Pieter de Smidt, PT, DPT, discusses rebuilding tolerance for exercise and overcoming fear
According to Pieter de Smidt, the entire idea of exercise for the purpose of pain management can be somewhat counter-intuitive.
de Smidt, PT, DPT, Cert. MDT, MTC, is the owner of Reset-Wellness Physical Therapy in Houston, TX. For years, Dr. de Smidt has been a proponent of using exercise for pain reduction but finds many patients to be somewhat confused when he introduces the concept.
“When your body’s in pain,” he explained, ‘You figure you need to lay down, stay still and not move. From the start, that’s a hurdle we need to clear – making people understand that doing nothing is actually the worst thing for you.”
de Smidt cited evidence that exercise is a key component in helping individuals to increase their pain threshold. “By gradually tolerating more and more activities, your body can handle more,” he explained. “But pain is very complex.”
For example, an acute injury like a sprained ankle is likely to respond to somewhat lessened general activity. The idea is to keep the person moving while getting the swelling out of the ankle and hastening a return to normal. The complexities begin when dealing with chronic pain.
Chronic pain occurs when the body itself has healed up, but the pain persists. This type of pain has more of a connection to the sensitivity of the central nervous system rather than extensive tissue damage. Beyond the importance of exercise itself is the education required of the patient dealing with chronic pain.
“My job is to educate the patient that pain and tissue damage don’t necessarily go hand-in-hand,” said de Smidt. “You can have pain without any tissue damage, and you can have tissue damage without feeling any pain. For just about any injury, we can find examples of studies with people who have torn rotator cuffs, herniated discs… just about any body part, we can find examples of imaging with significant injuries without any pain. And it works vice versa too – an image that looks normal, but the person is in a great deal of pain.”
Once the patient realizes that injury and pain aren’t always existing in a direct correlation, de Smidt can begin a series of exercises or a protocol designed to overcome the patient’s belief that a certain movement or exercise will cause them further damage. “I’m not as interested in what your x-ray or MRI says as I am in how you are moving,” he summarized. “What can you do? What can’t you do? What feels good, what does not feel so good, and what are you afraid to even attempt?”
That initial ‘inventory,’ as de Smidt calls it, determines how to proceed with the patient. Repeated movements can, at times, lessen a particular source of pain. No matter how severe chronic pain is, most people have something they can do comfortably. “I want to find the movements that are not painful, and try those first,” he said. “If it’s painful to bend backward, but you’re able to bend forward, we’ll start with [the forward bends], make the body comfortable, then gradually try to rebuild that tolerance for bending backward.”
de Smidt uses a traffic light-related analogy to direct his patients in terms of allowing their pain levels dictate their level of exercise at any given time, using the famed 1-10 pain scale.
If your pain level is between 0-2: Green Light (“Keep going with your exercise program, everything is alright.”)
If your pain level is between 3-5: Yellow Light (“Monitor what’s going on, your pain should not flare up or last for longer than one hour after exercise.”
If your pain level is between 6-10: Red Light (“We need to change something about this exercise, it’s causing more pain than benefit.”)
Not surprisingly, people who are actively working out are more open to exercise as a means to dealing with their pain. For these patients, de Smidt deals with an opposing problem – convincing the runner, for example, to modify his routine enough to avoid reinjury. While this may be a challenge in itself, de Smidt says this is accomplished far more easily than convincing a sedentary individual to perform a set of stretches twice per day.
“They look at me like, ‘Every day?!?’” he laughed. “I try to tell them doing different things, giving your body some variety, balances things out, gets the blood flowing. Sitting isn’t so bad, standing isn’t so bad, but doing only one of those things all day long can cause problems. It’s my job to find that balance through movements you can perform most comfortably.”
When discussing pain these days, the topic of medication and specifically opioids is unavoidable. de Smidt once worked with a group of spinal surgeons and was accustomed to working with patients who had undergone several surgeries with mixed results. In other words, these were the patients for whom opioids were designed; those who had exhausted most other means of attaining relief from their pain.
“Pain medication can be helpful,” de Smidt allowed. “But the trick is to make people understand that the medications are just masking what’s going on, it won’t give you back your strength, flexibility, etc. Opioids are the wrong approach to chronic pain specifically, they are designed for nociceptive pain. This leads to problems because people take more and more medication, hoping for the desired results. Opioids aren’t designed to provide those results with chronic pain.”
While medications can serve a purpose, de Smidt says his job is more about asking the right questions. “What do you want to attain? How much are you willing to do to be able to go for a walk, to play golf again?” he asked. “How much time are you willing to spend on reaching this goal?
“It’s complex. It’s about stress, diet, alcohol intake. Maybe I can’t fix everything, but I can start that discussion with the patient, help them to understand what it will take to achieve their desired results.”
Exercise-Induced Hypoalgesia
By definition, hypoalgesia denotes a decreased sensitivity to painful stimuli. Exercise-induced hypoalgesia (EIH) can be compared to the runner’s high. It’s got a greater degree of variability with chronic pain populations, according to some studies, but is poorly understood in a greater sense. “There is definitely some benefit to cardiovascular exercise for about 20-30 minutes,” said de Smidt. “They can drop your pain levels to the point that we start to see some progress.”
In the meantime, de Smidt’s guiding principle is that exercise in general is only as good as the movement that is chosen for the patient. “I find exercises you like to do, you’re able and willing to do,” he explained. “I can prescribe the best form of exercise for you, but if you hate doing it or don’t have the necessary equipment, there won’t be any benefit.”
