have a subgroup of patients that are surprised that exercise (such as it is) that initially hurt, actually made them feel less painful afterward.

The problem, to come back around to Gil's original post, is what is happening, and what do we do, for those who hurt during and after exercise and even flare-up afterword; all of which is no surprise to the patient because they already know exercise doesn't help their pain.

[Barrett Dorko]

When does "movement" become "exercise"?

[Diane]

All we can do is warn them, frame pain properly, treat them appropriately before during and after, and help them understand that they must, and how to, recruit themselves.
Nice paper, free access.

Pain neurophysiology education improves cognitions, pain thresholds, and movement performance in people with chronic whiplash: a pilot study.

[zimney3pt]

When does "movement" become "exercise"?

This is a great question, I think sometimes if I mention the word exercise, I can trigger the pain neuromatrix with some patients. So with them I tend to use the word movement instead. Usually trying to continue to teach motion is lotion and your nervous system likes space, movement and blood. Maybe use the story of the Sea Squirt that actually absorbs and gets rid of it's own nervous system after it attaches itself to a rock as it doesn't need it anymore once it doesn't need to move and becomes more like a plant. Even though the word and thought of movement can still trigger the pain neuromatrix, probably not as much as the word or thought of exercise for most. Exercise, for many, has more of a negative connotation due to cultural issues.

Since exercise is a subset of motion. Physical exercise is always motion, but motion is not always exercise and only becomes exercise when it fits the definition of exercise. Which I would say is a bodily activity directed toward maintaining or improving physical fitness and overall health by being structured, planned, and repeated.

[Jon Newman]

Originally Posted by Barrett Dorko

When does "movement" become "exercise"?

That's a question that is likely to produce a variety of reasonable answers. I think exercise encompasses movement but movement need not be exercise. I think the changing in position of two points relative to each other constitutes movement.

I read the dictionary definitions exercise and I think the word is broad enough in meaning that many instances of movements could be included or excluded depending one's conceptual bucket at the moment of discussion. I think in casual PT conversation, it would mean some sort of (usually repetitive) movement primarily intended to increase physical fitness.

I see my post crossed with Kory's. We seem to be on the same page.

[Diane]

What Kory said in post 23 is how I handle it too.
Actually Jon, I'd go the other way round and say that exercise (cows) is a subset of movement (animals).
It's supposed to be a special subset, in that the point is supposed to be about paying inward conscious attention to how one's body is moving, and how it feels, but I'm afraid you're right - the meaning has blurred into the drone of a treadmill or stationary bike or the clang of steel & iron weights/barbells or loud crashy music or the glint of mirrored walls.

[zimney3pt]

the meaning has blurred into the drone of a treadmill or stationary bike or the clang of steel & iron weights/barbells or loud crashy music or the glint of mirrored walls.

Yes much of this is not planned or structured and repeated incorrectly to actually do much to improve physical fitness and overall health.

[Jon Newman]

Originally Posted by Diane

Actually Jon, I'd go the other way round and say that exercise (cows) is a subset of movement (animals).

I probably didn't express myself well but I think we're on the same page. I was thinking in terms of what else needs to be specified in order for something to be considered a cow, and not just an animal. You need to be an animal to be a cow just as you need movement for most PT related definitions of exercise. But while a platypus is an animal, it is not a cow. At what point does an animal become a cow?

[Diane]

Originally Posted by Jon Newman

I probably didn't express myself well but I think we're on the same page. I was thinking in terms of what else needs to be specified in order for something to be considered a cow, and not just an animal. You need to be an animal to be a cow just as you need movement for most PT related definitions of exercise. But while a platypus is an animal, it is not a cow. At what point does an animal become a cow?

I thought I answered that in #25, ("the point is supposed to be about paying inward conscious attention"). I meant in contrast to doing things with attention focused outward on whatever is being done as an action output to accomplish some kind of task - doing the dishes etc.

[Jon Newman]

Yes, you did. I didn't mean to imply you didn't. I was just carrying on. Bloviating, I think it's called. Sorry about that.

[Barrett Dorko]

I wrote We're looking for a movement, not for an exercise.

When I simplify Melzack's diagram I choose the word deformity to circle and then suggest we use that as our entryway into the "input side" - of this thing, hoping and working to change that in the right direction. It will take a movement, and instinctive movement is our best choice for pain relief.

It won't make us healthy or strong or beautiful.

[Diane]

@Barrett, exactly. 'Exercising' something else beside externally motivated movement or 'exercise.'

I think, given what is now understood about the brain, both terms need revising.

[Diane]

I wonder what this tells us about "movement"?

