In 1970, University of Washington anesthesiologist John J. Bonica, MD, almost single-handedly created the specialty of treating chronic pain. By 1985 pain clinics had sprung up all over the world, each with a different approach. But what treatment patients received depended not on what was wrong with them but what kind of specialist their doctor was. If you saw a surgeon, you got surgery. Anesthesiologists performed nerve block injections. Rheumatologists (specialists in arthritis) prescribed anti-inflammatory drugs. Neurologists administered anti-seizure drugs. Psychologists gave patients cognitive behavioral therapy. Other treatments included physical therapy, chiropractic, acupuncture, biofeedback, hypnosis, spiritual healing, meditation, and group therapy.
Everyone was shocked when they analyzed treatment results: all the patients had similar outcomes. Regardless of the treatment approach, about a third of patients in each clinic were the same or worse, a third were slightly better, and a third clearly benefited from treatment. Each approach could boast of patients nobody else could help — they had improved miraculously under their care. But overall, none of the clinics’ results were significantly different from placebo.
This dismal picture changed dramatically in the mid 1980s, when two Dallas physicians created the PRIDE program, based on the principles of sports medicine. If a professional athlete is injured, he or she goes through a rigorous program of rehabilitation lasting weeks, exercising 6-8 hours a day. No one asks the athlete if the exercise hurts; no one cares. Within a few weeks, the athlete is back at his/her sport.
The PRIDE program focused on workers compensation patients with low back injuries. The typical PRIDE patient had undergone two back surgeries and been off work for two years. The usual prognosis was dismal: only 5% of these patients ever returned to work of any sort. But at the PRIDE program, 82% were back without restriction in their original jobs a year after completing the program. These statistics were unheard of. (See Mayer TG and Gatchel RJ, Functional Restoration for Spinal Disorders. Philadelphia: Lea & Febiger, 1988.)
The PRIDE program called their approach functional restoration. Its value has since been proven around the world. It is the approach I favor for almost everyone with pain.
The key insight in functional restoration is to focus on treating patients’ lousy fitness and poor function. Most pain treatments are passive: you lie there and they treat you. Passive treatments often fail, with a few exceptions: for a week or two after surgery or an injury, or as an adjunct to active therapy. And occasionally people receive lasting benefit from massage or acupuncture, although more often the relief from these measures is fleeting.
What’s active therapy? Become fit, flexible, and strong: regain the function you lost as a result of your pain. Becoming fit means aerobic fitness: walking or bicycling or swimming more than most people your age. Flexible comes from stretching, and strength from calisthenics and lifting weights.
I kid my patients that if they walked five miles in less than 1-1/2 hours every day, their pain would go away. This isn’t quite fair, because few of my patients with back or leg pain can walk more than 1-2 miles a day at most. So being able to walk five miles means you’re already at least some better. But the principle remains: more exercise, more fitness, and more function mean less pain. As I discuss in the section on exercise, you’ll also notice improvements in mood, energy, sleep, and ability to concentrate.
For most people this means physical therapy. But there’s a problem: most physical therapy is ineffective. I call it “shake and bake”: massage and heat. Often therapists add ice packs or ultrasound. This is passive therapy, and for almost everyone it’s a waste of time. Be certain your therapists know about functional restoration and can show you how to do it. (Note that a limited amount of passive therapy can help to reduce pain flare-ups that may occur with active exercise.)
Once again: any treatment where you lie there and they treat you is passive. It rarely works used by itself. (Of course, some kinds of pain require different approaches, and occasionally a passive treatment works wonders.)
As you become fit, you can do more exercise without causing pain. Your goal is to become more fit than anyone you know. This takes months, sometimes longer. Once you’ve achieved a high level of fitness, often your pain has lessened to such an extent you can cut back on your exercise schedule and still remain comfortable. However, many people find they have pain relief only if they continue their exercise regimen.
Exercise smarter than your pain
Most of my patients think I’m crazy when I tell them they need to exercise. They’ve tried it, and it just makes their pain worse.
