Last week I discussed the soreness that you may get after exercise. This week, I’m turning my attention to using exercise to relieve pain. You may have been lucky enough to catch the BBC One programme “The Doctor Who Gave Up Drugs” with Dr. Chris van Tulleken. If you did, you’ll have seen the almost miraculous transformation of Crystal, a young lady crippled with chronic, severe, nonspecific back pain. Crystal had been prescribed high doses of painkillers for the previous three years, yet the pain still severely restricted her movement, and she was unable to take part in the daily activities of life and work. Years of limited movement had weakened her muscles, worsening the pain further. She had visited various medical specialists, but as the cause of her pain was yet to be identified, she was managing her condition with painkillers. I use the word “manage” with reluctance. In practice, the painkillers were not helping - the long-term efficacy of both prescription and over the counter painkillers is dubious, and the side effects of continued use are many, and well established. Furthermore, they do nothing to address the cause of the pain, so once the effectiveness has started to wane, the sufferer is left not only with their pain, but now also dependent on the painkillers.
Dr van Tulleken sent Crystal to a Kung fu master, as a slow and controlled method of exercise. Here is a clip of her first session:
You can see Crystal's efforts to mask her pain in her restricted facial movements - and that’s before she tries moving her limbs, when the true extent of her pain becomes clear. Twelve weeks and lots of Kung fu later, Crystal was moving well, and had ceased taking painkillers. Although the programme didn’t go into detail, those 12 weeks were no walk in the park. Crystal had to withdraw from her drugs - a tapered reduction supervised by her doctor - and she worked through a lot of pain before she improved. To what extent her pain had diminished wasn’t made clear, but in a way, that’s not as important as the fact that she was now managing her condition, and had regained her life. Crystal's remission will depend on lifelong continued exercise, whether that is through Kung fu, or other disciplines. It sounds like a huge commitment, but the alternative is a bleak outlook of dependency and pain. She demonstrated the determination and resilience that make me optimistic for her future.
The point made by Dr van Tulleken was that there is insufficient support for sufferers of chronic pain to use exercise as a safe and effective alternative to medication. Telling patients to exercise is all well and good, but without intensive support, it is hard to see how a sufferer of chronic pain could bring themselves to exercise, and keep at it, long term. We see pain as a warning sign that we are hurting ourselves - as it often is. But there are also situations when we have to accept pain as part of a process of recovery. Without specialist support - and I myself am not qualified to advise on what pain is safe to work through - it is instinctive to stop. Furthermore, some types of pain have been shown to be unresponsive to exercise. Where you have been advised by your doctor to keep moving in spite of pain, it can be helpful. For example, attempting to protect arthritic joints by not moving them may lead to a loss of range of movement, and long-term worsening of the condition. However, I will only encourage you to move through pain under the guidance of your medical professional. Likewise, if you are taking painkillers long term, please do not stop or reduce your treatment without first consulting your doctor.
A single case study will never satisfy the scientist in me, so next week I will cover the mechanisms of pain management through exercise and the evidence base behind it.
Do you get stiff, sore muscles the day after exercising, or maybe the day after that? Perhaps you find yourself walking downstairs tentatively supporting each step with the bannister rail, “Ouch! Ouch! Ouch!" This is the classic symptom of delayed onset muscle soreness, or DOMS. It’s a sign that you’ve worked your muscles hard - harder than they are used to. But does it indicate strengthening muscles, or is it an the result of damage? The short answer is, it’s a bit of both, but the damage isn’t harmful.
A common misconception is that DOMS is caused by a buildup of lactic acid, and that you can flush it away by water or massage. Neither is it the result of inadequate warm-up before or stretching after exercise. The mechanism behind DOMS is thought to be the result of inflammation caused by tiny tears (microtrauma) in the muscle tissue. This damage is one of three key mechanisms that lead to hypertrophy (muscle growth), the other two being mechanical tension (eg weight bearing) and metabolic stress (“the burn”).
Some people are motivated by DOMS - “Whoop whoop! I had a great workout yesterday! I can hardly move!!”; whereas others are deterred from exercising, particularly, for example, if they have a physically demanding job and their performance is impaired by the aches and stiffness that follows an exhausting workout. Or if it is simply too demoralising to find climbing stairs a strugggle. Badly timed DOMS can also impair athletic performance.
So, what does DOMS tell you about your workout? While it does mean that you’ve pushed yourself, in their review on the effectiveness of DOMS as an indicator of muscle adaptations, Schoenfeld and Contreras wrote, “it remains debatable as to whether DOMS is an accurate gauge of muscle damage” and continued, “although DOMS may provide a general indication that some degree of damage to muscle tissue has occurred, it cannot be used as a definitive measure of the phenomenon”. If you continue at the same level of effort, your experience of DOMS will diminish with each subsequent workout. It is possible get fit without getting DOMS, but for most of us it is part and parcel of the process. If, however, your soreness lasts for more than a few days, it can mean that you’ve overdone your workout, and if you regularly experience serious, long-lasting DOMS, then you risk injuries associated with overtraining.
If DOMS bothers you, then here are my tips to get stronger while minimising soreness:
If in spite of these precautions, you get troublesome DOMS, anything that increases blood flow to the affected muscles - massage, a heat pack or a hot bath - can help to alleviate the soreness. Gentle exercise can also help; although it can initially be uncomfortable, as you get into your stride, it eases off. Once your muscles have cooled down again, the soreness will return, but it does provide short-term relief, and won’t add to the soreness the following day. If your soreness is very painful, then anti-inflammatory drugs such as ibuprofen and aspirin can help to alleviate the symptoms, but I would never recommend painkillers as a first recourse. This will get better on its own.
If you want to get strong, DOMS can be your friend. Just think of it as one of those crazy friends that you you enjoy having a wild party with once in a while, but is simply too exhausting to be around all of the time.
When new clients come to my Pilates classes, I always ask about their goals. The most common ones tend to be to increase core strength and improve flexibility, with close runners up being to tone up, improve posture, reduce back pain, or improve the pelvic floor. Pilates can help with all of these things.
The surprise benefit - and that which is reported to me most often after people have been coming for a while - is how well you feel for doing Pilates. People leave with a sense of ease in the body, and have an enduring sense of wellbeing. The emotional benefits of setting aside an hour in a busy schedule are valued by Pilates devotees, and it becomes a priority in their lives. While there is no overtly spiritual dimension to Pilates, it involves mindful movement, like a physical meditation. A state of psychological flow is often reached, where you become fully immersed in a feeling of energized focus and enjoyment as you concentrate on the precise movements. Spending time in the zone can help you to progress more effectively in what you are learning, and also feel greater happiness and emotional wellbeing.
Distractions can prevent you from fully connecting your mind and body, so here are my tips for getting the most out the mind-body connection in Pilates:
Fitness and Pilates instructor with a passion for science.