11 min read

Rethinking pain: Increase your life in spite of chronic pain

Rethinking pain: Increase your life in spite of chronic pain

Today I want to talk about chronic pain and what could be some potential contributors as well as some treatment methods. I will mainly be talking about central sensitization and nociplastic pain (don’t worry I will explain what those are in the next paragraph). I want to make it very clear that these are concepts, and not truly known mechanisms, since the nature of them makes it difficult to study in humans. Before I get into the definition, these two concepts would fall within chronic pain1 and so I will be talking about treatments for these concepts and chronic pain together.

Central sensitization and nociplastic pain

At the core, both of these concepts describe pain that has no actual damage or inflammation accompanying it, but rather you have general areas of pain and hypersensitivity (normal things are painful or a bigger pain response than normal to painful stimuli).2-5 Central sensitization kind of goes a step further to try to explain the mechanism behind the classification. In central sensitization your brain and the neurons in your spinal cord become more sensitive to pain, thus making it easier to feel pain and potentially making it a higher intensity.2-5 Kim5 described it as your brain “turning up the volume” for pain, and one way that I like to describe it is that your body is on high alert and looking for pain. I want to point out is that the hypersensitivity can make normal tasks painful and thus make you afraid of doing certain movements,6 which can negatively impact your quality of life. Basically to sum it all up, you feel pain more often, and the pain can be worse!

What can cause it?

Now that we have a brief understanding of the two concepts, how do they come about? Well, sensitization may occur after an injury, prolonged exposure to pain, surgery, osetoarthritis and more.2,5,7,8 Expanding to chronic pain in general, other risk factors include stress, poorer sleep, and physical inactivity,9-12 with work stress being a strong independent factor that outweighs physical activity.12 This is an important point for guiding your treatment and looking at things that are not your pain, but may actually be playing an important role in your pain. Sometimes working together with your health care provider to come up with strategies that change your lifestyle can be the most impactful, and where the treatment focus should be.

An important point to consider for the aging population with osteoarthritis (OA), is that chronic pain in the form of sensitization or nociplastic pain can often accompany hip and knee OA.8 This furthers the point that the physical changes as seen with OA may not always be the cause of pain, and increase the importance of education and exercise as part of the treatment.5,8,13,14 It is known that some inflammation in the joint lining is a sign of OA13-16 which may be one of the influencing factors for the sensitization.8 I would also go as far to argue that the outdated and inaccurate view of OA as wear and tear could lead to fear of movement and also create a learned pain response to movement, thus increasing the amount of pain experienced in this condition.

Continuing with this point, people who have sensitization and OA, typically also have higher expectations for surgery, which results in worse outcomes after since their expectations are often impossible to meet.5 Again, this point is highlighting the importance of managing expectations through education. This education isn’t a quick two minute talk about what osteoarthritis is and what is going to happen in the surgery, it needs to go a lot deeper than that. You need to gain a much deeper understanding of what is happening, why it may be happening, EVERY treatment option, and what to expect as an outcome. If you are not receiving this from your practitioner then they are not properly educating you.

How can chronic pain be treated?

Now that my little rant is over, what should your treatment look like? First and foremost it should be specific to you and your goals, with a focus on enhancing your quality of life and what you can do, rather than decreasing pain.4,17 Understanding that the focus should be on increasing what you can do is a large part of the education, which is the other main component of treatment.4,5,17,18 Before I lose you, let me explain why the treatment focus should be on increasing what you can do, rather than on pain reduction. Pain is tricky and it may be difficult to decrease the total amount of pain that you feel in a day;4,17 however, by increasing what you can do, your pain becomes a relatively smaller part of your life. In other words, your pain hasn’t changed sizes, but your life has become much BIGGER.

Also, addressing the lifestyle factors of sleep, stress, and physical activity can play a role in improving chronic pain.4,6,9-12,17-21 I won’t go into stress reduction and sleep treatments in this article, but i will talk about the benefits of exercise!

It has been shown time and time again that exercise is helpful for chronic pain,6,19-24 and it can actually also improve your sleep!20,25 That is a nice added bonus from exercise. Often the mechanisms by which exercise is thought to help you with chronic pain is its ability to release opioids (feel good chemicals) as well as change how your body feels pain.6,19,20 One thing that isn’t talked about in the studies that I would like to point out, is that exercise can also be an avenue for education that shows you that certain movements are ok and that you are strong and capable!

