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No Pain No Gain: Helping or Hurting?

Table of Contents

Key Takeaways:
  • Pain is a staple in the physical therapy career field, but shouldn’t be the main focus of rehab
  • It can be tempting to avoid pushing into painful movements when writing exercise programs, but it can help with outcomes
  • When patients are told that experiencing some pain during an exercise plan is ok, they do more volume with more intensity and develop things like confidence and self efficacy

Physical Therapists are surrounded by pain. A large chunk of our job is to assess someone who has concerns about their pain or symptoms, and figure out a way forward. We learn a lot about pain in school, and also not nearly enough about pain. Considering we still don’t have a great understanding of what pain is, it’s understandable that we don’t learn or know everything we need to to manage it. 

When you have a patient sitting in front of you, asking how to relieve pain or symptoms, it’s easy to get sucked into focusing only on pain, trying everything you can to avoid making it worse for them, while trying to make it better. I’m here to discuss the contradiction that leaning into pain while creating an exercise based plan of care is actually the better option between pain or no pain.

Pain and Training

When you think of moderate to high intensity exercise, pain or symptoms are nearly always in the conversation. In fact, because exercise occurs while you and your patients are alive, it would be weird if it wasn’t in the equation. But many people, physical therapists included, feel that it most certainly shouldn’t be present, not only during physical activity, but at all. Perhaps living in a pain free world is coming in the near future, just as soon as we can get pain figured out and all. Until then, you should expect it to be a staple in everyone’s reality.

I tend think of pain during training almost as an occupational hazard of sorts. The point of physical activity is to stress you and your body, and while applying stress, finding points of intolerance is natural, and kind of the point. That’s how we create greater tolerances and find things that aren’t tolerated well enough. 

The problem comes when you start to associate pain or symptoms in physical activity with a need to halt all physical activity out of fear of something being broken or breaking, so to speak

Hurt Doesn’t Equal Harm

One of the mantras that I teach in our course on strength training is that hurt doesn’t equal harm. There can be “tissue abnormalities” without symptoms being present, just as there can be symptoms present without tissue abnormalities. So when pain or symptoms rear their ugly head during training, fighting the reflex to fear the worst is a super power that you need to develop. 

Pain vs No Pain

So which is better? An exercise program done with a rehab intention with pain, or without it?

If we look at studies¹⁻² that specifically tell their test groups to either perform the program with pain or without pain, we actually see that they do just about the same in regard to pain and symptom modification. 

The important difference that you need to consider is that the group that is instructed to perform the program totally avoiding pain is usually doing so by drastically decreasing program intensity or volume. On the other side of this coin, the group told to exercise with tolerable amounts of symptoms were doing just more activity in general

If there is one thing we know about physical activity, its that there is a dose dependent response, meaning that with higher intensity and higher volume, there are better strength and hypertrophy outcomes. There are caveats to this that I’ve discussed in the past, so be sure to watch my other videos. 

So the big question here is, if you can gain similar rehabilitation outcomes both cuing patients to exercise with and without pain, but one group experiences greater health benefits than another, which would you choose?

  1. Smith BE, Hendrick P, Bateman M, et al Musculoskeletal pain and exercise—challenging existing paradigms and introducing new British Journal of Sports Medicine 2019;53:907-912.
  2. Smith BE, Hendrick P, Smith TO, Bateman M, Moffatt F, Rathleff MS, Selfe J, Logan P. Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis. Br J Sports Med. 2017 Dec;51(23):1679-1687. doi: 10.1136/bjsports-2016-097383. Epub 2017 Jun 8. PMID: 28596288; PMCID: PMC5739826.

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