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Rehab Science · Chapter 5

How to Overcome Pain

Whatever the pain type, the strategy follows three phases: reduce symptoms (phase 1), address impairments such as weakness and lost range (phase 2), then build capacity with full-range resistance training (phase 3). Active strategies have the strongest long-term evidence; passive strategies are mainly for short-term symptom relief.

CompleteSource: Rehab Science · Ch 5 · PDF pp. 80–104
You will learn to
  • ✓ Describe the three-phase approach to pain
  • ✓ Contrast active and passive strategies
  • ✓ Apply PROM → AAROM → AROM progression
  • ✓ Explain why isometrics, eccentrics and graded exposure reduce pain
1.

The three-phase approach

📖 Rehab Science

Phase 1: calm the pain—avoid or modify what flares it up, and use self-massage, gentle aerobic exercise and mobility. Phase 2: fix what pain has taken away—movement, range and early strength, accepting mild-to-moderate discomfort. Phase 3: build capacity with full-range strength training so it is less likely to come back.

Diagram · The three-phase frameworkOriginal illustration
1Calm it down• Reduce pain; modify aggravators• Soft tissue, mobility, isometricsProgress when:No pain at rest≤ 3/10 with the exercisesinflammatory phase2Restore movement• Range of motion & control• Isometric + eccentric loadingProgress when:Full range with controlMild-to-no painmaturation phase3Build capacity• Full-range resistance training• Progressive overload; sportProgress when:Pain resolved — keeptraining to prevent recurrenceremodelling phase
The same framework treats pain and injury. Progression is driven by symptoms and function—not by days—and with injury it also respects tissue healing time. — Based on concepts in Rehab Science Ch 5 (PDF pp. 80–82), Ch 10 (PDF pp. 182–190), Ch 11 (PDF p. 203).
Source: Rehab Science · Ch 5 · PDF pp. 80, 81, 82· 1 original research citationshow sources ▾
Also cited by the book on these pages:
  1. [Ch 5·10] Lima LV, Abner TSS, Sluka KA. Does exercise increase or decrease pain? Central mechanisms underlying these two phenomena. J Physiol. 2017;595(13):4141-4150. find original ↗

Page numbers are those of the uploaded PDF edition. "Find original" opens a PubMed search for the cited study.

2.

Active vs passive strategies

📖 Rehab Science

Active = you move yourself (walking, lifting, mobility). Passive = something else moves or stimulates you (foam roller, strap stretch, heat, ice). Active strategies create lasting change; passive ones mostly give short-term relief. Mild discomfort during exercise is fine if your usual symptoms are not worse a few hours later.

  • Passive → phase 1 symptom control
  • Active → phases 2 and 3, prevention and long-term health
Source: Rehab Science · Ch 5 · PDF pp. 82, 83· 5 original research citationsshow sources ▾
  1. [Ch 5·1] Belavy DL, Van Oosterwijck J, Clarkson M, et al. Pain sensitivity is reduced by exercise training: Evidence from a systematic review and meta-analysis. Neurosci Biobehav Rev. 2021;120:100-108. find original ↗
  2. [Ch 5·2] Vaegter HB, Jones MD. Exercise-induced hypoalgesia after acute and regular exercise: experimental and clinical manifestations and possible mechanisms in individuals with and without pain. Pain Rep. 2020;5(5):e823. Published 2020 Sep 23. find original ↗
  3. [Ch 5·3] Sluka KA, Frey-Law L, Hoeger Bement M. Exercise-induced pain and analgesia? Underlying mechanisms and clinical translation. Pain. 2018;159 Suppl 1(Suppl 1):S91-S97. find original ↗
Also cited by the book on these pages:
  1. [Ch 5·10] Lima LV, Abner TSS, Sluka KA. Does exercise increase or decrease pain? Central mechanisms underlying these two phenomena. J Physiol. 2017;595(13):4141-4150. find original ↗
  2. [Ch 5·12] Sluka KA, Frey-Law L, Hoeger Bement M. Exercise-induced pain and analgesia? Underlying mechanisms and clinical translation. Pain. 2018;159 Suppl 1(Suppl 1):S91-S97. find original ↗

Page numbers are those of the uploaded PDF edition. "Find original" opens a PubMed search for the cited study.

3.

Soft tissue mobilisations (self-massage)

📖 Rehab Science

Foam rollers suit big muscles; small balls suit areas near joints. Massage helps by improving blood flow and giving your nervous system a new, non-threatening input—not by "breaking up knots". Aim for a "good hurt", spend 1–2 minutes on tender spots, and stop if you feel sharp, travelling pain, tingling or numbness. The effect lasts about 20–30 minutes.

