Should exercise be painful?

Should exercise be painful?

When assisting a patient with rehabilitation from injury or pain, a major question that needs to be asked is "should this patient exercise through pain or not?" This becomes even more pertinent if the patient's condition consists of primary pain (1). And there have certainly been arguments for both sides on this topic (2-4) as pain management has been emerging as an increasingly relevant matter in current medicine.

Most practitioners realise that that there cannot be a "blanket rule" that can be applied to all, but every patient is an opportunity for a practitioner to clinically apply biopsychosocial framework followed by a construction of case formulation (5, 6). Thus the decision to exercise through pain or not is usually a destination that a practitioner can naturally arrive after such preceding thought-processes.

There are four important factors to consider when deciding whether or not a patient should exercise “through pain”:


1) Pathophysiology of the current condition
2) Mechanism of the pain being experienced
3) Patient’s attitude and beliefs
4) Level of endogenous modulation


1) Pathophysiology of the current condition

Perhaps the most obvious one; certain pathophysiological states logically indicate that exercising in pain would not be a sensible choice: e.g. acute inflammation post traumatic injury with tissue disruption. However some conditions are not as clear-cut: e.g. chronic patellofemoral pain. In such instances critical analysis of the diagnosis would be necessary before a decision is made: if a clinician was to reason that such patellofemoral condition was a result of muscle dysfunction from pain inhibition (7), it may be more reasonable to exercise without pain as further pain is likely to reinforce inhibition, especially in the early stages.

2) Mechanism of the pain being experienced

"Mechanism-specific approach" classifies pain into four categories (8, 9): nociceptive, inflammatory, neuropathic and dysfunctional (or nociplastic). While there are no “hard-guidelines” that can clearly define a given pain into such categories, it is not difficult to make a hypothetical call after a thorough case formulation construction, and such approach is absolutely necessary to provide a foundation of care for complex multi-dimensional conditions such as primary pain. Once mechanism of pain is hypothetically determined, the implication of experiencing such pain while exercising becomes clearer; e.g. certain nociceptive pain may be ignored, or even beneficial, whereas inflammatory and neuropathic pain is generally best to be avoided. Dysfunctional / nociplastic pain will need to be deconstructed - i.e. cause of the pain analysed - before determining the possible effects of experiencing such pain while exercising.

3) Attitude and beliefs

Pain excitation or inhibition from cortical and subcortical centres are well-documented through literature (10-12) and anecdotes, and the main constructs behind this powerful process are the attitude and beliefs of the patient. This is where fear-avoidance and catastrophising exist at one extreme, and placebo response and attentional modulation at the other. How a clinician positively “manipulates” these is critical to the success of the rehabilitation and is often dependent upon the “art” of communication and persuasion skills. Graded exposure (13, 14) is one of the most important and widely-used cognitive framework on which exercise therapy can be effectively integrated.

4) Suspected level of endogenous modulation

This resides closely to “attitudes and beliefs” as their end-effect is also endogenous modulation. However there are many other factors that can influence endogenous modulation (e.g. genetic, DNIC, autonomic regulation, gender, age, fitness, physical and psychological history) and these are important data that need to be considered to hypothetically assess the “activity level” of patients' endogenous pain modulation. In essence, stronger the modulation is suspected, stronger the exercise stimulation may be, and possibility of exercising through pain.

It is critical to specify the intention or aim behind exercise programmes when prescribing to patients as this will often give a quick indication of how the experience of pain should be handled. For example, in a case of mobilisation of joints and soft tissues post fracture with no significant pain issues, it is probably useful to “stretch into the pain zone" if this coincides with the restriction in range of motion and evidence of tissue shortening (i.e. nociceptive pain).

Compared to this in management of primary pain the goals are, in most cases, to modulate pain and facilitate neural recruitment. Thus how a clinician teaches patients to handle pain when it inevitably occurs during exercises - whether to alter exercises to minimise pain or to "ignore and keep going" - will need to be carefully considered in accordance with abovementioned factors to ensure the best outcome.


1. Treede RD, Rief W, Barke A, Aziz Q, Bennett MI, Benoliel R, et al. A classification of chronic pain for ICD-11. Pain. 2015;156(6):1003-7.

2. Booth J, Moseley GL, Schiltenwolf M, Cashin A, Davies M, Hubscher M. Exercise for chronic musculoskeletal pain: A biopsychosocial approach. Musculoskeletal Care. 2017.

3. Daenen L, Varkey E, Kellmann M, Nijs J. Exercise, not to exercise, or how to exercise in patients with chronic pain? Applying science to practice. Clin J Pain. 2015;31(2):108-14.

4. Smith BE, Hendrick P, Smith TO, Bateman M, Moffatt F, Rathleff MS, et al. Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis. Br J Sports Med. 2017.