My favorite example of what not to do is a woman with back pain who’d spent five years lying in bed. As you might imagine, she was incredibly frustrated. For three days she’d be in too much pain to move but would become more and more upset. Finally her pain would diminish. She’d leap out bed and weed the garden for three hours. Blam! Back in bed for three days.
She did two things precisely wrong. First, rest is your enemy. Within appropriate limits, you need to move. Virtually anyone who spends most of their time in bed will be in pain. But then she engaged in extreme effort that she was not fit enough to do properly. I call this “binary exercise”: 100% or nothing, with nothing in between.
The best approach is to do small amounts of exercise within your range of tolerance several times a day.
Miliary pilots sometimes talk about “flying beneath the radar.” This refers to entering enemy territory where surface-to-air missiles will shoot you down if you fly high enough to show up on their radar screens. If you fly at treetop level, you’re invisible to the air defense system. The analogy here is to do just enough exercise to become fit, but not so much you “show up on the radar,” i.e., have a pain flare-up. Do exercise and stretching frequently but gently. Then, as you become more fit, you can do more without having pain.
The other important principle is no one set of exercises works for everyone. The only way to figure out what will work for you is trial and error. Moreover, what causes flare-ups today may be the best exercise you can do two months from now. Be creative. Figure out how to finesse problems as they occur.
To illustrate the point, I often tell my patients the following fairy tale. Imagine you’re in Blythe, California, a small town on the 10 Freeway in the middle of nowhere in the desert. It’s near the Arizona border, about as far east as you can get on the 10 and still be in California. You’ve got to drive to Palm Springs, which is about 100 miles to the east, right off the 10 freeway. No problem, right? Hop on the 10 and you’re there in two hours. It’s midnight, so there’s little or no traffic.
But tonight there’s a problem: the entire 10 westbound is closed. So you have to drive on the 10 eastbound, going the wrong way against the traffic. There are two lanes and so you should be mostly okay, but sometimes the traffic increases and so you’ll have to get out of the way. The trick is to stay alert. Don’t hit a truck! There aren’t any rules, just keep awake and drive by the seat of your pants. Occasionally, if the traffic is especially heavy, you may have to pull over briefly. But if you stay by the side of the road all night, you’ll never get to Palm Springs.
This is the best mental image I can think of for exercising when you have myofascial pain. It feels like exercise is going against the traffic, against what your body wants. But if you don’t exercise, you get worse. Myofascial pain waxes and wanes, just as the “traffic” becomes heavier and lighter. Exercising in a way that causes a flare-up is what I call “hitting a truck.” How do you avoid it? Stay out of the way! — in other words, learn what works and what doesn’t for you. As you become more fit, you’ll find that exercise that hurt at one point now feels great.
Caveats and exceptions
Okay, you’ve decided to become fit flexible and strong and to get rid of your pain. Here’s the “on the other hand” part:
First, certain passive therapies can be miraculous. I’m particularly fond of acupuncture (especially for osteoarthritis and myofascial pain) and deep tissue massage, also known as myofascial release. And as noted above, virtually every kind of therapy can show you one or two patients who did well with their approach and nothing else.
Second, you need to give up the idea you’ll become completely free of pain. Certainly this occurs, and I say more elsewhere about how to do this. At least for the first few months of treatment, you need to focus on fitness and function, not pain. In the end, you may find your pain is still there but down to a dull roar: a nuisance that no longer runs your life.
Third, certain patients with severe injuries, marked neurologic impairment, or medical disabilities can’t exercise safely. Your doctor needs to evaluate the appropriateness of this approach for you.
Fourth, it takes a year to get better. Most of this you’ll do on your own. Good physical therapists are ruthless: they’ll taper and stop treatment as soon as you understand what you need to do and have begun doing it on your own. Join a gym or the YMCA, but be certain you’ve received adequate instruction on what to do and how to pace yourself.
Finally, few patients get very far until they understand the emotional factors of their pain problem.