What kind of exercise?

Ok sick, I’m sure that you have already heard that exercise helps, but is there a certain type of exercise that is more beneficial for you? The highest quality evidence shows that the answer is no20,23 which is great and allows for freedom when individualising the exercises. There are some papers that show certain types of exercise could be more beneficial,21,24 but when I dove deeper into the articles and looked at the interventions, I noticed an interesting trend. The types of exercises that showed better results were typically ones where the patients were working harder. This means that they were doing more than just a few clamshells or deadbugs. Studies that looked at resistance training and used protocols that more closely fit criteria for hard sets26 had better results than the exercises that didn’t.27,28

To me, this shows that the exercise interventions may just need to be difficult enough in order to produce change. This means that you can do whichever exercise you enjoy and is meaningful to you, but you have to do it hard enough. To use a cliché: if it doesn’t challenge you, it doesn’t change you. This doesn't mean that you have to train as hard as a pro athlete, but just that the exercise should be harder than what you typically do in your daily life.


To sum it all up, chronic pain is weird and can be quite debilitating. A potential mechanism of chronic pain is central sensitization in which your body gets better at feeling pain. This sensitization can come about from many different things, but the main treatments for it are: education in order to help you understand what is going on and allowing you to interact with your pain in a different way, managing stress, improving sleep, and doing exercise. The type of exercise doesn’t matter and it should align with your goals and what is meaningful to you!

Change can take time, but I hope that this article has helped you to gain a better understanding and can also help you improve. As always, it’s time to go out and move!

*This is an informational resource and not medical advice, please consult your healthcare practitioner for diagnosis, treatment, and guidance.