5. Eells TD, Kendjelic EM, Lucas CP. What's in a Case Formulation? Development and use of a Content Coding Manual. Journal of Psychotherapy Practice and Research. 1998;7(2):144-53.

6. Linton SJ, Nicholas MK. After assessment, then what? Integrated findings for successful case formulation and treatment tailoring. In: Breivik H, Campbell WI, Nicholas MK, editors. Clinical Pain Management: Practice and Procedures. 2nd ed: CRC Press; 2008. p. 95-106.

7. Mense S. Muscle pain: mechanisms and clinical significance. Dtsch Arztebl Int. 2008;105(12):214-9.

8. Vardeh D, Mannion RJ, Woolf CJ. Toward a Mechanism-Based Approach to Pain Diagnosis. J Pain. 2016;17(9 Suppl):T50-69.

9. Woolf CJ. Pain: Moving from Symptom Control toward Mechanism-Specific Pharmacologic Management. Annals of Internal Medicine. 2004;140:441-51.

10. Goffaux P, Redmond WJ, Rainville P, Marchand S. Descending analgesia--when the spine echoes what the brain expects. Pain. 2007;130(1-2):137-43.

11. Kenntner-Mabiala R, Andreatta M, Wieser MJ, Muhlberger A, Pauli P. Distinct effects of attention and affect on pain perception and somatosensory evoked potentials. Biol Psychol. 2008;78(1):114-22.

12. Wiech K, Ploner M, Tracey I. Neurocognitive aspects of pain perception. Trends Cogn Sci. 2008;12(8):306-13.

13. de Jong JR, Vlaeyen JW, Onghena P, Goossens ME, Geilen M, Mulder H. Fear of Movement/(Re)injury in Chronic Low Back Pain. Education or Exposure In Vivo as Mediator to Fear Reduction? The Clinical Journal of Pain. 2005;21:9-17.

14. Vlaeyen JW, de Jong JR, Geilen M, Heuts PHTG, van Breukelen G. The Treatment of Fear of Movement/(Re)injury in Chronic Low Back Pain: Further Evidence on the Effectiveness of Exposure In Vivo. The Clinical Journal of Pain. 2002;18:251-61.

Fibromyalgia - part 2: context of the diagnosis

Fibromyalgia - part 2: the context of the diagnosis

(Below is the transcription of the above video)

In order to recover from fibromyalgia, there are two things that have to be done:

1. Stop doing things that are stuffing you up

2. And instead do things that help you.

First of all let’s look at the things that I have seen so many people with fibromyalgia do, that actually perpetuate the condition rather than assisting in recovery.

I will go through four most common and critical mismanagement of fibromyalgia. You could say they often occur somewhat in this sequence and they are VERY closely related.


1. Lack of appreciation of the context involving the diagnostic term “fibromyalgia”

2. Misinformation on the condition

3. Over-identification or emotional investment on the condition

4. Mal-adaptation that follows on the body


The first important thing is that these are not easily identifiable due to the fact that they are “below the surface”. But you sure feel the effect.

The mismanagement that I would like to discuss in this video is the first one: lack of appreciation of the context involving the diagnostic term – “fibromyalgia”.

First of all, let’s define fibromyalgia (and I’d like to add that most “fibromyalgia” patients that I see are often not even aware of this to begin with, which pretty much underlines the point that I want to raise):


Fibromyalgia is diagnosed in patients with chronic widespread pain and associated symptoms of fatigue, unrefreshing sleep, or cognitive dysfunction (or a combination thereof) for at least 3 months.(1)


(and for those who are interested in details of one of the most accepted diagnostic criteria, you can go to the website on the screen.)

The key here is that the symptoms that pertain to the diagnostic criteria (pain, fatigue etc) sit within a continuous spectrum; some are very mild and borderline fibromyalgia while others can be full-blown and significantly debilitating. And not only that, even though it is generally accepted nowadays that the symptoms of fibromyalgia are the result of dysfunctions in endogenous pain modulation(3-5), it is very difficult to establish a measurable relationship between the dysfunction and the symptoms experienced. 

All this means is that when a diagnosis of fibromyalgia is given, it does not (and should not) mean anything more than the exact definition given above; nothing more, nothing less – i.e. fibromyalgia is simply a description of symptoms and has always been.

The problem occurs when the terminology “fibromyalgia” is associated with certain ideas or beliefs – ideas that may be true for the very severest of the spectrum (and that’s not many) – but everyone who receives the diagnosis is lumped together under that idea.

In my opinion and experience vast majority of patients who have been diagnosed as fibromyalgia could have easily had their symptoms explained as:


"a severe but temporary dysfunction of the body due to a series of events that overloaded the system, and/or non-events where there should have been for the benefit of the body, in combination with failure of the body to optimally adapt to the stimulus related to those events and/or non-events.”


An example of such event that overloaded the system may be a prolonged stress from work that may have gradually impacted on endogenous pain modulation. An example of non-event where there should’ve been, could be not knowing how to activate endogenous pain modulation when a body is genetically predisposed to pain facilitation.

