474 | What interventions have the best evidence for down-regulating pain sensitivity (breath, sleep, graded exposure, strength, walking)

[00:00:05] Welcome to the Optimal Body Podcast. I'm Dr. Jen and I'm Dr. Dom and we are doctors of physical therapy bringing you the body tips and physical therapy pearls of wisdom to help you begin to understand your body, relieve your pains and restrictions and answer your questions. Along with expert guests, our goal of the Optimal Body Podcast is really to help you discover what optimal means within your own body. Let's dive in.

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[00:01:50] So we've been asked, you know, what are the evidence-based interventions that are going to be best for down-regulating pain sensitivity? And I think this is particularly important when we're not talking necessarily about one pain point, but chronic pain, pain that continues to be consistently coming back.

[00:02:11] You know, what is evidence-based? Is it a massage tool? Is it a foam roller? Is it the breath work that people talk about? Like, what are the top things that I really should be focusing on bringing into my life so that I help to down-regulate this pain?

[00:02:28] And I think this is so important because in so many of the recent podcasts and in so much of the recent research, especially related to specific diagnoses like plantar fasciitis, Achilles tendinopathy, any sort of itis or apathy around the body that might be recurring. They're realizing, okay, we need to treat this a little bit differently than we treat somebody the first time they get plantar fasciitis in an acute setting. Right.

[00:02:58] Because this pain sensitivity component and pain patterns in our nervous system are going to be much more present and they might not respond as well to the gold standard treatment for an acute plantar fasciitis or an acute injury, essentially. So let's talk about the first one. The one that should be top of mind, I think, for just everyone. And that's aerobic exercise.

[00:03:25] So that is just you're getting out, you're walking or cycling or doing something that you can continue for a long period of time. That has been shown to be the best pain sensitivity signal. Decreaser. Regulator. Regulator. Regulator. And again, keep in mind, we're talking about pain sensitivity here, not about pain scores.

[00:03:47] And one of the reasons that the mechanisms through which this works when we exercise or when we exert our body physiologically, there is a ton that goes on. You know, one, we're going to get our heart working. We're going to get more blood pumping and flowing. All the systems of our bodies kind of get upregulated just a little bit, even just going on a walk.

[00:04:08] And then there are also all sorts of processes where our body starts to release our endogenous endorphins, which are happy chemicals, happy signalers in our body that might boost our mood a little bit. It also helps activate areas in our body that are our pain inhibition pathways. There's one area in our brain called the paraqueductal gray. I know that for whatever reason. That one has always stuck with me. That's like our opioid center.

[00:04:38] You know, it's like our endogenous opioid center where we are able to inhibit pain in the body just by doing this aerobic exercise. And so this is where this is one of just the cleanest, most repeatable ways that we can really have this exercise induced hyperalgesia, which is our body's own pain inhibition.

[00:04:59] Right. So because if you could just go out and walk, if you can go and find a bike that you can ride for, you know, an extended period of time, it becomes that repeatable thing that we can our system can continue to rely on and come back to.

[00:05:12] And in people with chronic musculoskeletal pain, a systematic review found that all 11 included studies reported aerobic exercise increased pressure pain thresholds or decreased pain ratings with a median improvement in pain sensitization of 10.6%. And that ranged all the way from 2.2% to 24.1%, which is a huge improvement in pain.

[00:05:38] And exercise was typically walking or cycling at submaximal intensity with a gradual progression. And the effect showed up after a single session in some studies and then some up to 2 to 12 weeks. So even just thinking, just going out for a walk, just getting up, just moving. Like the number one thing we're trying to combat here, especially when we're in chronic pain and we just don't feel good in our body, is moving more. Yeah, we've explained on other podcasts what pain sensitivity is in general.

[00:06:06] And I suppose we maybe should have started with that, but it's like, it's essentially this volume knob. We've had guests on that have explained it in a different way and where when we don't have any pain, our knob might be at zero. And we initially feel pain when we get above a five or a six or something to that degree. As we have had pains in a certain area multiple times or something like that, our body starts developing this pattern. And now our knob always just sits at a two or a three. It's starting to sit a little higher.

[00:06:35] It's starting to sit a little higher. So your pain threshold before you get to that five or six where you feel pain is already there. You only have two or three more numbers to go. So you're kind of resting at this baseline level. And what we're saying aerobic exercise do is it helps to slowly bring that base level back down. And think about it like all these other things that get added into the system that can kind of make our cup overflow. And that pain really weren't, our system is unable to block it out anymore. Maybe we're not sleeping well.

