Chronic pain affects a staggering number of people worldwide, a fact that reflects both its widespread and complex nature and the challenge that represents its treatment (1). While injury, long-term illness, and disability can all lead to chronic pain, evidence indicates a strong contribution of occupational and lifestyle factors to both chronic disease and chronic pain (2). Chronic pain is associated with physical disability and psychological stress, and some studies suggested that it may be linked to increased risk of all-cause mortality (3, 4). Research has shown that exercise can effectively alleviate chronic pain, especially widespread pain that characterizes fibromyalgia (5, 6). However, the perception that physical activity (PA) and exercise may aggravate pain symptoms is still common, hindering participation in exercise activities and preventing or delaying rehabilitation (7). 

Still, whether PA and exercise in general can reduce the risk of death in chronic pain patients is still a lingering question in chronic pain research.

Does Exercise Modify the Risk of Mortality for People with Chronic Pain 

The National Health and Nutrition Examination Survey (NHANES) is part of a research program initiated in the early 1960s and designed to assess the health and nutritional status of adults and children in the United States. It combines interviews, physical examinations, and laboratory tests to determine the prevalence of health problems and risk factors for diseases. NHANES findings are also the basis for national standards for height, weight, and blood pressure. Since 1999 the survey is conducted annually on a nationally representative sample of about 5000 people each year. Data from this survey is widely used in epidemiological studies and health sciences research. 

Using NHANES data collected between 1999 and 2004, and 2011 mortality data from the National Center for Health Statistics linked to the NHANES participants, a 2019 study published in the American Journal of Health Promotion examined whether regular engagement in exercise modifies the risk of mortality in people with chronic pain (8).

Chronic pain was assessed through NHANES’ pain questionnaire (2003-2004) and classified into 3 groups based on the American College of Rheumatology’s definition of chronic pain (9, 10): 

1. No chronic pain (NCP): absence of pain lasting ≥3 months (n = 6153)

1. Localized chronic pain (LCP): presence of chronic pain in one or a few body regions (n = 935)

1. Widespread chronic pain (WCP): presence of chronic pain across the entire body, i.e. on both sides, above and below the waist, and at one or more axial locations (n = 296). 

Physical activity was self-reported by participants based on their engagement in moderate and vigorous-intensity PA in leisure time over the past 30 days. Activity types, frequencies, and durations were recorded and the time spent in aerobic PA was calculated to categorize participants into 3 groups (11): 

1. No PA (N-PA): no engagement in PA (sedentarism)
2. Insufficient PA (I-PA): engagement in PA <150 min/week
3. Sufficient PA (S-PA): engagement in PA ≥150 min/week

Proportion of individuals (%) corresponding to each pain condition/PA category 

Compared to the NCP group, it can be appreciated that a larger percentage of individuals within the LCP and CWP groups did not engage in PA (N-PA), while involvement in PA (I-PA and S-PA) was clearly lower in the WCP condition. 

Over a median of 9.8 follow-up years, mortality rates were higher for LCP and WCP (17.7 and 19.6 deaths per 1000 person-years, respectively) compared to NCP (15.14 deaths per 1000 person-years). After factoring in several variables: age, gender, race/ethnicity, education level, marital status, and annual household income (sociodemographic covariates), diabetes, stroke, cancer, heart disease, weight status (chronic health conditions), and alcohol consumption and smoking (unhealthy lifestyle behaviors), regression analyses confirmed a greater risk of mortality for LCP and CWP. 

Pain or No Pain, Exercise Can Delay Death 

However, this trend was no longer valid, and even reversed, when PA levels were included as covariates. Namely, regardless of chronic pain conditions, individuals with S-PA tended to have lower risk of all-cause mortality when compared to those with NCP and N-PA. 

In other words, people with chronic pain who exercised on a regular basis had a lower risk of death than people without chronic pain who did not exercise.

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How Can We Promote Exercise for People with Chronic Pain? 

Most studies to date suggest a modest association between chronic pain and increased mortality (4). However, this relationship is moderated by many modifiable and non-modifiable factors: biological (age, comorbidities), psychological (stress, depression), social (education, economic status, social isolation/interaction), and behavioral (nutrition, exercise, smoking and drinking habits) (12). The results of the study reviewed here are significant because they show that a single modifiable parameter, PA, can greatly reduce mortality in people with chronic pain after many of the above factors are taken into account. 