Combined together, these things FACILITATE pain – and tip the balance towards pain facilitation away from pain modulation. Which means that you’ll be susceptible to feeling an unnecessarily amplified amount of pain regardless of the visible condition of the body.

I suggest that you take a moment to examine this diagram. If there are some aspects that you do not fully understand, please leave a comment – we’ll do our best to answer it.

Anyhow when the symptoms are explained in this way (that was just an example), as opposed to sticking a label such as fibromyalgia, patients can be free from the "baggage" that comes with the label; instead they can focus on finding insights necessary for an effective management for his or her own condition rather than ones that belong to the severest of all fibromyalgia spectrum (which unfortunately are the easiest to discover from terribly unreliable sources such as the internet). 

But regrettably, the culture of medicine and patients’ expectations hinge on "having a diagnosis" - neither clinicians nor patients are often satisfied without giving a condition a label. In fact, numerous clinicians and patients are more satisfied with having a diagnostic label that only explains the fact that certain symptoms exist, rather than giving and receiving an explanation consisting of reasonable and rather helpful hypotheses behind such symptoms;

Some patients will even tend to complain “oh the doctor/physio/specialist couldn’t come up with the diagnosis for my condition” when actually more scientifically accurate and thorough explanations are given.

So if you’ve been told that you have fibromyalgia. I encourage you to jettison the diagnosis label. While there is an innate urge to label symptoms, it really does not do you any favours. Going without diagnosis feels really weird. But trust me, it will make you lighter and free up your headspace so you can actually focus on more important things to get yourself better.

Over the next series of videos, we’ll have a look at the rest of the invisible parts of the iceberg that can sink you. Meanwhile, if you have any questions please leave them in the comments and we’ll do our best to answer them.



1. Rahman A, Underwood M, Carnes D. Fibromyalgia. BMJ. 2014;348:g1224.

2. Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Katz RS, Mease P, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care and Research. 2010;62(5):600-10.

3. Loeser JD, Melzack R. Pain: an overview. The Lancet. 1999;353(9164):1607-9.

4. Marchand S. The physiology of pain mechanisms: from the periphery to the brain. Rheum Dis Clin North Am. 2008;34(2):285-309.


5. Melzack R, Katz J. Pain. Wiley Interdiscip Rev Cogn Sci. 2013;4(1):1-15.

Fibromyalgia - part1: introduction

Fibromyalgia - part 1: introduction

(Below is the transcription of the above video)

Over the next series of videos I would like to share a few things about fibromyalgia, or specifically, common mistakes in regards to the management of fibromyalgia both by health professionals and patients. 

The goal of these videos is to help you to see some different perspectives in regards to fibromyalgia which is a multi-dimensional conundrum, and even discover certain notions, beliefs or behaviours that might have been contributing to the perpetuation of the condition. Such discovery can be absolutely crucial for a successful recovery.


Because fibromyalgia is NOT like your normal “injury”; if you’ve *sprained a joint or broken a bone what do you do? You rest while the injury heals. If you’ve got a bad case of flu or other illness, what do you do? You rest and recover.

But it is a mistake to categorise fibromyalgia like that – in most cases if you sat on your backside and waited for fibromyalgia to improve, it won’t; in fact it will get worse.

You might be thinking that the reason for the persisting nature of fibromyalgia, the fact that the pain just seems to hang around and doesn’t leave you alone, is simply because you have fibromyalgia (which sounds pretty obvious).

However I would like you to think slightly differently: that the most common reason for the persistence of symptoms with fibromyalgia is not the condition itself but mismanagement of the condition.

What I mean by mismanagement is how the condition is HANDLED by both health professionals and patients. And it is such poor handlings that directly result in the active perpetuation of the condition.

In other words, and I’d like to say this with the kindest intention, what stops the successful resolution of fibromyalgia is, you. It all comes down to how YOU handle or mishandle the condition.

And whether you are aware of it or not there are MANY ways one can develop the very subtle and not-so-useful art of mismanagement.


So, over the next few videos, I would like to discuss most common and significant types of mismanagement that occurs to variable extents for ALMOST ALL fibromyalgia cases.

But for now, the most important thing is that you have to be OPEN to possibilities. If you are not, I hope that that viewpoint can be changed in near future with my help. Because yes fibromyalgia is complicated but WE have made it a lot more difficult than it should be, and turned it into a bit of a monster.

Managing chronic pain - Sean

Managing chronic pain is a bit like scaling a mountain. Except you have no idea how high the mountain is.

Discouragement is a part of the journey, thus handling such emotion is one of the keys to managing pain. A competent and passionate health professional should be able to be your guide through these peaks and troughs.

Sean* tells us his journey and perspective. I think he has some great points that anyone going through chronic pain can relate to.

(*not his real name)