[00:07:05] We're really stressed with our job. We have other life factors. Someone just passed away in the family. You have more stresses. You have financial stress. Whatever might be going on is all compounding into a body's ability to reduce that pain sensitivity. So if we can find mechanisms that can help with that, even if we can't control some of these other factors, like that's what we're really wanting to do so that we stop that cup overflowing so much.

[00:07:33] And now I think what's important to remember is that when we're talking about aerobic exercise, yes, you could do this for an extended period of time, but we're not saying you need to go out and walk or ride a bike for 60 minutes. We're talking four to 10 minutes and getting started. Like, can you just start a little bit of something because a little bit is going to be better than nothing. So where in your life can you add in a little bit of aerobic activity? Just four to 10 minutes a day.

[00:07:59] Especially depending on where you're at, because some of these things people might think about walking or biking. Well, that's when I have pain. I have pain when I walk. And so it might be tough to get out. But aerobic activity is anything that can get your heart rate elevated. So it might take some creativity, but there are options that most people should be able to find, regardless of what type of pain issues you might be dealing with. Yeah. I mean, they're swimming, they're sitting down on a bike and doing the arm bike. There's different things that we can do that's going to be elevating our heart rate.

[00:08:29] And you've got to find the one that kind of works for you in a place that you can easily access it. The number two that we're going to talk about is exercise training, which includes strength training and how this helps to also improve pressure pain thresholds. And what was seen is that more so than a single session effect, multiple weeks of training seemed to produce a more durable impact on pain threshold and pain sensitivity. Which continues to just make so much sense to me.

[00:08:57] But I know that could be a really intimidating factor when you're telling someone who's in pain to start strength training, right? But when we looked at the evidence, so a systematic review or meta-analysis of 15 exercise training studies in pain syndromes reported exercise training was effective for reducing pain sensitivity, which is increasing that pain threshold versus control with an overall effect size at about 0.60.

[00:09:26] So that is pretty high when we're talking about really being able to be effective in creating change in those pain thresholds. So there was an important nuance to this systematic review. The paper noted that when split into resistance training versus aerobic versus multimodal categories, because each of these papers studied a slightly different type of exercise, the subgroups themselves didn't always have super significant effect,

[00:09:55] which helped the paper kind of conclude that multimodal approaches or grouping all exercise into this one category, there really wasn't a superior form of exercise that stood out. So the how and why, you know, why does exercise help modify or change our pain sensitivity levels? Similar to what we found in the aerobic training section has to do mostly with physiologic changes

[00:10:21] and central neuroplastic changes like improved cortical inhibition, that kind of pain inhibition pathway that we were talking about, immune and inflammatory modulation. You see a lot of different changes in our immune and inflammatory processes during exercise, plus just in general, better self-efficacy, reducing kind of fear avoidance behaviors when it comes to movement and exercise.

[00:10:46] So it really is working physiologically, emotionally, psychologically to help reduce those pain sensitivity. I mean, I think that's like the biggest impact when it comes to strength training is really improving our confidence and movement overall. What can I start doing when I add muscle? Oh, all of a sudden it doesn't feel as scary to bend down and move this or pick this up or lift my child, lift my dog, whatever that may be. Like you have more access to independence when you start strength training in a safe and gradual manner.

[00:11:16] Right. So especially when you're in pain, if you could just start small, like do things that you don't feel like maybe even constitute strength training. Maybe you're just doing air squats when you're outside with your kid or you're doing pushups at a counter. Whatever you could do to start adding in slow, intentional muscle building exercises, you will be surprised that you might start to see your balance improve.

[00:11:43] Or you can suddenly lift your groceries with more confidence and lift things up onto the counter. When we can really start to improve our confidence, like that also plays a huge role in just our pain sensitivity and what we feel like we could do within our body. So I just this can be a really slow, progressive approach. It's not anything that we're saying go under a barbell and start lifting super heavy, but really mindfully two to three times a week.

[00:12:07] What can I start doing just to start like 10 minutes of getting more movement in that's going to make my muscles feel stronger? Lunges, squats, pushups, pulls, presses, like these are things that you can do and you don't need access to a ton of equipment. And as we go through these categories, it's not like we're kind of separating them out because the research likes to isolate different variables from each other. But it's not like you're only picking one or the other.

