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CAMERON CRAMEY
Cameron Cramey is Senior Physiotherapist at the Haemophilia Treatment Centre at the Royal Adelaide Hospital, South Australia.
The why, how and what to do!
Musculoskeletal pain is a persistent companion for many people with a bleeding disorder. Most people are familiar, to varying degrees, of the benefits of movement and exercise as a key management strategy for a range of medical conditions; its role in managing persistent pain is perhaps less understood. At the 2024 World Federation of Hemophilia Congress I presented a session on the role of physiotherapy in the management of persistent pain. This is a summary of that session.
Exercise provides both short- and medium-term physiological benefits for pain. The term ‘physiological’ refers to changes or alterations occurring in an individual’s body.
Exercise has been shown to stimulate release of endorphins. These ‘happy hormones’ can improve things such as mood, sleep, memory, concentration and arousal/engagement in our environment. Other chemicals that are released are thought to play a role in ‘dampening’ down our bodies pain response. Improved blood flow as a result of exercise is also thought to assist in more efficient removal of waste products.1
So, to get a hit of pain relief . . . try moving! The evidence suggests the more you do it, the ‘stronger the hit’.
Another key benefit of exercise is that it can assist in a person’s ability to function within their community. The pain literature consistently refers to active self-management as a key pillar in managing pain.
Active self-management requires engagement within our community. This may include things such as:
Engaging in such activities can help you build and maintain habits that sustain a healthy lifestyle (e.g. exercise, eating and sleeping habits).2,3,4
As a physiotherapist, to optimise long term pain control, emphasis shifts from focussing on the pain to maximising an individual’s function within their community. A well-designed exercise programme will assist in this.
Other well-known benefits of exercise include:
In this era of new therapies we can be more confident that exercise/activity-induced discomfort is less likely to be attributable to a bleed.
‘but it hurts – aren’t I doing more damage?!’
If we consider the context of people with bleeding disorders, there are many plausible reasons why exercise may result in a pain response in the absence of any tissue harm or damage. Typically, these reasons are centred around prior experiences.
Historically many people with bleeding disorders are likely to have experienced a bleed or worsening pain as a result of exercise prescribed by a health care professional. Such experiences are more likely to negatively influence an individual’s expectation regarding future exercise prescription. This phenomenon is called the ‘nocebo’ effect, whereby expectation of a negative or painful experience results in an increased likelihood of experiencing heightened pain.6
Movement-evoked pain is a similar concept that is under ongoing research in the chronic pain literature. It suggests that features such as fear avoidance, diminished activity engagement and health anxiety are all dynamic factors that are thought to amplify pain generated by movement.8
Many of us will be familiar with the phenomenon of delayed onset muscle soreness (DOMS), which often occurs when we engage in an unfamiliar activity or return to an activity after a prolonged break. Diminished exercise and tissue tolerance increases susceptibility to DOMS and other soft tissue conditions (tendinopathy). Some people with bleeding disorders will be particularly susceptible to this if they have a prior history of recurrent periods of immobility as a result of muscle or joint bleeds.
An individual’s functional capacity/tolerance for exercise will only ever be slightly greater than the load that is applied. To make gains in strength and function the principle of ‘overload’ needs to be applied. Historically this has been the most challenging part of exercising for people with bleeding disorders. With access to new therapies, this balancing act has gotten easier… however, it remains challenging. For this reason, it must be supervised by someone with appropriate experience, prescribed at an appropriate dosage in the initial phase, and carefully progressed.
‘If we could give every individual the right amount of nourishment and exercise, not too little and too much, we would have found the safest way to health.’
Hippocrates
‘The best exercises are the ones that get done!’
Exercise is not a ‘one size fits all’ approach. Exercise prescription should be tailored to the individual with particular consideration to relevant co-existing health conditions, prior experiences, interests and goals.
Improvements take time and are not likely to be linear. Persistence is crucial and any exercise programme will likely require some form of ongoing commitment for long term gains.
If a chosen exercise doesn’t fit your lifestyle and is not enjoyable it is very unlikely to be a sustainable long-term option.
This concept is supported when we review the literature regarding the benefits of exercise for a few common musculoskeletal health complaints:
Hip and knee osteoarthritis: exercise therapy improves patient outcomes, regardless of disease severity or associated health conditions – no single type of exercise therapy is superior to another.4
Chronic neck pain: exercise is beneficial for neck pain; there is no significant difference between movement, strengthening and mind body exercises (e.g. yoga, pilates, Tai Chi). One study suggests that a 20 minute cycling programme demonstrates equivalent results!8
Chronic back pain: exercise is beneficial for back pain; there is no significant difference between pilates, resistance training, movement and aerobic exercise.9
Exercise is an effective way to improve pain, function, participation in the community and optimize health aging. When embarking on an exercise programme it should be supervised, appropriately graded, and carefully progressed. This is particularly important in the early phases of any programme. An exercise programme should be tailored to the individual, enjoyable, sustainable and goal oriented.
Get creative, anything that gets you moving and off the couch is a great place to start!
1. Rice D, Nijs J, Kosek E, et al. Exercise-induced hypoalgesia in pain-free and chronic pain populations: State of the art and future directions. The Journal of Pain 2019 Nov;20(11):1249-1266. Doi.org/10.1016/j.jpain.2019.03.005.
2. NSW Government. Agency for Clinical Innovation. https://aci.health.nsw.gov.au
3. U.S. Centers for Disease Control and Prevention. Physical activity basics and your health.
4. De Zoete RMJ. Exercise therapy for chronic neck pain: tailoring person-centred approaches within contemporary management. Journal of Clinical Medicine 2023;12(22): 7108. Doi.org/10.3390/jcm12227108
5. American College of Sports Medicine. ACSM’s Guidelines for exercise testing and prescription. 11th edn. Philadelphia: Lippincott; Williams & Wilkins, 2021.
6. Vaegter HB, Jones MD. Exercise-induced hypoalgesia after acute and regular exercise: experimental and clinical manifestations and possible mechanisms in individuals with and without pain. Pain Reports 2020 Sep 23;5(5):e823. Doi.org/10.1097/PR9.0000000000000823.
7. Leemans L, Nijs J, Antonis L, et al. (2022) Do psychological factors relate to movement-evoked pain in people with musculoskeletal pain? A systematic review and meta-analysis. Brazilian Journal of Physical Therapy 2022 Nov-Dec;26(6):100453. Doi.org/10.1016/j.bjpt.2022.100453.
8. Young JJ, Pedersen JR, Bricca A. Exercise therapy for knee and hip osteoarthritis: is there an ideal prescription? Current Treatment Options in Rheumatology 2023 May 20:1-17. Doi.org/10.1007/s40674-023-00205-z.
9. Hayden JA, Ellis J, Ogilvie R, Malmivaara, A, van Tulder MW. Exercise therapy for chronic low back pain. Cochrane Database of Systematic reviews. 2021 Sep 28;9(9):CD009790. Doi.org/10.1002/14651858.CD009790.pub2
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