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10 Articles in Volume 16, Issue #5
A Review of Skeletal Muscle Relaxants for Pain Management
Applying Kinesiology as a Multi-Prong Approach to Pain Management
Arachnoiditis: Diagnosis and Treatment
Bench to Bedside: Clinical Tips from APS Poster Presentations
Conversation With David Williams, PhD, President of the American Pain Society
Letters to the Editor: Prince Fentanyl Overdose, High-Dose Opioids, Mystery Care
Los Angeles Times Versus Purdue Pharma: Is 12-Hour Dosing of OxyContin Appropriate?
My Experience With OxyContin 12-Hour Dosing
Technology: Changing the Delivery of Healthcare
The Neuroscience of Pain

Applying Kinesiology as a Multi-Prong Approach to Pain Management

“We don’t stop playing because we grow old. We grow old because we stop playing.”—George Bernard Shaw

Pain clinicians can apply the principles of kinesiology to enhance a patient’s quality of life. In academia, kinesiology refers to the melding of various aspects of care that “focuses on movement and physical activity” to enhance quality of life.1 In the realm of pain management, this means:

  • Exercising for enhancement of health and fitness level
  • Learning movement skills
  • Engaging in activities of daily living, such as doing chores, working, or playing sports.

The advantages of this approach include reduced use of medications and the psychological benefits of remaining active and engaged in life. This article reviews the benefits of kinesiology to enhance the effectiveness of multidisciplinary pain management, with a special focus on elderly patients.

What Is Kinesiology?  

Kinesiology comprises many specialized areas of study and professions that examine and assess causes, processes, consequences, and contexts of physical activity from diverse perspectives.1 Areas of kinesiology include (but are not restricted to) exercise physiology, motor development, motor learning and control, biomechanics, sports management, athletic training and sports medicine, physiotherapy, rehabilitation therapy, measurement and evaluation of physical activity, history of physical activity, psychology of physical activity, philosophy of physical activity, physical education pedagogy, physical activity and public health, and the sociology of physical activity. An interdisciplinary approach involving several of these diverse areas can be implemented in treating and preventing many medical issues, including chronic pain.1

The Problem of Pain

Pain is a widespread health issue that affects approximately 100 million Americans.2 According to an Institute of Medicine (IOM) report, the frequency of pain is highest among elderly Americans,2 who are an increasing proportion of the population (Figure 1).3,4

According to the IOM report, roughly 30% of older Americans suffer from chronic pain, and 50% of community-dwelling older adults suffer from chronic pain.2 Mailis-Gagnon et al found that about 40% of chronic pain cases in the elderly are general musculoskeletal pain, and 35% are peripheral neuropathy.5

The most common causes of chronic pain in older adults include arthritis, cancer, diabetes, cardiovascular disorders, and neurologic diseases.6 Thus, there is a great need for effective chronic pain management interventions for all segments of the population, especially the elderly.

Older adults with chronic pain face multiple barriers, including transportation difficulties, fear of pain or injury, and lack of motivation.7 Because chronic pain is so prominent in this population, it is important to remember the relationship that exists between psychosocial constructs, such as depression, anxiety, fatigue, sleep deprivation, and chronic pain. It is a problem that affects all areas of life, resulting in a decrease in movement, socialization, and sleep.8

Because of their focus on a multi-prong approach to care, kinesiologists are at the forefront of treating chronic pain in the geriatric population as well as the general population.

Exercise, Pain, and Psychosocial Functioning

In 1973, three independent research groups, led by Dr. Solmon Snyder at Johns Hopkins University, Dr. Eric Simon at New York University, and Dr. Lars Terenius at Uppsala University, in Sweden, detected that brain membranes have receptors to which opiates bind.9 Two years later, the neuropharmacologist Hans W. Kosterlitz discovered an endogenous substance with biochemical properties similar to those of opioids, which he called enkephalin.10-12

Intense exercise has been shown to act as a stimulus that promotes hypoalgesia and mood elevation through endorphin release.13 Although researchers have investigated the influence of endorphins, especially ß-endorphins, on the psychosocial concomitants of pain, there has been little investigation of how endorphins influence the physiologic aspect of pain or the aspects of pain processing within the cortex involving interactions among neurons, neurotransmitters, neuromodulators, neuroreceptors, etc (see Neuroscience of Pain).