[00:12:37] And again, in this exercise section, it includes aerobotraining as well. So if you do a strength workout or two in a week and then you have another day you go out for a walk, there you go. You're starting to build your program to help modify this pain sensitivity. And number three was sleep intervention, which had a small pain effect, but a huge amplifier control. Poor sleep reliably increases pain reactivity.

[00:13:05] Improving sleep often reduces the baseline threat or sensitivity state. Which, I mean, I see this all the time within myself and also my patients, right? If someone is not sleeping well, their incidence of feeling more pain, feeling more tightness, more tension within the body is going to be so much higher. It is shocking how many people where it's like you didn't necessarily change the exercise protocol or what you did biomechanically.

[00:13:32] But if you just improve your sleep, the amount of change that you can start to see within your pain, it just it's incredible how it could change, especially when we're talking about this chronic pain. And what we mean by it didn't have a huge pain effect is like improving your sleep in the short term didn't immediately bring down the pain number. Right.

[00:13:53] You know, if you were at an eight pain level like that might not change a ton, but the overall pain sensitivity just by giving your body that better recovery, all the beautiful things that our physiology does while we're sleeping helped to bring down that pain threshold, which long term will help impact that pain number. You're recharging your battery. Think of it like a phone. It's not going to it's going to be glitchy. It's not going to work as well when it's running at a really low battery.

[00:14:18] But when you plug in your phone, it's just like you're plugging in your body when you get that rest and recovery. It's so incredibly essential. And we see from systematic reviews and meta analyses how pain improvement, you know, even just a small effect of 0.2 was seen post treatment. And then the probability estimates of less pain at 58 percent post treatment and 57 percent follow up at about 12 months.

[00:14:46] So you have to think about this of improving your sleep over a long period of time as well. But I mean, you can really start to see more strong outcomes the more that you really work on improving your sleep habits. And again, add this into the routine like this study. It was specifically on CBTI, which is a treatment for insomnia. But finding a way to move the needle a little bit in your sleep. Like we're parents of two kids.

[00:15:14] We both probably get up multiple times every night. That doesn't mean that there's nothing we can do to improve our sleep hygiene, to improve, you know, our sleep habits. Getting into bed earlier, not being on screens. There's so much that we could do. Plenty that we could do to help improve our quality of sleep.

[00:15:31] So number four, we go into cognitive behavioral approaches, cognitive behavioral therapy, something that's, you know, very popular and very common to treat a wide variety of different psychological, social, cognitive, mental disabilities. And so how does it do for pain? Right. And an episode I want to refer you back to would be episode 455 with Rachel Zoffness.

[00:15:55] If you were to try to understand this a little bit and listen to anyone on behavioral therapy and how that affects pain and really understanding the psychological side of pain, this would be a really good episode to listen to. And just how we talk to our body plays a huge role in the pain sensitivity that we feel on a day to day basis. And so we are increasing our threat response every time we tell our body that there is threat present.

[00:16:21] So if I am telling myself that my back is thrown out, that my knee is just grinding, it's just wear and tear, it's just bone on bone. It's just, you know, if we continue to use these words that sound very inflammatory to our brain and to our system, we're increasing that pain sensitivity. So it's like, how can we start to talk about our pain experience in a different way?

[00:16:44] It doesn't have to be a positive way, but even if we just started to speak differently about our pain experience, about what we can do on a day to day basis rather than what we can't do. Like this all has to do with that pain catastrophizing, you know, when we catastrophize our pain to a level that maybe people have told us, like my MRI looks horrible or this is bad. When we catastrophize pain, we increase that pain sensitivity, that threshold.

[00:17:09] And so it makes our body a lot more sensitive to feeling pain on a day to day basis. And when we can work on this, especially when you're talking to a therapist, this is where it could be really beneficial. We start to see major improvements, even people just reading books, how the body keeps the score or one on back pain I can't think of right now. But when people even just read books on how they're starting to talk differently about their body, huge pain reduction.

[00:17:36] And the biggest difference that was seen in this meta analysis done on cognitive behavioral therapy used for pain, pain catastrophization saw the biggest effect, saw a huge effect there. Pain intensity itself had a moderate impact and disability. People who consider that their pain is actually debilitating to the point that they aren't able to do things in their everyday life had a small effect. But I think, you know, Jen hit it on the head.

[00:18:02] It's just like finding those couple skills that you can use throughout the day to reframe, reframe what you're thinking. Like, OK, my brain, I'm feeling pain. My brain is predicting danger. It's giving me some information, but it's not damage. Like, how do you how do we reframe it that it's not something that's further damaging my knees, further damaging my back? Yeah. Or another option is values based action.

