Daniel Lawrence is a British Physiotherapist with a clinical background in both sport and general healthcare settings - both within the national health service and private sector. Daniel is the author of ‘Lower Limb Tendinopathy’ and ‘A Practitioner's Guide to Clinical Cupping’ and currently serves as European Director of Education for the popular RockTape brand. His YouTube channel, @ThePhysioChannel, continues to serve as a great resource for therapists and patients around the world.  

Daniel’s session at Therapy Expo 2023 explored the role of exercise in pain relief, and the different forms this might take. He also introduced the challenges that this concept might raise, including exercise-induced hyperalgesia, and suggested multiple strategies for overcoming these.  

Mechanisms of exercise-induced pain relief 

Daniel began the session by explaining the role of baroreceptors in pain relief during exercise, likening it to the release of endogenous opioids. He described how exercise is the trigger for multiple systems in the body: the endocannabinoid system to release natural cannabinoids, similar to those found in hemp oil, and the serotonergic system, associated with feelings of well-being, further contributing to pain relief. 

Daniel challenged the common belief that specific exercises like Pilates or yoga are the best for back pain, asserting that walking is equally as effective, and presented research studies in support. One such study, involving 1,476 participants with back pain, concluded by finding no strong correlations between improvements in physical function and reductions in pain. The study suggests that exercise can lead to pain relief without significant improvements in strength, flexibility, or endurance, emphasising the non-specificity of exercise for pain relief. 

Challenges  

Despite this, Daniel explained that the biggest challenge hindering the success of exercise-induced pain relief is patients who do not respond to exercise prescription as expected.  

“Unfortunately, some patients suffer from dysfunctional exercise-induced hyperalgesia. It's where the plan doesn't work.” 

He discussed the concept of exercise-induced hyperalgesia, where exercise can actually increase pain sensitivity in some patients. Subgroups of patients, such as those with fibromyalgia, chronic fatigue syndrome, or osteoarthritis, are more likely to experience negative effects from exercise. He presented more studies showing that forced exercise can in fact lead to increased inflammatory mediators, whilst allowing patients to exercise at their own pace can lead to better outcomes.  

Overcoming these challenges 

Daniel then explained five different strategies for addressing patients who do not respond to exercise as expected.  

Opioid Tone: Regular exercise increases endogenous opioid levels in the brain, which can enhance pain relief. Sedentary individuals have lower opioid tone, leading to a potentially more negative response to exercise. However, regular exercise can gradually increase opioid tone, reducing pain flare-ups over time. 

“If they don't experience exercise from pain relief, keep going with the plan, and the chances are that they will then start to experience it after multiple sessions. Ultimately, the trajectory is in a positive direction.” 

Crossover Effect: Exercise does not need to target the painful area directly. For instance, if a patient has shoulder pain, using an exercise bike or focusing on other body parts can still yield systemic pain relief. Increased blood pressure from exercise can trigger analgesic effects even if the exercise isn’t directly working on the painful joint. 

Medications: Selective serotonin reuptake inhibitors (SSRIs) may improve the exercise experience for some patients with pain by enhancing their pain response to exercise.  

“If anybody has a more positive experience of exercise, you've won. You've succeeded.” 

Unlike traditional painkillers, SSRIs can help initiate positive outcomes with exercise, without the potential for developing harmful dependencies, therefore potentially allowing for reduced medication use over time, whilst maintaining the positive experience associated with exercise.  

Addressing Psychological Barriers: Daniel used a case study with a patient named Zara, who was reluctant to perform exercises due to her beliefs about knee damage (reinforced by her practitioner), highlighting the importance of addressing patients' thoughts, beliefs, and emotions as part of a holistic approach. 

“If the patient's got barriers in their own mind, the exercises won't work. […] Thoughts, feelings and behaviours are really important.” 

 Effective rehabilitation requires understanding and modifying these psychological barriers, ensuring goals align with patient motivations and preferences. 

Practical Adjustments: Daniel acknowledged the need for personalised exercise plans, emphasising fewer, more tailored exercises and patient-centred goals, whilst reiterating the significance of integrating psychological considerations into physical rehabilitation.  

Check out the full session recording below: 

If you would like to purchase access to all the 2023 session recordings for just £20+VAT, please contact our Delegate Manager at k.wright@closerstillmedia.com    

Daniel will be speaking at Therapy Expo 2024 in the RockTape Movement Summit across both days of the event. Check out the full conference programme here