In 2008, research using positron emission tomography (PET) measured exercise-induced opioid release and its relation to mood.14 The researchers were the first to evaluate the influence of exercise on the endorphinergic system in the central nervous system.14 This study revealed that vigorous exercise resulted in changes in the central opioid receptor-binding that affect mood. Bender et al demonstrated that dynamic and anaerobic exercises increased ß-endorphins.15 In contrast, resistance and aerobic exercises show small effects on ß-endorphins.16

Studies also have found that opioids are released predominantly in the prefrontal cortex and limbic/paralimbic regions, specifically the prefrontal/orbitofrontal cortices, the anterior cingulate cortex, bilateral insula, parainsular cortex, and temporoparietal regions, which are essential in emotional processing.14

Endorphins possess an affinity for µ, ∂, and k opioid receptors. ß-endorphins have both µ and ∂ receptor recognition. However, there is evidence that points to the importance of the link between ß-endorphins and µ-receptors. These receptors are coded by the µ-opioid receptor gene (OPRM1) gene A118G, and are found predominantly in the thalamus, limbic system, and basal ganglia.17 More specifically, these receptors are highly concentrated in the amygdala, nucleus accumbens, and anterior cingulate cortex (ACC).

Peciña et al evaluated 50 participants comparing the OPRM1 G carriers (recessive gene), with 2 dominant alleles (AA) in a homozygote dominant gene to investigate the influence of the single nucleotide polymorphism (SNP) on the OPRM1 personality trait of neuroticism and the DA neurotransmitter system.17 The study revealed that the gene A118G OPRM1 polymorphisms have an influence in individual variations in pain responses. For example, Peciña et al found G carriers have reduced availability of µ-opioid receptors, relative to AA homozygotes. The investigators found that there were lower responses of endogenous opioids and DA systems in response to pain-placebo administration.17

They also found that OPRM1 G carriers, compared to AA homozygotes, produced less opioid release in the anterior insula, amygdala, nucleus accumbens, thalamus, and periaqueductal gray/brainstem, less dopamine release in nucleus accumbens, and greater mood disturbances under pain-placebo conditions. Additionally, the researchers found an inverse correlation between higher ratings in levels of neuroticism, especially in vulnerability to stress and depression, and OPRM1 availability.17

Indeed, pain conditions often correlate with mental health conditions. A common association to pain is depression. Nearly half of all patients with chronic pain suffer from major depressive disorder (MDD). MDD can lead to individuals having suicidal ideations, as observed in a study where patients with chronic pain were twice as likely as non-pain controls to commit suicide.18

It also has been suggested that pain can result in sleep disturbances. In addition, high pain intensity and increased sleep disturbances were found to be associated with depression.19

Furthermore, a study also evaluated the role of acute psychosocial stressors in eliciting pain behavior in individuals who suffered from chronic neck pain. The stressors were associated with lower cortisol awakening responses, after adjustments were made for age and sex. The results concluded that individuals with a longer duration of chronic neck pain exhibited higher cortisol levels, linking stress to pain.20 These results indicate that stress can exacerbate pain conditions.

It should also be noted that, in an early study conducted by Kline et al,21 it was found that increasing ß-endorphin levels induced changes in different types of psychiatric disorders, such as depression, schizophrenia, and neuroses. Cohen et al reported evidence to suggest that endorphins affect mood, but that mood also depends on many other factors such as personality type, social interactions, and environmental cues.22

A study involving individuals who participated in the sport of rowing (crew) showed that, compared with individual training, group training significantly increased pain threshold.22 This illustrates the influence of synchronized group activity on physical and psychosocial interactions and pain. This might explain why other synchronized activities, such as laughter, music, and religious rituals, can also give a sense of euphoria.22 These results suggest that endogenous opioid release occurs, not only under stress, but also during other activities, such as social interactions that involve cognitive and emotional processes.

