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Pain, movement and adaptation - the good, the bad and the inconclusive.

By Laura Rathbone

Reflection on Reading 1 for April 2023:

Hodges, P.W. and Smeets, R.J., 2015. Interaction between pain, movement, and physical activity: short-term benefits, long-term consequences, and targets for treatment. The Clinical journal of pain, 31(2), pp.97-107. LINK

Pain and movement is a widely discussed, and explored area of rehabilitation but many questions still remain.  This month’s paper written by Hodges et all asks us to consider the different theories and the many unanswered questions.

“Treatments that focus on physical activity and exercise are the cornerstone of management of many pain conditions, but the effect sizes are modest.”

This paper asks us to contemplate the ways in which movement may be changed by the experience of pain and how movement may be important in the recovery from pain.

Movement is recommended as a fundamental part of rehabilitation for msk-related pain and many chronic primary and secondary pain conditions. Yet, the effect sizes are small and we have unclear guidance as to what type of movement is best. The goal for including movement in therapeutic approaches is equally unclear, are we moving to reduce pain? Optimise loading? Or, is it just about goals-orientated movements? 

Perhaps our choice depends upon what we consider to be the problem and which theory of pain and movement we use.

This paper mentions multiple theories such as the ‘vicious cycle’ theory, pain-adaptation theory,  fear-avoidance theory, maladaptive cognitions (kinesphobia and catastrophisation), Avoidance-endurance theory and others to help us understand why a person experiencing pain may also experience changes in how they move their body.

None of these theories are sufficient to explain both the individual and varied experiences of movement reported by people experiencing pain or observed in people with pain.  But do they work together to give us clinically relevant information?

The paper is working hard to contain the sheer complexity of movement and pain, by explaining all the many ways that movement may be altered by pain by splitting its commentary up into multiple parts and dealing with the evidence supporting and negating the importance of certain mechanisms and processes. 

Ultimately, the paper seems to say clearly that pain can affect a persons movement in different ways.  This may lead to observably altered movement, un observable alterations such as redistribution offload and coordination across different structures and the lack of uniformity across people and experiences. 

It seems to me that this paper is advocating for clinicians to take a movement-restoration approach that doesn't centre too closely on any particular theory, as restoring ‘optimal’ movement patterns may not reduce pain and reducing pain may not return ‘optimal’ movement patterns. 

Equally, this paper acknowledges that movement-restoration is a recommended approach for most pain experiences (acute/chronic and across suggested mechanistic approaches to diagnosis), but that this might not be the case for each individual.

“The likely solution is to individually tailor the increase of exercise load”

Instead, perhaps we should hold all the theories lightly and focus on the experience of the person when they move and what it means for them.

This paper is a lovely review of the more dominant theories around movement and pain, drawing in the more dominant dualistic narratives around physiological mechanisms and cognitive-affective processes. 

It repeatedly falls into the mereological fallacy trap, conflating nociception with pain multiple times and appealing to reductionism on both sides of dualism, but yet, I have found it a helpful piece to read.  

Getting to grips with the vastness of the varied theories for pain and movement adaptation helps me to take a step back from the complexity of the pain experience and return to the person’s experience as the main guide for rehabilitation. 

Key points:

Movement adaptation associated with pain is complex and may or may not be causally and/or clinically relevant. But, they could be very relevant to that person.  And this is where our skills for rehabilitation and therapeutic collaboration can be most helpful. 

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