On this episode of the St. Louis Pain Expert Podcast, Dr. Dave Candy and Dr. Nate Kadlecek discuss daily habits to relieve chronic pain including how to start a daily exercise routine.
Table of Contents
- Exercise and Chronic Pain: A Catch 22?
- Benefits of A Daily Exercise Routine For People With Chronic Pain
- How To Start A Daily Exercise Routine If You Have Chronic Pain
- Steps To Forming Of Daily Habits
- Other Daily Habits To Help People With Chronic Pain
- Other Resource To Improve Your Daily Habits
Daily Habits To Relieve Chronic Pain: The Daily Exercise Routine
Dr. Dave Candy: So we were in a Facebook group recently talking with some researchers that wemutually know and you'd asked a question about if there's any research out about if exercise practices carried out over along term, say a year or more, helps people with chronic pain.
I think the mutual conclusion was there isn't, and there probably can't be because there'sone big factor that would get in the way
If people stick to it, chances are they'll get better, but there's a large drop-off rate
Exercise and Chronic Pain: A Catch 22?
Can you explain a little bit about some of the results that you've seen with patients who have adhered to an exercise program for a year or more and then we'll get more down to how to do that if you have chronic pain.
You know, if it hurts you tend not to want to move, but you need to move to make it stop hurting. So it's kind of acatch-22.
Dr. Nate Kadlecek: It is, yeah that's a great question.
Let me start with a story and I Iasked this client in mind if I could use her real name and real experiences and she said, yes, totally fine.
So Danielle is a client that I've worked with now for over two years.
She had had an injury that wasn't work related, but there was a lot of things going on in her life at the time.
Her marriage was dissolving at the at the time. Her son was really young. She had developed some pain in her glutes and low back and this just continues to get worse and worse and worse.
This started seven years ago and things just continued to get worse. She wasn't able able to really work anymore.
She was barely able to take care of her son she when we met in October 2020 she could only walk 200 steps to her mailbox.
Any more than that and she would just have a horrible flare-up of just sciatic pain down her legu.
She'd gone through Physical Therapy, and it didn't work for her.
She tried a bunch of different things hadn't really worked for her she couldn't even drive her son to school. It was only a mile away, so it's not like it's it was super far, but just getting into the car and doing the motion of pressing the gas pedal down just would flare things up horribly.
She couldn't even drive. So and she's not like 80. She was 37 when we met.
She used to go to the gym all the time. She was fit. She could leg press over 300 pounds. She could squat, deadlift, and do all those things.
A Common Myth About Chronic Pain
One of the common things that people who don't have chronic pain often will say is that they (people with chronic pain) weren't active or they weren't fit before. But the reality is that a lot of people who are now struggling with chronic pain... they used to be super fit and active.
You've probably seen this too. It's not like they weren't doing anything before.
So I want to obliterate that myth.
So Danielle was really active. This happened to her in October2020 when we met she was on the verge of just giving up and just throwing in the towel.
"Is this is what my life is going to be just like?"
Really hard core depression at the time just not knowing how she's going to care for her son who was less than 10 at the time. So young and lots of energy.
So we just happen to meet in my Facebook group and she saw what I was doing with people.
Benefits of A Daily Exercise Routine For People With Chronic Pain
She saw kind of the message that I was putting out there that was hey there aren't quick fixes but if you do something for a long enough, consistently enough, it's likely that you will see the benefit.
She just had that mindset.
I remember her telling me, "I will do this as long as it takes to get better for myself and my son. I can't live like this anymore."
That mentality that she had Ithink is a big part of why she's done so well.
Because she had something, her son, and her parents are getting older too. They have some healthc onditions she has to help them. She knew that she's like okay I have to like be able to be there for my family and so she had something out there that would give her the motivation on days that she just didn't want to do it.
Where she would get up and go and so that was a big important part, and the fact that she was consistent.
She was consistent with her movement routine over the course of 18 months.