[Gil Haight]

Yesterday on NPR's Science Friday, the guest Holly Tucker discussed the gory origins of modern day blood transfusions. Something she said about "blood letting" reminded me of this discussion (bear with me). Apparently early ideas about the heart were rooted in the idea of the organ being a furnace where blood was burned as fuel. When someone became sick with a fever, fuel was removed to help return to normal.
The incorrect understanding of the circulatory system led to years of improper treatment , although some success must have occurred with removal of blood volume. O.K. it is not as dramatic but an idea such as the misunderstanding of what exercise does(regarding pain relief) can get in the way of new, more complete appreciation of what is really happening.
I don't think we should get caught up in terms at this point. What is more important is the origin of the activity. Kory's point about exercise, whether super training or graded, as planned, repetitive, and structured is quite correct and significant. In other words intentional, voluntary and effort-related. The concept of ideomotion considers a type of motion which, of course, is much different. It is not effort related, not planned and although the idea may be intentional, the movement is not. Isn't there an interesting comparison available here?
Gil

[Barrett Dorko]

You're right Gil.

That's why I always say ballet and improvisational. Ballerinas have told me, "I relieve my pain by dancing improvisationally for a while."

Maybe people don't know enough abut these dance forms or they are driven to admire the ballerina without knowing (or wanting to know) how painful the form is. They should watch Black Swan to find out.

[smith]

Originally Posted by Barrett Dorko

I wrote We're looking for a movement, not for an exercise.

When I simplify Melzack's diagram I choose the word deformity to circle and then suggest we use that as our entryway into the "input side" - of this thing, hoping and working to change that in the right direction. It will take a movement, and instinctive movement is our best choice for pain relief.

It won't make us healthy or strong or beautiful.

Margin for championships is too close. Difficult to win these titles if the nerves are too sensitive. If the nerves are functioning correctly you may have a chance.

[Gil Haight]

I heard recently that a big reason why many (20-40%) of the american public is against taxing the rich is because they either seen themselves in this group or believe they will someday get there. Neither is true at least nowhere near those percentages. Smith's comment leads me to believe many in pain see their plight in terms of being competitive physically. It is no wonder why we are not able to suggest an alternative.
Gil

[Barrett Dorko]

Gil, I heard that too.

If you ask most people (including therapists) if they're having any pain they'll say, "No," pause, and then say, "Well, I have (insert joint or other mesodermal structure here) pain, but I'm over 40/50/60 or fat or out of shape, or lazy or clutzy."

Of course, none of these things constitute an origin of pain.

In short, according to the culture, pain is expected, inevitable even. Kind of like wealth.

I'm sixty, have no pain. I'm not wealthy either.

[Diane]

[This is a bit of a tangent, but right now I'm reading Deer Hunting with Jesus, by Joe Bageant, and gaining a lot more insight into US 'heartland' mindset, including factors that seem like they would pertain to this thread.]

[Jon Newman]

Here's a link to a new paper--Effects of Exercise on Endogenous Pain-Relieving Peptides in Musculoskeletal Pain--A Systematic Review

Clin J Pain. 2011 May;27(4):365-74.

Effects of exercise therapy on endogenous pain-relieving peptides in musculoskeletal pain: a systematic review.

Fuentes C JP, Armijo-Olivo S, Magee DJ, Gross DP.

OBJECTIVE:
To review the literature regarding the effects of exercise in patients with musculoskeletal pain on modifying: (1) the plasma or cerebral spinal fluid concentrations of pain-relieving peptides and (2) changing the cerebral activity of areas linked with pain processing and modulation systematically.
METHODS:
An extensive search of bibliographic databases including MEDLINE, EMBASE, EBM Reviews-Cochrane Central Register of Controlled Trials, ISI Web of Science, Scopus, PeDro, AMED, and CINAHL was made. Two independent investigators screened the titles of publications and completed quality assessment of the selected studies.
RESULTS:
The search of the literature resulted in a total of 1819 published studies. Of these only 1 study of low methodological quality was considered to be relevant. The agreement between reviewers to select the articles was κ=1. The agreement for the methodological quality evaluation was κ=0.9.
DISCUSSION:
Given the small number of studies identified and the low quality of research, no firm conclusions could be reached about the impact of therapeutic exercise on modifying concentrations of pain-relieving peptides or its effect on changing the cerebral activity of areas linked with pain processing in patients with musculoskeletal pain. There is a clear need for well-designed trials examining exercise therapy interventions and their effect on both pain-relieving peptides and cerebral activity in patients with musculoskeletal pain.

PMID: 21430521