Thoughts on Pain Management

christophernetley
Apr 3, 2024
12 min read

Updated: May 8, 2024

What are your options for dealing with joint and muscle pain? I’ve heard this problem described as the SuperMarket effect. Imagine going to the chip aisles of a large grocery store. Which chips do you buy? How do you make the right choice? The chips at eye level are being strategically presented to you by the supermarket. These are the first chips you will see and you are most likely to select from these options. As you look around you may notice some other chips are labeled as “all natural” and “organic.” Is that a better choice? Some chips are significantly cheaper and even on sale. Do you make a choice based on price alone? Then you see the brand of chips that your friend recommended. She had a good experience with those chips. Is that the right choice for you? Maybe you do not even need chips. Maybe crackers would suit you better. Or, how about a mixed bag that contains multiple types of crunchy treats that are both salty and sweet? This is literally what goes through my mind when my wife just writes “chips” on the shopping list.

Dealing with pain presents a similar dilemma. How do you select the best option (or options) for you? Here are some choices that may or not be at eye level:

Soft tissue therapies such as massage, cupping, scraping, dry needling, and kinesio-tape.
Joint manipulations such as getting your back cracked by a chiropractor or joint mobilizations without a thrust or a crack.
Modalities such as e-stim, laser, ultrasound, shockwave, and TENS units
Supplements such as glucosamine, collagen, and herbal supplements.
Medical treatments such as: pain medication, anti-inflammatories, injections, or surgery.
Physical activity and exercise such as walking, moderate or vigorous cardio, strength training, yoga, pilates, stretching, or rehab.

Another option is simply to do nothing. Just walk away from the chip aisle completely. The interesting thing is that none of these options clearly outperform any of the others in research or in clinical practice. You can find literature to support and refute all of them (both peer reviewed and anecdotal case studies). Unfortunately, clinical practice is even more confusing than the literature.

If you are in pain and you see a specialist, what do you think that specialist is likely to recommend? For example, if you suffer from back pain and you go to a traditional chiropractic office, it is very likely that they will recommend a chiropractic adjustment. If you see a massage therapist for the same case of back pain, they will probably recommend a massage. A shoe store will probably recommend new shoes to fix your back pain. A mattress store will probably recommend a new mattress. You can clearly see the trend. This brings us back to the chip aisle analogy. How do you choose which specialist to call? None of these options are necessarily 100% wrong because these may all be viable therapies for your specific episode of pain.

But how is it possible that you could receive such diverse recommendations for the same case of back pain? All of these specialists are likely to claim that the “root cause” of your pain just so happens to be the exact service or product they sell.

There are so many options because pain is complex and poorly understood. There does not seem to be a universal consensus on how to treat pain. So, any one (or any combination) of options may or may not work for you. Doing nothing may also work just as well as doing anything. Oddly enough, avoiding therapies all together, staying physically active, and maintaining a positive outlook tend to work just as well as (if not better than) most treatments.

But, when selecting your bag (or bags) of chips, it is important to know that one of these options is extremely unique when compared to all the others. Let’s talk about physical activity. Physical activity and exercise can be helpful for short-term pain relief and long-term pain management for 3 main reasons:

Reason #1) Movement may help reduce pain.

We all experience this phenomenon when we stub a toe or jam a finger and instinctively hop around or shake our hand. There are many theories for why movement makes us feel better.

This is not new information, nor does it necessarily make exercise a unique option. It is worth stating that movement is a common mechanism that produces positive results for most of our pain management therapies. That is to say, creating movement is a common theme for many treatments.

Reason #2) Movement doesn’t require a doctor visit.

The second reason why physical activity is useful for pain management is that movement can be performed by you without clinical supervision. Physical activity is free. Exercise can prepare you for activities and positions that may provoke pain, which can build tolerance and confidence. This preparation goes beyond merely getting stronger, because strength does not guarantee less pain. Exercise and general physical activity offer you the ability to gradually expose your body to more stress in manageable doses. Imagine the shock of jumping into a scolding hot tub without any warning. Now imagine how much different it would feel to slip into a lukewarm warm bath and then allow the water to gradually heat up. Exercise intensity, duration, and frequency can be adjusted to appropriate levels, creating a comfortable entry point for any movement or position. Then, over time, exercise can “heat up” at a manageable pace. Eventually, you can build a tolerance to any activity.

This does begin to separate physical activity and exercise from other pain management options. You don’t necessarily need to schedule an appointment with a healthcare provider to move more. But if you don’t know where to begin, seeking guidance from a healthcare provider or a fitness professional can be valuable. The beautiful thing about movement and exercise is that you can self-administer your own treatment multiple times each day. So you end up benefiting from effective treatment at much higher doses. More care for less money with better health outcomes. That’s not a bad offer.