For the first six months, we were just testing things we were testing different movements.
Changing up the Locking speed changing up the walking durationm changing up different types of exercise and movement.
I'll be honest, there were several times where she flared up pretty bad and it lasted for a couple weeks.
This is a big part of why people dropoff.
Because they assume that they try something new and then it flares them up and that means that "all movement is bad for me" and this is therefore just going to be the rest of my life.
I want to really correct that.
Yes there are going to be times where you get flared up especially when you're trying to really like address a problem.
It might be that you get flared upfor a couple weeks or even a month.
And that's super hard to deal with. That is really really difficult.
If you're doing it on your own, it's really hard to get through that on your own.
Even if you're working with a therapist that's really difficult because maybe they didn't set the expectation for you, that:
You are going to flare up. It's not IF, it's WHEN. You just use are. We'regoing to try to avoid it as much as we, can and we're going to come with a game plan to reduce that from happening or reduce the intensity, but we need to set those expectations from the very beginning.
I sat with Danielleand said, "Hey, we're going to do our best to to give you really small bite-sized pieces of movement just to work on some of your functional deficits that you're having", for example like bending over. She couldn't do it just to even pick things up from the floor.
So we started little bending routines here and there just to slowly increase range of motion.
We had to go incredibly slow overthe course of a year in order for her to make significant progress.
The problem with traditional physical therapy and healthcare in general is that the way that the system is set up.
Oftentimes you go to physical therapy for two times a week for six weeks or two times a week for three months.
The problem is is that the way that physical therapy is often billed. You have to bethere for a certain amount of time if you're using insurance.
So the issue is when you have chronic pain and it's really irritable, sometimes the only thing that you can tolerate is one set of ten of one exercise and that might be your movement for the day.
Now this seems incredibly small, but the the problem is that when you're going to PT a bunch of times, sometimes the therapist has to put you through like five or ten different exercises to be able to fill the time up.
It works for people who are generally going to get better anyways.
It doesn't really matter the exercise dosage... they just need to move.
But for somebody who is super irritable in terms of their their symptoms and get with very small amounts of movement, having a time-based treatment paradigm is probably the worst thing that you could do for somebody who can't tolerate it.
The incentive is all wrong.
I think that we need to think about "what is the optimal dosage of movement for this particular person?"
Does that mean it's going to take two minutes per day on their own time? Is that going to be 5 minutes 10 minutes?
Is itgoing to be one exercise, two exercises, etc.
And then maybe the time that we spend together is just going to be discussing how to best move forward and maybe addressing some of the fears that you might have.
Learning how to manage flare ups and really learning more about the science behind the pain versus just using that time for for exercise.
Yyou can use thosethe sessions too for you know changing the form on certain exercises to make you feel better and making adjustments that way
To summarize, that we need to come up with a more innovative approach to helping people with chronic pain
Especially where they get irritated really really quickly...
Because the current system that we're using is not working
Dr. Candy: I totally agree andyou brought up some great points. I'm just going to kind of summarize those really quickly and you can correct me if I didn't catch any of those:
- Dispelling that myth that people wholive in chronic pain are just lazy or that they don't take care of themselves or that they're couch potatoes. In fact sometimes, I think it's harder for people who havebeen at the top and then fallen so farthat to see where they once were and where they now are it's just really depressing.
- The stick-with-it-ness: being consistent over time even when it's hard.
- Having something to to get better for. Having a motivation that I need to get better for my child for my parents... for whoever else may depend on me. If you're just doing it for you, then there may not be as big of a motivation. Or if you're just trying to do it to get rid of the pain and not for some larger, greater good then there may not be sucha great motivation. But if you have something bigger or external to yourself that that drives you forward then there is that motivation, and you can stick it with it long enough to actually see results
- Finally, that we need to change the practitioner's role from being a personal trainer who counts the reps to more of a coach and an educator. I think that's really why we're both here today... to educate people and Empower them to do things on their own time when they're not with you or I or another physical therapist.