[00:18:25] How do we focus on activities that help us fulfill something that we enjoy going to an event with family, finding a time to take a walk with our dog or our children or our partner? And then the last is catastrophization interruption. Like, if you find yourself talking to somebody or spinning into a catastrophization cycle, talking about your knees, your back, your problem area in a negative way. Pause. Name it.

[00:18:55] OK, I'm spinning into that cycle and then move on. And number five, I feel like kind of pulls a lot of what we've been talking about together. So this is graded exposure, graded exposure to the activity that was initially causing you a lot of pain. And this can feel really scary because this is tapping you back into the place maybe that initiated the pain where you feel the pain.

[00:19:20] So if someone avoids movement because it feels dangerous, their system gets more reactive. So exposure retrains, literally is retraining that safety within the brain for the body to start to respond. And this is where it is going to take a long time. And it's not supposed to be something that's like, give me the magic pill, the magic fix that's just going to get rid of my pain.

[00:19:46] But this is to get you back into functioning in everyday life in a better capacity with less pain. And the evidence points out just that, that the effect gets larger the longer that we work on this graded exposure. Really helping address a fear avoidance behavior type thing where with the graded exposure, we start to have less fear surrounding certain activities.

[00:20:11] And that's why we have a larger effect the longer we do an intervention like this. And with this graded exposure, it's not something where you're like pushing through the pain. Okay, I just have to do the activity even if it is a little scary and I'm having pain. It's more the dosage that's the problem. So how do we dose that activity or dose that movement in a way that isn't perceived as threatening by our brain and we can do it more comfortably? That's what's going to grow that confidence.

[00:20:40] Now, something we talk about on the podcast a lot too, I feel like, especially when you're initially having pain symptoms, is breath work. So we want to talk about like kind of where does that fit in to all of this conversation when we're talking about pain sensitivity. And we have to understand like the five categories that we talked about, those are all things that can be built upon long term.

[00:21:02] So this is for the best evidence that's going to give you the best long term carryover that you can continue to come back to over and over again. Breath work, we see the highest quality really, it's strongest for those acute pain instances. So say you feel like you threw out your back, you get on the floor, you do intentional breath work and all of a sudden your pain is gone.

[00:21:26] It doesn't mean that your body has reprogrammed all of a sudden and you are pain free for life. It's just in that moment, maybe I can get up and I could do what I was supposed to. So that's where breath work can really be so impactful and why we talk about it so much when it comes to pain, because it's that thing that's going to help you downregulate right in that moment so that we're not catastrophizing our pain. And we're saying, OK, what can I do now moving forward?

[00:21:53] So when we talk about breath work as well, this is really like getting you back into that parasympathetic. So if we think about it on like an arc or like a circle, our parasympathetic, we want to focus on more of a long exhale and a shorter inhale. That's a really basic way that we can start to think about getting more into a parasympathetic state and using breath work. Think of like you're going for a massage and you do a long exhale.

[00:22:18] It's like, oh, or someone scares you and you're like, we focus on the inhale. Right. And that's more sympathetic. So that's like a really easy way to start to think, OK, I'm going to focus more on that exhale, that breathing out, that blowing slowly through pursed lips, that exhale through my nose. If you could start to think about those in those moments of feeling that pain, all of a sudden that can really flip the switch. It's really a state shifter.

[00:22:47] You know, it helps you shift state from fight, flight, fear, you know, in that initial injury to, OK, how can I feel like I have more control right now, more safety, more stability? And that can really be pivotal in how the journey goes from there. You know, in that immediate moment, do we tighten up, tense up, go lay on the couch with a hot pack and possibly start to catastrophize about what the heck just happened to our back?

[00:23:17] Or do we try to do something in the immediate that is going to help downregulate? The meta analysis showed really pretty high effect sizes for pain intensity threshold for just acute clinical injuries. It was interesting because it said for burn patient, burn pain trials found a much larger effect, a really high effect. So again, in that immediate, if you are able to control your breath, you're able to shift your state. And that can really help with the path moving forward.

[00:23:46] Thanks so much for tuning in to another podcast. I hope we see you back. And of course, if there are tools that you heard or that, you know, could be beneficial for someone in your life who is dealing with chronic or consistent pain, please send this episode along. This is how we get help out to more people so that we can help reduce pain altogether and continue to learn. We hope to see you back on another podcast.