Exercise Rehabilitation; Is it okay to work through pain?

Exercise Rehabilitation; Is it okay to work through pain?

We get a lot of questions about whether or not it’s okay to exercise through pain, how do I know it’s too much or am I doing more damage than good?

What even is pain?

To understand pain, we often give the analogy of an alarm system. Think about a car sensor to alert you of surroundings, it acts to give you information re: a threat that could potentially damage your car if you continue doing a movement (crash/tissue damage). However sometimes the sensor can become faulty, it might beep without anything around that could potentially cause harm (this alludes to chronic pain). Similarly, it might beep too fast for the actual distance to a threat (hyperalgesia), or it might even beep for things that shouldn’t cause major structural damage like a pillow, soft shrub, etc (allodynia).

Hyperalgesia: Enhanced sensitive to pain/noxious stimuli
Allodynia: Pain due to a stimulus that does not normally provoke pain

Pain is typically a warning signal, your brain outputs pain to stop you from doing a potentially harmful movement/task which could potentially lead to tissue damage. Think about if you have a bad fall and cut yourself as well as fracture a bone, pain acts as a protective mechanism so you don’t put ongoing pressure on the open wound which may increase tissue degradation, or that you don’t keep moving the fracture which may prevent bone union/healing. For reasons unknown, this pain process sometimes cascades, causing your nervous system to be overly alert (central sensitisation) and lead to a decreased pain threshold/chronic pain (longer than 6months). From there on out things that shouldn’t hurt start hurting, movements that used to be okay feel damaging, that faulty sensor keeps sending out pain signals after the tissues should have healed (even broken bones should only take <12wks to heal).

Let’s consider the majority of people (85%) that have functional pain systems that haven’t fallen into a chronic pain state. The leading reason for why people come to the clinic, and the number one outcome/goal for most people is getting out of pain post injury. The gold standard of therapy and the most evidence-based treatment is exercise. So how do we regulate how much pain is ok when going through exercise rehabilitation?

Analogy: Therapeutic Medication Dosage

Just like other medicine, exercise requires a therapeutic dose. If you had a headache and took too small a dose of paracetamol, you would likely see no effect. This might cause you to blame paracetamol for not working for your specific condition (this happens a lot with exercise, doing too little and discounting it as an effective treatment). However on the other side of the spectrum if you had a headache and ate a whole box of full strength Panadol you would probably have paracetamol poisoning and die, similar to if you overdid your exercise with really heavy/painful weightlifting and running a marathon whilst pushing through pain, you would definitely make yourself feel worse and cause more structural/tissue damage.



Visual representations of Pain Threshold

Images taken from ‘Fitness Pain Free’ (credits to Dan Pope DPT, OCS, CSCS, CF L1)

Dan Dope Visual representations of Pain Threshold

Source: Dan Dope

From these 2 diagrams you can see what happens to the pain system and visualise the decrease in threshold which was explained above. The system is more sensitive post injury/pain and things that didn’t hurt prior start to hurt in order to protect the system from ongoing potential tissue damage.

With respect to this, the exercises we choose will be tailored toward the new threshold, in rehabilitation we aim to modify joint/tissue loads to induce relative rest and calm down the injury in order to build everything back up (with more resilience).

Source: Dan Dope

How much pain is okay? The traffic light system

There exists a ‘goldilocks concept’ attributed to pain during exercise. There is best evidence to support prescribing exercise that pushes into a bit of pain, because this stimulates tissue adaptation and functional progress. It must be just enough stress without hindering recovery and the subsequent rehabilitation process, avoiding the need to completely rest as shown in the ‘blow through pain’ diagram.

The general rule that clinicians like to abide by is the traffic light system
0-3/10 pain is a green light – continue doing these exercises without too much worry (the optimal stress zone!)
4-5/10 pain is a yellow/amber light – take a step back and reflect, is this pushing too far and affecting other sessions? Are pain ratings still in this zone after 24hrs? If yes, we need to modify and/or regress the exercises.
6+/10 pain is a red light – very likely too much tissue stress and detrimental to the exercise rehabilitation process, we don’t want chronic irritation and/or pain which continues to sensitize and overstress our systems/tissues.

If you’re getting minimal pain and it is settling after a 24hour period, you’re very likely causing optimal stress for adaptation. If it flares up and sticks around for more than a day, there could be cause for concern and exercise type, dosage, tempo, other rehab parameters may need to be adjusted!

But pain scares me!

Graded exposure or ‘reconceptualisation of pain-related fear’ also plays a part in the therapeutic exercise response/adaptation when going into mild amounts of pain during rehab. If we push into a bit of pain, recover well and witness our bodies improve functionally, our bodies naturally restructure our thoughts and anxieties about the injury/pain – leading to positive benefits!

Source: @thedgeu

This graph has been taken from @theedgeu, aiming to illustrate various types of adaptation and the relationship which exists with optimal stress. Tissues need to go through adequate stress in order to become more resilient, think about any type of progression in life – we often fail so that we can learn, and we occasionally push to muscle failure so that we can grow muscle size, if we didn’t surpass an optimal stress threshold then we would likely be stagnant in our lives. The same thing goes for rehabilitation. Training to mild amounts of pain during rehabilitation and providing our body systems with that optimal stress has been researched to improve functional outcomes faster and lead to improved tissue adaptation. However, also pictured in the graph is what happens when we overstress the system/tissues. If we are always pushing through pain and letting that linger into the subsequent rehabilitation sessions, mal-adaption will occur and the tissues may remain chronically irritated, the key is finding that sweet spot by following the traffic light suggestions as above when training with pain!

Our goal is to help people stay active whilst injured, modifying load/complexity of movements and not eliminating exercise altogether. We promote exercising with confidence, with the reassurance that pain is not causing ongoing damage to the tissues (it is just a warning signal).


By Physiotherapist Kavan Chen