So thank you for raising all those good points
How To Start A Daily Exercise Routine If You Have Chronic Pain
Lets talk about how someone who is in chronic pain gets started on that process. Becausethere is that temptation and motivation to just want to say "Forget it. I'm too far into this hole. I'm just gonna have to live with it for the rest of my life."
Yeah, that's a great great question. I'm gonna pull to the ending of Danielle's story.
She can now walk 10,000 steps.
She could only walk 200 steps, and now she's going to Dragon Con - it's kind of like the Dungeons and Dragons of Comic-Con. She can now go to those conventions which was a huge part of her enjoyment. She can fly there.
She can drive her son to school. She can be there for her parents.
And this is somebody who literally could not walk up the steps.
So where we got started:
We looked at:
- What are your current functional abilities?
- How far can you walk?
- Can you bend?
- Can you get up from the floor?
- Can you do a squat?
All of these little things that you need to be able to do to basically function as a human?
We look at those, and then we start at the smallest dose.
I like to start everybody as they're capable on a walking program focusing on steps.
Not focusing necessarily on going a mile or anything like that, but if you can walk 200 steps great let's do that once per day.
And maybe if that's too much, we break itinto 100 steps twice per day.
We find something very attainable something that's not something you can do very successfully and then we build from there.
And you might be thinking,"Well what in the world is doing 100 steps twice per day going to do for me?"
What it's doing for you is it's not going to change you physiologically, necessarily right.
It's not it's notgoing to magically build a bunch of bone density or muscle mass or like increase your cardio-respiratory capacity by justd oing that.
But think about it this way...
Building Your Show Up Muscle
You are increasing your ability to show up and move even when you have discomfort.
Showing up and moving and establishing a new habit of movement that is actually going to help you when it's time to increase the intensity and duration.
We have to establish the routine of moving.
We want to make that as easy and painless as possible because you've already been dealing with pain. You don't want to keep dealing with more and more.
So we need to establish a movement routine that doesn't significantly alter where you're at currently.
Then over time, you're just adding steps every week every couple weeks. All of a sudden, you're feeling the same but you're doing 10 times as much.
So you're feeling the same you were doing 100 steps and you're feeling okay now you're doing 1,000 steps and you feel okay, and then all of a sudden you do that long enough and you get to like 5,000+ steps .
You're walking basically mile at that point.
So it's really important to establish the habit first, and that's by doing the smallest possible dosage that you can do without necessarily making things worse.
That helps toe stablish that habit.
So that that's how people should get started.
And that doesn't just that's not just for exercise that's for anything you want to do
Remove the barriers.
We have this idea that everything has to be hard. Like if we're not working hard then it's not worth it.
But you do like you don't have to die on that hill.
In fact like there's lots of people who've died on that hill, and it's not a good hill to die on because you don't feel good doing it.
Instead, if you want the actual outcome that you desire, don't die on the hill.
Just take it nice and slow and you will actually reach the outcome as opposed to getting buried under the snow trying to like climb Everest.
So that would be my main message:
Start small, establish the daily habit, and then you can build from there.
Even though those 200 steps a day may not physiologically change you, it allows you to take 300 steps, and then 400 steps, and then 500 steps and so on and so forth.
Steps To Forming Daily Habits
So let's talk about habit formation I know that's one of your areas of expertise how do you establish those daily routines and daily habits?
Choose The Daily Habit
So first it is looking at: What habit do I want to establish?
How do I want to be, or how do I want to show up in the world?
Like who basically who do I want to be. So that takes a bit of introspection itself.
Tie The Daily Habit To Something Important
Once you've established the types of daily habits that you want, you need to tie them to something that's important to you.
For the example, "I want to improve my health right" this is a habit that a lot of people want to improve for the New Year.
But why do you want to improve your health. What's good about improved health?
Well, because I have cardiovascular disease that runs in my family and my father's had a heart attack. And I want to be there for my kids and grandkids when they get older.