  1. Treede RD, Rief W, Barke A, Aziz Q, Bennett MI, Benoliel R, Cohen M, Evers S, Finnerup NB, First MB, Giamberardino MA, Kaasa S, Korwisi B, Kosek E, Lavand'homme P, Nicholas M, Perrot S, Scholz J, Schug S, Smith BH, Svensson P, Vlaeyen JWS, Wang SJ. Chronic pain as a symptom or a disease: the IASP Classification of Chronic Pain for the International Classification of Diseases (ICD-11). Pain. 2019 Jan;160(1):19-27. doi: 10.1097/j.pain.0000000000001384. PMID: 30586067.
  2. Latremoliere A, Woolf CJ. Central sensitization: a generator of pain hypersensitivity by central neural plasticity. J Pain. 2009 Sep;10(9):895-926. doi: 10.1016/j.jpain.2009.06.012. PMID: 19712899; PMCID: PMC2750819.
  3. Schuttert I, Timmerman H, Petersen KK, McPhee ME, Arendt-Nielsen L, Reneman MF, Wolff AP. The Definition, Assessment, and Prevalence of (Human Assumed) Central Sensitisation in Patients with Chronic Low Back Pain: A Systematic Review. J Clin Med. 2021 Dec 17;10(24):5931. doi: 10.3390/jcm10245931. PMID: 34945226; PMCID: PMC8703986.
  4. Nijs J, Lahousse A, Kapreli E, Bilika P, Saraçoğlu İ, Malfliet A, Coppieters I, De Baets L, Leysen L, Roose E, Clark J, Voogt L, Huysmans E. Nociplastic Pain Criteria or Recognition of Central Sensitization? Pain Phenotyping in the Past, Present and Future. J Clin Med. 2021 Jul 21;10(15):3203. doi: 10.3390/jcm10153203. PMID: 34361986; PMCID: PMC8347369.
  5. Kim MS, Kim JJ, Kang KH, Kim MJ, In Y. Diagnosis of Central Sensitization and Its Effects on Postoperative Outcomes following Total Knee Arthroplasty: A Systematic Review and Meta-Analysis. Diagnostics (Basel). 2022 May 17;12(5):1248. doi: 10.3390/diagnostics12051248. PMID: 35626402; PMCID: PMC9141391.
  6. Borisovskaya A, Chmelik E, Karnik A. Exercise and Chronic Pain. Adv Exp Med Biol. 2020;1228:233-253. doi: 10.1007/978-981-15-1792-1_16. PMID: 32342462. Kroll HR. Exercise therapy for chronic pain. Phys Med Rehabil Clin N Am. 2015 May;26(2):263-81. doi: 10.1016/j.pmr.2014.12.007. Epub 2015 Feb 21. PMID: 25952064.
  7. Previtali D, Mameli A, Zaffagnini S, Marchettini P, Candrian C, Filardo G. Tendinopathies and Pain Sensitisation: A Meta-Analysis with Meta-Regression. Biomedicines. 2022 Jul 20;10(7):1749. doi: 10.3390/biomedicines10071749. PMID: 35885054; PMCID: PMC9313266.
  8. Zolio L, Lim KY, McKenzie JE, Yan MK, Estee M, Hussain SM, Cicuttini F, Wluka A. Systematic review and meta-analysis of the prevalence of neuropathic-like pain and/or pain sensitization in people with knee and hip osteoarthritis. Osteoarthritis Cartilage. 2021 Aug;29(8):1096-1116. doi: 10.1016/j.joca.2021.03.021. Epub 2021 May 8. PMID: 33971205.
  9. Lindell M, Grimby-Ekman A. Stress, non-restorative sleep, and physical inactivity as risk factors for chronic pain in young adults: A cohort study. PLoS One. 2022 Jan 21;17(1):e0262601. doi: 10.1371/journal.pone.0262601. PMID: 35061825; PMCID: PMC8782303.
  10. Aili K, Andersson M, Bremander A, Haglund E, Larsson I, Bergman S. Sleep problems and fatigue as predictors for the onset of chronic widespread pain over a 5- and 18-year perspective. BMC Musculoskelet Disord. 2018 Nov 3;19(1):390. doi: 10.1186/s12891-018-2310-5. PMID: 30390670; PMCID: PMC6215341.
  11. Mork PJ, Vik KL, Moe B, Lier R, Bardal EM, Nilsen TI. Sleep problems, exercise and obesity and risk of chronic musculoskeletal pain: the Norwegian HUNT study. Eur J Public Health. 2014 Dec;24(6):924-9. doi: 10.1093/eurpub/ckt198. Epub 2013 Nov 28. PMID: 24293504.
  12. Fanavoll R, Nilsen TI, Holtermann A, Mork PJ. Psychosocial work stress, leisure time physical exercise and the risk of chronic pain in the neck/shoulders: Longitudinal data from the Norwegian HUNT Study. Int J Occup Med Environ Health. 2016;29(4):585-95. doi: 10.13075/ijomeh.1896.00606. PMID: 27443755.
  13. Bannuru RR, Osani MC, Vaysbrot EE, Arden NK, Bennell K, Bierma-Zeinstra SMA, Kraus VB, Lohmander LS, Abbott JH, Bhandari M, Blanco FJ, Espinosa R, Haugen IK, Lin J, Mandl LA, Moilanen E, Nakamura N, Snyder-Mackler L, Trojian T, Underwood M, McAlindon TE. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage. 2019 Nov;27(11):1578-1589. doi: 10.1016/j.joca.2019.06.011. Epub 2019 Jul 3. PMID: 31278997.
