Chronic Pain Patients Need Movement, Not a Lecture About Exercise

Few phrases can make somebody with severe chronic pain feel dismissed faster than, "You need to exercise more."

The advice may be medically reasonable, but the delivery often isn't.

Movement can help people with chronic pain; exercise therapy can reduce pain and improve function in conditions including chronic back pain, fibromyalgia, and hip or knee osteoarthritis.

CDC guidance includes aerobic, aquatic, and resistance exercise among non-drug treatments clinicians can consider.

Nonopioid therapies are at least as effective as opioids for many common types of acute pain.
Clinicians should maximize use of nonpharmacologic and nonopioid therapies as appropriate for the specific condition and patient and only consider opioid therapy for acute pain if benefits are anticipated to outweigh risks to the patient. Many acute pain conditions can often be managed most effectively with nonopioid medications. Noninvasive and nonpharmacologic approaches to acute pain also have the potential to improve pain and function without risk for serious harms.
Clinicians can consider using nonopioid therapies to treat common types of acute pain including:
Low back or neck pain
Dental pain
Kidney stone pain
Pain related to musculoskeletal injuries (such as sprains, strains, tendonitis, and bursitis)
Pain related to minor surgeries typically associated with minimal tissue injury and mild postoperative pain (e.g., simple dental extraction)
Headaches, including episodic migraine

But there's a great deal of ground between "movement can help" and "just exercise."

High-impact chronic pain is pain that frequently limits a person's life or work activities. In 2023, 8.5% of American adults met that definition. Among adults with chronic pain, 34.9% had high-impact chronic pain.

From the CDC:

Data from the National Health Interview Survey
In 2023, 24.3% of adults had chronic pain, and 8.5% of adults had chronic pain that frequently limited life or work activities (referred to as high-impact chronic pain) in the past 3 months.
Chronic pain and high-impact chronic pain both increased with age.
American Indian and Alaska Native non-Hispanic adults were significantly more likely to have chronic pain (30.7%) compared with Asian non-Hispanic (11.8%) and Hispanic (17.1%) adults.
The percentage of adults with chronic pain and high-impact chronic pain increased with decreasing urbanization level.
Chronic pain and pain that often restricts life or work activities, referred to in this report as high-impact chronic pain, are the most common reasons adults seek medical care, and are associated with decreased quality of life, opioid misuse, increased anxiety and depression, and unmet mental health needs. In 2019, 20.4% of adults had chronic pain, and 7.4% of adults had high-impact chronic pain. This report uses data from the 2023 National Health Interview Survey (NHIS) to provide updated percentages of adults who experienced chronic pain and high-impact chronic pain in the past 3 months by selected demographic characteristics and urbanization level.
The percentage of adults who had chronic pain and high-impact chronic pain in the past 3 months was higher in women than men.
In 2023, 24.3% of adults had chronic pain, and 8.5% of adults had high-impact chronic pain.
Women were more likely to have chronic pain (25.4%) and high-impact chronic pain (9.6%) than men (23.2% and 7.3%, respectively).

For someone in that group, getting dressed can require effort, a shower can take planning, grocery shopping may mean deciding whether there will be enough strength left to make dinner, and walking from the parking lot to an appointment may already be part of the day's physical workload.

So when a patient says exercise hurts, the answer shouldn't automatically be, "Do more."

Pain patients aren't exempt from the benefits of movement, and they shouldn't be frightened into avoiding every activity. But movement has to meet the person where he is.

CDC guidance for people with chronic conditions says some activity is better than none and tells people to be as active as they are able. It also recommends consulting a health professional about appropriate types and amounts of activity. A generic exercise sheet doesn't accomplish any of that.

A useful plan asks better questions: What can the patient do now? Which movements trigger a flare? How long does the flare last? Is walking tolerable while resistance work isn't? Would water exercise reduce stress on painful joints? Can activity be broken into smaller pieces instead of forcing the patient through one punishing session?

The goal should be sustainable function, not proving toughness.

CDC guidance also recognizes physical therapy as useful, particularly when low-intensity exercise hasn't improved pain.

Many acute pain conditions often can be managed most effectively with nonopioid medications (10,122). A systematic review found that for musculoskeletal injuries such as sprains, whiplash, and muscle strains, topical NSAIDs provided the greatest benefit-harm ratio, followed by oral NSAIDs or acetaminophen with or without diclofenac (122). NSAIDs have been found to be more effective than opioids for surgical dental pain and kidney stone pain and similarly effective to opioids for low back pain (10). Evidence is limited on comparative effectiveness of therapies for acute neuropathic pain, neck pain, and postoperative pain (10). For episodic migraine, triptans, NSAIDs, antiemetics, dihydroergotamine, calcitonin gene-related peptide antagonists (gepants), and lasmiditan are associated with improved pain and function with usually mild and transient adverse events (11).
ACP recommends NSAIDs or skeletal muscle relaxants if pharmacologic treatment is desired to treat low back pain (119). For acute musculoskeletal injuries other than low back pain, ACP and AAFP recommend topical NSAIDs with or without menthol gel as first-line therapy and suggest oral NSAIDs to relieve pain or improve function or oral acetaminophen to reduce pain (120). The American Dental Association (ADA) recommends NSAIDs as first-line treatment for acute dental pain management (123). For acute kidney stone pain, NSAIDs are at least as effective as opioids (124–127), can decrease the ureteral smooth muscle tone and ureteral spasm (128) causing kidney stone pain, and are preferred for kidney stone pain if not contraindicated. Triptans, NSAIDs, combined triptans with NSAIDs, antiemetics, dihydroergotamine, and acetaminophen are established acute treatments for migraine (11). Lasmiditan, an 5-HT1F receptor agonist, and ubrogepant, a gepant, were approved by FDA in 2019 for the treatment of migraine (129); another gepant, rimegepant, was approved in 2020. Lasmiditan and the gepants were more effective than placebo in providing pain relief at 2 hours, 1 day, and 1 week (11). Adverse events related to these newer medications require further study; however, their mechanisms of action are believed to be nonvasoconstrictive (130) and potentially carry lower risks than vasoactive medications in patients with cardiovascular risk factors (11).
When not contraindicated, NSAIDs should be used for low back pain, painful musculoskeletal injuries (including minor pain related to fractures), dental pain, postoperative pain, and kidney stone pain; triptans, NSAIDs, or their combinations should be used along with antiemetics as needed for acute pain related to episodic migraine. NSAID use has been associated with serious gastrointestinal events and major coronary events (8), particularly in patients with cardiovascular or gastrointestinal comorbidities, and clinicians should weigh risks and benefits of use, dose, and duration of NSAIDs when treating older adults as well as patients with hypertension, renal insufficiency, heart failure, or those with risk for peptic ulcer disease or cardiovascular disease. Vasoactive effects of triptans and ergot alkaloids might preclude their use in patients with migraine who also have cardiovascular risk factors (11,131,132). Clinicians should review FDA-approved labeling, including boxed warnings, before initiating treatment with any pharmacologic therapy.

Yet it acknowledges a problem chronic pain patients know well: insurance coverage, cost, transportation, and rural availability can make non-drug treatments difficult to obtain.

Telling someone to try physical therapy is easy. Paying repeated copays, driving an hour each way, missing work, and finding a therapist who understands the condition are another matter.

Good pain care requires more than repeating the word "exercise." It requires listening, adjustment, patience, and an honest measure of what the patient can actually sustain.

Movement should help a person reclaim pieces of life. When the prescription becomes another test the patient is expected to fail, medicine has missed the point.

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