Okay, that's a pretty like that's a pretty good reason to want to be healthy.
But sometimes we have to really dig down into why is it really important for us?
But that's not enough to establish the habit.
Remove The "All or Nothing" Mentality
It's good to know why it's important to you, but then the next thing is we have to remove an "All or Nonthing" mentality.
Let's say that your goal is to walk 10,000 steps a day because you know that that's really healthy for you and that's good for you.
And you say, okay I'm going to do 10,000 steps a day but you don't take the time to audit how many steps you're already doing.
If you're if you're only doing like a thousand a day or less doing 10,000 a day is going to be a 10x increase or a 1000% percent increase of of what you are currently doing.
That is an insurmountable goal for anybody.
You might be consistent with it for a couple days, a couple weeks, a couple months... but that is really a huge shift.
Make The Daily Habit Easy
So what I recommend instead is it's great to have a goal of like a big goal like that but what's more important is:
"What is realistic right now for me? What feels easy to me?"
Whenever you're establishing a new habit, you have your why figured out what that is and then the next step is "How can I make this as easy as possible?"
Where I could do it even when I'm chronically underslept and I hurt. What's the amount that I can do on a day where I just feel horrible?
That's the amount you should start with because then on your good days you can always increase as you feel as you feel comfortable.
But you want to start with something that you could even do on your worst days because that way, when they inevitably come around, you're not going to drop off and miss one day, two days, five days, etc.
Because that's when it starts to become really difficult.
"Well I didn't hit my 10,000 steps so I might as well just give up."
Let's start with: Your base was a thousand. Great let's start with a thousand a day. That's how much you've been doing already.
Now you're just cognitively aware of it and then as you establish that and you can really stay consistent with it.
Then we can start to increase that over time.
I'm using steps it can be other other habits of course but that's just an easy one to kind of wrap your head around.
So number one have your why. Number two, establish the lowest viable dosage.
So the easiest amount... and it could be like that that you're walking for two minutes at a time or one minute at a time or something easy, but again it's about building you're showing up muscle.
Once you've built your showing up muscle, then you can start to increase the difficulty of it.
Other Daily Habits To Help People With Chronic Pain
So we've discussed exercise, but what are some other daily habits that would help someone who's dealing with chronic pain?
There are a couple things.
Another habit that one of that Danielle was using was journaling.
She found that it was helpful for her to write down kind of how she was feeling and just to be more in tune with what she was dealing with
So that was one thing that she had built a habit with.
Her her sleep habits as well she started to change those too trying to really focus on.
Instead of staying up really, really, really late and watching shows or just kind of winding down that way, she reduced her time doing that.
Changing Beliefs About Pain
Honestly the biggest things that she did were around movement and then the rest of the time that we discussed around the mindset of somebody who can establish a new normal.
So changing like working on actually changing her belief structure around how long this will take.
What is a normal response to exercise versus an abnormal response to exercise.
So this kind of moves from daily habits to more of like belief change, but we really had to dive into even the difference between muscle soreness and pain.
Because if you had pain for a while but then you get muscle soreness, sometimes you're not able to differentiate between the two.
Because it's all just pain at that point.
We had to really fine-tune the language that we were using too.
So differentiating between the sciatic type pain versus this is more of a discomfort.
"Yeah okay, I did squats and my quads were sore."
So redefining the language that we were using was was important too, and so this actually was kind of a new type of habit as well.
Minimizing Catastrophizing and Panic
I talk with a lot of my clients about avoiding jumping to the worst case scenario and going down what I call the panic route.
For example, pain onsets and then just we just drop off a cliff don't do anything.
I encourage my clients to when they do start having the flare up or they're in the midst of one instead of going down the panic route, trying to look at it from an analytical perspective and that helps to remove the fear component.
Being prepared for flare ups and having two or three things that won't make it go away completely, but can control some of it.