Exercise, Pain, and General Health

The epidemiology of chronic pain reveals different underlying biopsychosocial influences and effects. For instance, individuals who suffer from fibromyalgia and/or rheumatoid arthritis (RA) not only suffer from debilitating chronic pain, but also are at increased risk for various cardiovascular adverse events.23-27 In contrast, individuals with chronic low back pain have not been known to suffer from these cardiovascular manifestations, but it is important to identify how chronic pain affects cardiovascular fitness.

Cardiovascular Health

Low Back Pain

Studies have shown that the chronic low back pain population, in comparison with an asymptomatic age- and gender-matched population, has a lower aerobic capacity caused by deconditioning that occurs from inactivity.28 In addition, the chronic low back pain population had a significantly higher body mass index that, in previous literature, has been linked to chronic low back pain resulting from obesity-related increased mechanical loads.29 Studies have observed that deconditioning of aerobic fitness in the chronic low back pain population is not dependent on pain intensity alone.30,31

Wittink et al observed that significant increases in pain level during a modified treadmill exercise test were not associated with level of aerobic fitness, suggesting that pain intensity may not uniquely be indicative of the level of aerobic fitness.30 Studies have also shown that, following a functional reconditioning intervention, chronic low back pain patients self-reported less pain, but maximal oxygen consumption (VO2max) remained the same. Again, this suggests that perceived decreases in pain did not result from increase in aerobic fitness.30 Finally, a study by Rasmussen-Barr et al found that working males who suffered from chronic low back pain had similar aerobic fitness levels as healthy males, which may signify that remaining active at work helps prevent aerobic deconditioning.32

Previous studies may not have been able to produce a training effect in chronic low back pain patients for a number of reasons. Nevertheless, the normal training guidelines of the American College of Sports Medicine are recommended to achieve observable cardiovascular fitness adaptations for chronic low back pain patients.33

In the geriatric population, Landmark et al found that elderly patients with chronic pain who exercised 2 to 3 times a week reported 27% less pain compared to those who did not exercise.34 Also, elderly patients who worked out at least 4 times a week reported an overall greater reduction in chronic pain in comparison to the working adult population (20-64 years old) with chronic pain.

Rheumatoid Arthritis

Several studies have shown that individuals with RA have higher incidences of cardiovascular diseases, including pericarditis, amyloidosis, coronary vasculitis, rheumatoid nodules, arrhythmia, valve disease, congestive heart failure, and ischemic heart disease. There also is evidence that cardiovascular disease in this population is influenced by risk factors associated with RA, rather than normal risk factors (hypertension, increased body-mass index, smoking, diabetes, etc).23,26,27

In comparison with a healthy population, the RA population is 3 times more likely to be diagnosed with left ventricular systolic dysfunction.35 It is possible that some cardiovascular problems may be caused by medication used to alleviate RA pain, in particular nonsteroidal anti-inflammatory drugs (NSAIDs), which are known to increase the risk for cardiovascular events when they are taken in high doses or frequently.36

Fibromyalgia

Fibromyalgia (FM) is associated with autonomic nervous system dysfunction, such as dysautonomia, which causes sympathetic hyperactivity at rest and hypoactivity during exercise. Dysautonomia decreases autonomic control during various experimental procedures that involve an autonomic response.25,37,38