Once again, however, the simplicity of the study’s conclusion contrasts with the complexity of human behavior, and the physical and psychological burden imposed by chronic pain: it takes willpower, resolution, and resilience to exercise while experiencing pain (13). Attending to this complexity is a true challenge for physical therapists who must, on a daily basis, assess and treat chronic pain. 

A key step to motivate clients to get started with and, most importantly, maintain an exercise plan should be to try to modify their misconceptions about PA and pain (14). To this end, education about the benefits of PA on chronic pain (e.g. the findings of the present study) along with cognitive-behavioral skills embedded into Psychologically Informed Physical Therapy (PIPT) can be strong determinants of treatment success. 

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REFERENCES:

1- Treede, R. D., Rief, W., Barke, A., Aziz, Q., Bennett, M. I., Benoliel, R., … & Giamberardino, M. A. (2019). Chronic pain as a symptom or a disease: the IASP Classification of Chronic Pain for the International Classification of Diseases (ICD-11). Pain, 160(1), 19-27.

2- van Hecke, O., Torrance, N., & Smith, B. H. (2013). Chronic pain epidemiology – where do lifestyle factors fit in?. British journal of pain, 7(4), 209–217. doi:10.1177/2049463713493264

3- Torrance, N., Elliott, A. M., Lee, A. J., & Smith, B. H. (2010). Severe chronic pain is associated with increased 10 year mortality. A cohort record linkage study. European journal of pain, 14(4), 380-386.

4- Smith, D., Wilkie, R., Uthman, O., Jordan, J. L., & McBeth, J. (2014). Chronic pain and mortality: a systematic review. PloS one, 9(6), e99048. doi:10.1371/journal.pone.0099048

5- Ambrose, K. R., & Golightly, Y. M. (2015). Physical exercise as non-pharmacological treatment of chronic pain: Why and when. Best practice & research. Clinical rheumatology, 29(1), 120–130. doi:10.1016/j.berh.2015.04.022

6- Busch, A. J., Barber, K. A., Overend, T. J., Peloso, P. M. J., & Schachter, C. L. (2007). Exercise for treating fibromyalgia syndrome. Cochrane database of systematic reviews, (4).

7- Boutevillain, L., Dupeyron, A., Rouch, C., Richard, E., & Coudeyre, E. (2017). Facilitators and barriers to physical activity in people with chronic low back pain: A qualitative study. PloS one, 12(7), e0179826. doi:10.1371/journal.pone.0179826

8- Kim, Y. and Masataka, U. (2019). Chronic Pain, Physical Activity, and All-Cause Mortality in the US Adults: The NHANES 1999-2004 Follow-Up Study. Am J Health Promot. 2019 May 30:890117119854041. doi: 10.1177/0890117119854041.

9- Wolfe, F., Smythe, H. A., Yunus, M. B., Bennett, R. M., Bombardier, C., Goldenberg, D. L., … & Fam, A. G. (1990). The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Arthritis & Rheumatism: Official Journal of the American College of Rheumatology, 33(2), 160-172.

10- Dansie, E. J., Turk, D. C., Martin, K. R., Van Domelen, D. R., & Patel, K. V. (2014). Association of chronic widespread pain with objectively measured physical activity in adults: findings from the National Health and Nutrition Examination survey. The Journal of Pain, 15(5), 507-515.

11- Evenson, K. R., Butler, E. N., & Rosamond, W. D. (2014). Prevalence of physical activity and sedentary behavior among adults with cardiovascular disease in the United States. Journal of cardiopulmonary rehabilitation and prevention, 34(6), 406–419. doi:10.1097/HCR.0000000000000064

12- Mills, S., Nicolson, K. P., & Smith, B. H. (2019). Chronic pain: a review of its epidemiology and associated factors in population-based studies. British journal of anaesthesia, 123(2), e273–e283. doi:10.1016/j.bja.2019.03.023

13- Elliott, A. M., Burton, C. D., & Hannaford, P. C. (2014). Resilience does matter: evidence from a 10-year cohort record linkage study. BMJ open, 4(1), e003917.

14- Joelsson, M., Bernhardsson, S., & Larsson, M. E. (2017). Patients with chronic pain may need extra support when prescribed physical activity in primary care: a qualitative study. Scandinavian journal of primary health care, 35(1), 64–74. doi:10.1080/02813432.2017.1288815