So just even changing her thought pattern on that not going down the panic route but going down more of the analytical route to really say okay I'm hurting, and this isn't fun, and I don't like this... But I know I can do X, Y, and Z to help control symptoms while my body figures out the rest.
So that was something we also worked on together was identifying what thoughts and beliefs she had that were kind of keeping her in that chronically flared up state.
Then addressing those and kind of changing it.
I think mindset's really important in any goal and particularly with regards to pain. Some of the leading pain researchers in the world have shown that the ability to reconceptualize pain predicts success. And people who can't reconceptualize pain... it actually predicts failure
So the ability to change your mind needs to come before you have the ability to change your body.
Nutrition and Chronic Pain
We talked about gradual progression of activity. We talked about sleep habits. We talked about mindset. Where does nutrition come into things for people who are dealing with chronic pain?
I generally rely on others for their expertise on this, but there probably is some contribution of food in its relation to more of a low-grade chronic inflammation, but to what extent that is I I don't know for certain. Maybe you have more that you can add to that.
My main recommendation for people ispretty simple it's to you should eat thefoods that number one make you feel energized right. Generally those are not highly processed foods. They're calorically very dense and they have low satiety so meaning you can eat way more calories but feel less full. If you eat more fruits and veggies plus you increase your protein intake and then you just have your normal amount of fats, pretty much like a basic Mediterranean diet,that tends to work pretty well for people.
I think a lot of people get into the weeds too much when it comes to nutrition like trying to change every single thing. Trying to take a bunch of supplements., when really if you just keep it as basic as possible, you're likely going to cover all of your bases.
Now this isn't talking about weight loss or anything like that. That's more of a nuanced discussion as well, but for the most part, people probably get caught up in the weeds too much with nutrition kind of looking for the "one thing" that will make them better.
It's like looking for the "one specific exercise".
"If I could just figure out this one food that's causing my inflammation it'll just all make it go away."
But I I just haven't seen it happen with most people. Mmaybe there is that one person out there a few people out there where they do need a very specific dietary change, but if somebody's eating a really healthy Mediterranean style diet that works for most people.
I do agree that people tend to get caught up in the weeds too much. There are people with autoimmune conditions that have food allergies or food sensitivities to certain groups. I'd say those are probably more the exception than the rule.
In general if you clean up your diety by trying to eat foods as close as they were in nature and not highly processed and get all the green leafy vegetables, lean organic proteins,Omega-3s, and water... that helps most people
Then if you have all that in place and you do need to supplement that that's when it's time to start delving into supplements.
But I think people do go looking for the "Magic Bullet" a little bit:
This one exercise. This one back brace. This one supplement that all my ills would go away.
Spoiler Alert: There's usually not one magic bullet.
Like you said, it's consistency of doing a lot of little things right over time for most people.
Other Resource To Improve Your Daily Habits
What other resources would you recommend to someone who wants to improve their daily habits?
Whether that just be to be healthier coming into the new year, to get rid of some chronic pain that they have?
I'm just going to give one recommendation.
If I give too many people have uh paralysis by analysis.
Read the book or listen to a podcast episode with James Clear. He's the author of Atomic Habits.
You will never need to read another habit book in your life.
If you don't like reading books, listen to the podcast.
It gives you a very easy to follow habit formation strategy that you can implement
Again, it's a bit of shifting your belief structure that things have to be hard.
Things don't have to be hard.
Things are just as hard as you make them. Some things are inherently hard. For example, if you want to train for a marathon, yeah, it's probably going to be difficult. There are going to be times that are challenging.
But if you're just trying to establish a new habit, to get healthier, to reduce your pain, to be more functional to create a new normal... follow that book is excellent.
So that would be my recommendation my one recommendation check out James Clear, Atomic Habits.
He's awesome. I've learned a lot from him and a lot of my habit formation strategies that I use in clients is actually from him
Book mentioned in this podcast: Atomic Habit, by James Clear.
Click here to buy a copy on Amazon.
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