This abnormal heart response, known as chronotropic incompetence (CI), can lead to adverse cardiovascular events (similar to heart failure) due to the inability of the heart to meet the metabolic needs of the body.24,39 Ribeiro et al observed CI in 57.1% of an FM population.40 However, Figueroa et al observed decreases in reported subjective pain levels and improved vagal modulation (a parasympathetic response) at rest in FM patients after they completed a 16-week resistance-exercise intervention.25 Furthermore, Valim et al observed no relationship between a decrease in FM symptoms and improvement in cardiovascular fitness after a 20-week, moderate-intensity endurance exercise intervention.41

Bardal et al42 also observed that FM patients had cardiovascular adaptations to moderate-intensity endurance training that were similar to those observed in a healthy population. Higher attendance during exercise intervention also was associated with increased levels of cardiovascular fitness improvements. The FM population has been known to have a lower fitness level, which may be attributed to deconditioning and not solely due to FM-related symptoms. Indeed, the FM population appears to have the same capacity as healthy populations to improve cardiovascular fitness.43-45 Although both FM and healthy populations showed improvements in cardiovascular fitness, autonomic regulation was unchanged.42 Overall, low-impact training at a low to moderate intensity is recommended for FM patients. It is important to monitor intensity, frequency, and duration of training to elicit training adaptations that improve cardiovascular fitness without overexerting the individual.46

Barriers to Treatment

Depression and Anxiety

In the general population, McWilliams, Cox, and Enns have found a strong association between chronic pain and several anxiety disorders.47 They suggest that past studies overlooked many anxiety disorders by having participants fill out questionnaires rather than having them participate in structured, clinical interviews. Other researchers have found that greater levels of neuroticism are highly correlated with pain-related anxiety and chronic pain.48

Geriatric patients with chronic pain experience a higher rate of depressive symptoms compared to their younger counterparts. Chronic low back pain, a prevalent form of chronic pain among the elderly, often results in a high incidence of depression as well as anxiety.49 In addition, the relationship between sleep disturbances, which are common among elderly patients, and depression has been shown to be proportional to the severity of the patient’s chronic pain.49 Meeks et al showed that reduction in socialization due to depression was associated with an increase of suicide ideation among the psychiatric geriatric population,50 but some studies have shown that geriatric patients may cope more effectively with pain, and tend to have higher social and physical functioning than younger age groups with the similar levels of chronic pain.8 Studies have suggested that the best approach to treating chronic pain and depression in a geriatric population is a combination of cognitive-behavioral treatment paired with an exercise-based intervention.8

One of the most common forms of anxiety is pain-related anxiety, or anxiety in which a person overreacts to the threat of pain.47 In fact, kinesiophobia is the excessive, persistent fear of moving because of fear of physical injury as a result of a past accident.51 Symptoms of kinesiophobia tend to be avoidance and fear of rehabilitation from an injury.51 As a result, kinesiophobia acts as a strong predictor of chronicity in low back pain after an initial injury.52

Kinesiophobia can be a major challenge to treating chronic pain. Despite any improvement in an individual’s physical mobility, the fear of injury still persists.51 Fear/avoidance behaviors associated with kinesiophobia can make exercise interventions and treatment of secondary conditions more difficult, so the psychosocial construct of kinesiophobia should be treated first.

Fatigue and Sleep Disorders

A strong association has been found between chronic pain, fatigue, sleep disturbances, and depression.53 Fatigue experienced with chronic pain has been shown to deteriorate quality of life.54 Suggested treatments for fatigue vary across specialties, but treatment generally targets a patient’s quality of sleep.54 Treatment of the potential underlying disorders of anxiety and depression with medication or exercise interventions has been shown to improve quality of sleep and, thereby, decrease fatigue.54 Sleep disturbances, much like fatigue and depression, are proportional to the severity of the disability.54

In the general population, the risk of sleep disturbances is 2 to 5 times higher for individuals experiencing chronic pain.55 Morin, Gibson, and Wade found that the inability to initiate or maintain sleep correlated with greater pain intensity.56 These researchers also found that individuals who lie down or nap during the day to escape chronic pain had more difficulty sleeping at night.56 In fact, some have suggested that the first step to treating chronic pain comorbid with sleep disturbances is “cleaning up” an individual’s sleep hygiene and treating them with cognitive-behavioral techniques to promote sleep.55