Reason #3) Movement offers health benefits, not just pain management.

The 3rd reason why physical activity is useful for pain management is that movement has a very wide range of health benefits that extend far beyond pain reduction. This characteristic makes physical activity and exercise very unique compared to all the other options. Now let’s consider the benefits of physical activity and exercise. Moving more often can:

improve your mood and your sleep;
slow the effects of aging;
lower your risk for heart problems, high blood pressure, type 2 diabetes, and some kinds of cancer;
help maintain your immune system, which may lower your risk of infection, lessen the symptoms and speed the recovery of various illnesses;
help keep your mind sharp as you get older and lower your risk for Alzheimer’s and dementia;
increase your energy levels and it can simply make your life better.

When managing muscle and joint pain, we must at least consider the possibility that nothing we do will make the pain go away faster or prevent the pain from returning. We need to acknowledge that most of our therapies & treatments for pain, at best, may only provide limited relief (including exercise). Let me be clear, I am not saying that people who are physically fit suffer from less pain. Physical activity and physical fitness are not necessarily the “cure” for pain; however, moving more and improving physical fitness offer undeniable health benefits.

At the same time, they make you more adaptable and empower you to (at least partially) self manage your health and painful experiences.

But we need to be honest; getting our backs cracked, taking supplements, having our joints lasered, and most of the other popular pain therapies are probably not going to offer the long-term results that many people want. Which does not make them useless or pointless. I will address the utility of these therapies later in this blog post.

If what I am saying resonates with you, let’s consider the possibility that there are no superior pain treatments, and that most treatments only work for some people (sometimes), and that painful episodes tend to last a particular amount of time regardless of what we do. If we can be open to these possibilities, then we can ask one really important question:

During a painful episode, can we maintain or even improve our overall health?

Let’s take a step back. For a moment, let's stop hyperfocusing on the body part that hurts and consider the entire person. We can prioritize things we know to maintain and improve health, such as general physical activity, strength training, improving cardio, good quality sleep, nutrition, stress management (and good mental health in general), appropriate management of any other health issues, and (of course) not smoking.

Why is it important to prioritize health when suffering from chronic pain? When in pain, there is a tendency to let our health decline. People tend to move less. When we move less and stop exercising, we lose muscle mass and our heart and lung fitness suffer. These changes are associated with poor health and chronic disease. Some people tend to eat more and gain weight while they are in pain. Weight gain is also associated with poor health and chronic disease. Sleep can be affected. It has been suggested that sleep is the most important thing we do each day to maintain health (for the brain and body). Mental stress can have even more impact when we are in physical pain. Many people do not realize that there is an association between physical pain and mental health challenges like stress and depression. Some people will turn to coping mechanisms like tobacco, alcohol, and recreational drugs. Some will misuse painkillers. None of these are positive for your health. Appropriate management of other health issues is also a huge factor in pain management. Besides physical pain, what else is your body dealing with? Do you have any other health issues that need to be managed first or addressed during the pain management program? Or, is your body going through something that is currently undiagnosed?

I will use my dad’s experience as an example. In episode one of the Build Beyond Podcast, I shared my dad’s cancer story and how he inspired the name of this podcast. He was diagnosed with metastatic lung cancer five weeks before he died. My dad did not just wake up one day feeling unwell and then die five weeks later. He had been struggling with numerous issues for years. I remember conversations with him when he described feeling like his body was falling apart. He had been to many specialists for various issues. Looking back, it seems that he slipped through the cracks because his healthcare providers were hyperfocusing on his chief complaint on that particular day, which was usually related to physical pain. In my dad’s specific case, he needed someone to step back and look at him as a whole person. He needed someone to (at least for a brief period) consider his overall health and not just his achy joints.

An earlier diagnosis may not have saved him. I know this. But more time would have been nice.

I am not using this story to scare you or to suggest that you run to the nearest oncologist. My point is that there is a lot that we can accomplish while we are in pain. As the painful episode runs its course, we can do our due diligence to rule out scary diagnoses. Often, this can be accomplished with a thorough health history and an in depth discussion about the thing that hurts. And during this discussion we can take time to highlight potential ways to improve health.

Consider the idea that pain is a request for change. Episodes of pain can either be demoralizing or they can be motivating. If we allow pain to demoralize, there is a tendency toward lifestyle changes that are not associated with health or pain management: less movement, poor nutrition, poor sleep, increased stress, substance abuse, etc.