  14. Kolasinski SL, Neogi T, Hochberg MC, Oatis C, Guyatt G, Block J, Callahan L, Copenhaver C, Dodge C, Felson D, Gellar K, Harvey WF, Hawker G, Herzig E, Kwoh CK, Nelson AE, Samuels J, Scanzello C, White D, Wise B, Altman RD, DiRenzo D, Fontanarosa J, Giradi G, Ishimori M, Misra D, Shah AA, Shmagel AK, Thoma LM, Turgunbaev M, Turner AS, Reston J. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis Care Res (Hoboken). 2020 Feb;72(2):149-162. doi: 10.1002/acr.24131. Epub 2020 Jan 6. Erratum in: Arthritis Care Res (Hoboken). 2021 May;73(5):764. PMID: 31908149.
  15. Man GS, Mologhianu G. Osteoarthritis pathogenesis - a complex process that involves the entire joint. J Med Life. 2014 Mar 15;7(1):37-41. Epub 2014 Mar 25. PMID: 24653755; PMCID: PMC3956093.
  16. Katz JN, Arant KR, Loeser RF. Diagnosis and Treatment of Hip and Knee Osteoarthritis: A Review. JAMA. 2021 Feb 9;325(6):568-578. doi: 10.1001/jama.2020.22171. PMID: 33560326; PMCID: PMC8225295.
  17. Nijs J, Leysen L, Vanlauwe J, Logghe T, Ickmans K, Polli A, Malfliet A, Coppieters I, Huysmans E. Treatment of central sensitization in patients with chronic pain: time for change? Expert Opin Pharmacother. 2019 Nov;20(16):1961-1970. doi: 10.1080/14656566.2019.1647166. Epub 2019 Jul 29. PMID: 31355689.
  18. Galvez-Sánchez CM, Montoro CI, Moreno-Padilla M, Reyes Del Paso GA, de la Coba P. Effectiveness of Acceptance and Commitment Therapy in Central Pain Sensitization Syndromes: A Systematic Review. J Clin Med. 2021 Jun 19;10(12):2706. doi: 10.3390/jcm10122706. PMID: 34205244; PMCID: PMC8235706.
  19. Kroll HR. Exercise therapy for chronic pain. Phys Med Rehabil Clin N Am. 2015 May;26(2):263-81. doi: 10.1016/j.pmr.2014.12.007. Epub 2015 Feb 21. PMID: 25952064
  20. Cohen SP, Vase L, Hooten WM. Chronic pain: an update on burden, best practices, and new advances. Lancet. 2021 May 29;397(10289):2082-2097. doi: 10.1016/S0140-6736(21)00393-7. PMID: 34062143.
  21. Hayden JA, Ellis J, Ogilvie R, Stewart SA, Bagg MK, Stanojevic S, Yamato TP, Saragiotto BT. Some types of exercise are more effective than others in people with chronic low back pain: a network meta-analysis. J Physiother. 2021 Oct;67(4):252-262. doi: 10.1016/j.jphys.2021.09.004. Epub 2021 Sep 16. PMID: 34538747.
  22. Hayden JA, Ellis J, Ogilvie R, Malmivaara A, van Tulder MW. Exercise therapy for chronic low back pain. Cochrane Database Syst Rev. 2021 Sep 28;9(9):CD009790. doi: 10.1002/14651858.CD009790.pub2. PMID: 34580864; PMCID: PMC8477273.
  23. Owen PJ, Miller CT, Mundell NL, Verswijveren SJJM, Tagliaferri SD, Brisby H, Bowe SJ, Belavy DL. Which specific modes of exercise training are most effective for treating low back pain? Network meta-analysis. Br J Sports Med. 2020 Nov;54(21):1279-1287. doi: 10.1136/bjsports-2019-100886. Epub 2019 Oct 30. PMID: 31666220; PMCID: PMC7588406.
  24. Tataryn N, Simas V, Catterall T, Furness J, Keogh JWL. Posterior-Chain Resistance Training Compared to General Exercise and Walking Programmes for the Treatment of Chronic Low Back Pain in the General Population: A Systematic Review and Meta-Analysis. Sports Med Open. 2021 Mar 8;7(1):17. doi: 10.1186/s40798-021-00306-w. PMID: 33683497; PMCID: PMC7940464.
  25. Kredlow MA, Capozzoli MC, Hearon BA, Calkins AW, Otto MW. The effects of physical activity on sleep: a meta-analytic review. J Behav Med. 2015 Jun;38(3):427-49. doi: 10.1007/s10865-015-9617-6. Epub 2015 Jan 18. PMID: 25596964.
  26. Baz-Valle E, Balsalobre-Fernández C, Alix-Fages C, Santos-Concejero J. A Systematic Review of The Effects of Different Resistance Training Volumes on Muscle Hypertrophy. J Hum Kinet. 2022 Feb 10;81:199-210. doi: 10.2478/hukin-2022-0017. PMID: 35291645; PMCID: PMC8884877.
  27. Harts CC, Helmhout PH, de Bie RA, Staal JB. A high-intensity lumbar extensor strengthening program is little better than a low-intensity program or a waiting list control group for chronic low back pain: a randomised clinical trial. Aust J Physiother. 2008;54(1):23-31. doi: 10.1016/s0004-9514(08)70062-x. PMID: 18298356.
  28. Cai C, Yang Y, Kong PW. Comparison of Lower Limb and Back Exercises for Runners with Chronic Low Back Pain. Med Sci Sports Exerc. 2017 Dec;49(12):2374-2384. doi: 10.1249/MSS.0000000000001396. PMID: 28767525.