Motivation

Lack of motivation is a symptom of depression and, because chronic pain patients often are struggling with depression, they may have trouble finding motivation to apply exercise as a means of treatment. In the geriatric population, Tse, Vong, and Tang found that lack of motivation has been noted as a common reason for dropping out of treatment.57 The researchers addressed this problem with motivational interviews paired with their exercise approach. This resulted in an improvement in mood and a decrease in anxiety and depression. Exercise will work to reduce these psychosocial barriers in the long term, but a short-term solution is needed to create greater accessibility to geriatric individuals with depression.

Perceived Physical Functioning

Physical functioning influences performance during exercise interventions. Researchers have used self-rated questionnaires about how one’s physical condition limited completion of certain activities as a way to determine a person’s perceived level of physical functioning.58 The best way to improve the perception of physical functioning among individuals with chronic pain is exercise. In a study of patients with osteoarthritis, the greatest reduction of pain was found through aerobic activity.59 Aerobics, as well as strength training, improved the perceived physical functioning of patients. Tai chi also improved perceived physical functioning in a geriatric population suffering from chronic pain.60 Overall, regular, consistent activity in elderly individuals has been found to raise rates of perceived physical functioning.58

Benefits of Exercise

Exercise is recommended consistently to treat chronic pain and secondary problems associated with chronic pain, such as depression or anxiety.61 A debate exists over which type of exercise is the most effective treatment for chronic pain. A meta-analysis by Searie, Spink, and Chuter indicated that no particular type of exercise was conclusively the most beneficial to individuals with low back pain.62 Their findings suggested that the trials analyzed were inconsistent, creating outcomes that were not equal, so it was difficult to determine a consistent relationship between the exercises and pain.

Fatigue can make exercise seem overwhelming; the thought of exercising can be daunting, and fatigue becomes a barrier to treatment.7 However, the usual treatment of fatigue and sleep disturbance consists of an exercise intervention.54 Taibi and Vitiello suggested that hatha yoga was the best choice for older women with osteoarthritis “because yoga is known to reduce joint stiffness and directly affects sleep activation via a release of the neurotransmitters gamma-aminobutyric acid and melatonin.”63 Therefore, they recommended that nightly yoga practice would decrease pain and increase sleep. Although patients did not report decreased pain levels, the study did not have a problem with retention, since practice was done at home, and significant improvements in sleep and mood were seen in participants.

Exercise, overall, has been seen to reduce pain, promote sleep, lower depression, and enhance mood among individuals who suffer from chronic pain.61 In older patients, in particular, because pain is widely accepted as part of aging, there often is a high dropout rate for exercise treatment.57 Thus in the elderly population especially, the data collected about exercise as a means of treatment may not be fully representative of the potential it would have on treating or managing chronic pain.

Conclusions

There are many interacting constructs among the biopsychosocial components of chronic pain, including neurochemical, emotional-cognitive, and motor-cognitive processes. Understanding the often complex influences of these biopsychosocial interactions on chronic pain can enhance treatment, provide more promising outcomes, as well as decrease the need for pharmacologic agents. In this article, the field of kinesiology was introduced as a key component of effective biopsychosocial model-based interdisciplinary pain management programs. Such programs have been repeatedly documented to be effective in the treatment of musculoskeletal disorders, such as chronic low back pain.

In the next installment (to be published in the July/August 2016 issue of Practical Pain Managment), the role of kinesiology in improving balance will be examined—an important area of research due to the increasing population of Americans aged 65 years and older who have chronic pain. Therapeutically effective interdisciplinary pain management programs are available, to treat chronic illnesses such as chronic low back pain and to help patients maintain their functioning and ability to “play.”

Last updated on: August 4, 2016
Continue Reading:
The Neuroscience of Pain

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