But if we allow pain to motivate us by using it as a call to action, pain can transform into a catalyst for better health and, ideally, long-term pain reduction.

Pain can offer the motivation to discuss, prioritize, and begin to take action on things that improve health. The best part is that you can begin wherever you want. There is no fixed path.

You can consider the areas of your life that are not serving you well in relation to your health, prioritize them, and take action on the options that motivate you the most. You may want to begin by walking more or switching from regular soda to diet soda. You may join a gym, hire a personal trainer, or talk to your doctor about ways to improve your sleep. You may seek counseling for stress management or talk to a dietician about creating a nutrition plan. You may talk to someone like me who can help you formulate a plan and walk with you along your journey. You may even be motivated to begin with a combination of actions. It doesn’t matter where you start. It just matters that you start. Don’t expect perfection. Just strive for progress.

The great news is that during this process, pain therapy options like massage, laser, e-stim, chiropractic adjustments, medication, supplements, injections, and cupping may offer great ways to take the edge off while you work toward improving health and seeking long-term pain management strategies. These therapies can be seamlessly incorporated into a pain management plan, but they are merely adjuncts that may or may not have any effects depending on the individual. Also, keep in mind that many of the most popular pain management therapies do not outperform simply doing nothing over the long-term. Therapies can be extremely useful, if you value them and if they are administered appropriately.

We should be honest with ourselves that we may never be able to completely abolish pain. It has been said that the best predictor of pain is a previous history of pain. So, if pain is an inevitable human experience, then preparation and self management are valuable. If we can entertain the realistic possibility that pain may never be completely prevented or cured, then we are free to embrace effective short-term remedies that may help us weather the storm while we prioritize and execute effective long-term strategies for reduction and a return to activity. Movement and exercise offer viable options to help us prepare for painful episodes by improving our health and making ourselves more robust.

It does not appear that we currently have any universally effective short-term or long-term pain management options. Supplements, joint manipulations, soft tissue therapies, injections, medications, special exercises, and other therapies may not fix anything. When sold individually, most pain therapies are touted as addressing a “root cause,” often suggesting that pain results from a singular source. For example, you may be told that you have an injury that needs to heal or a broken part that needs to be fixed or a misalignment that needs to be corrected. We must be open to the reality that pain does not always have a singular root cause and that pain does not necessarily mean that you are broken, out of alignment, or need to heal.

If pain was that simple to treat, it would not be such a huge issue. Pain is complex. Complex problems require multifaceted approaches. And efforts to maintain or even improve health during this process should be paramount. If that’s what you want.

It is important to note that I am generalizing and not talking about specific joints or muscles. If you are suffering from pain and you want help, it can be valuable to seek guidance from a healthcare provider or coach who has experience working with your issue. Although there can be nuance when handling pain in different areas of the body, I believe that these recommendations will work well for most people dealing with joint or muscle pain in any region. My confidence stems from the focus on overall health, an emphasis on remaining active, and the desire to help people find effective ways to self manage without the need for routine “maintenance” care. This approach positions a health care provider as a guide, not a mechanic. I love the driving instructor analogy. Since your driver’s training course, how often have you needed instruction behind the wheel? A driving instructor teaches students not to need them. This analogy isn’t perfect, but I think most people can appreciate the intent. It seems that this mentality could be beneficial when helping people struggling with pain. Especially chronic pain.

I have included some references at the end of this blog. None of these papers provide a clear solution when it comes to pain management and this list is by no means comprehensive. But the list of references does begin to illustrate the general lack of consensus.

I am not including any research on the health benefits of moving more. At this point, I believe it is common knowledge that movement is beneficial.

It is recommended that we take 8,000 to 12,000 steps per day. It is also recommended that we resistance train 2 to 3 times per week. Cardio guidelines recommend a minimum of 150 minutes per week of moderate intensity activity or a minimum of 75 minutes per week of vigorous intensity activity or a combination of both. Aerobic activity should be spread out over 3 to 5 days per week. Of course, physical activity does not need to be regimented or organized in this manner. For example, many CrossFitters meet or exceed the guidelines through training sessions that combine strength training, muscular endurance, and cardio. You may also meet or exceed the guidelines through sports or recreational activities.

For more information on the physical activity guidelines, the American College of Sports Medicine is a great resource.

References

PMID: 37925996

PMID: 32795336

PMID: 34538747

PMID: 32756930

PMID: 25550671

PMID: 33596925

PMID: 33947735

PMID: 37239790

PMID: 24436697

PMID: 21599991