Diagram · How self-massage helpsOriginal illustration
Blood flow ↑vasodilationnutrient deliveryclears irritantsNovel inputnew sensation calmsthe nervous system(neuromodulation)✗ Not provenbreaking adhesions“releasing knots”permanent change
Soft tissue work appears to work through blood flow and nervous-system modulation—not by mechanically ‘breaking up knots’. Effects last ~20–30 minutes. — Based on concepts in Rehab Science Ch 5 (PDF pp. 84–87).
Source: Rehab Science · Ch 5 · PDF pp. 83–86· 7 original research citationsshow sources ▾
  1. [Ch 5·4] Bishop MD, Torres-Cueco R, Gay CW, Lluch-Girbés E, Beneciuk JM, Bialosky JE. What effect can manual therapy have on a patient’s pain experience? Pain Manag. 2015;5(6):455-464. find original ↗
  2. [Ch 5·5] Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Man Ther. 2009;14(5):531-538. find original ↗
Also cited by the book on these pages:
  1. [Ch 5·1] Belavy DL, Van Oosterwijck J, Clarkson M, et al. Pain sensitivity is reduced by exercise training: Evidence from a systematic review and meta-analysis. Neurosci Biobehav Rev. 2021;120:100-108. find original ↗
  2. [Ch 5·3] Sluka KA, Frey-Law L, Hoeger Bement M. Exercise-induced pain and analgesia? Underlying mechanisms and clinical translation. Pain. 2018;159 Suppl 1(Suppl 1):S91-S97. find original ↗
  3. [Ch 5·12] Sluka KA, Frey-Law L, Hoeger Bement M. Exercise-induced pain and analgesia? Underlying mechanisms and clinical translation. Pain. 2018;159 Suppl 1(Suppl 1):S91-S97. find original ↗
  4. [Ch 5·9] Tharmaratnam T, Civitarese RA, Tabobondung T, Tabobondung TA. Exercise becomes brain: sustained aerobic exercise enhances hippocampal neurogenesis. J Physiol. 2017;595(1):7-8. find original ↗
  5. [Ch 5·10] Lima LV, Abner TSS, Sluka KA. Does exercise increase or decrease pain? Central mechanisms underlying these two phenomena. J Physiol. 2017;595(13):4141-4150. find original ↗

Page numbers are those of the uploaded PDF edition. "Find original" opens a PubMed search for the cited study.

4.

Trigger points and "muscle knots"

📖 Rehab Science

Everyone has tender, ropy spots. Only work on spots that hurt at rest or with movement (active). Spots that are only mildly tender when pressed (latent) do not need fixing—they are usually normal anatomy.

Source: Rehab Science · Ch 5 · PDF pp. 86, 87· 4 original research citationsshow sources ▾
  1. [Ch 5·6] Quintner JL, Bove GM, Cohen ML. A critical evaluation of the trigger point phenomenon. Rheumatology (Oxford). 2015;54(3):392-399. find original ↗
  2. [Ch 5·7] Shah JP, Thaker N, Heimur J, Aredo JV, Sikdar S, Gerber L. Myofascial trigger points then and now: a historical and scientific perspective. PM R. 2015;7(7):746-761. find original ↗
Also cited by the book on these pages:
  1. [Ch 5·9] Tharmaratnam T, Civitarese RA, Tabobondung T, Tabobondung TA. Exercise becomes brain: sustained aerobic exercise enhances hippocampal neurogenesis. J Physiol. 2017;595(1):7-8. find original ↗
  2. [Ch 5·10] Lima LV, Abner TSS, Sluka KA. Does exercise increase or decrease pain? Central mechanisms underlying these two phenomena. J Physiol. 2017;595(13):4141-4150. find original ↗

Page numbers are those of the uploaded PDF edition. "Find original" opens a PubMed search for the cited study.

5.

Aerobic exercise

📖 Rehab Science

Walking, cycling, swimming or hiking for 20–30 minutes can ease pain by improving blood flow, calming the nervous system and lifting mood. If chronic pain is the main problem, make aerobic exercise a priority—but with a fresh injury choose an activity that does not stress it.

Source: Rehab Science · Ch 5 · PDF pp. 88, 89· 8 original research citationsshow sources ▾
  1. [Ch 5·8] Tan L, Cicuttini FM, Fairley J, et al. Does aerobic exercise effect pain sensitisation in individuals with musculoskeletal pain? A systematic review. BMC Musculoskelet Disord. 2022;23(1):113. Published 2022 Feb 3. find original ↗
  2. [Ch 5·9] Tharmaratnam T, Civitarese RA, Tabobondung T, Tabobondung TA. Exercise becomes brain: sustained aerobic exercise enhances hippocampal neurogenesis. J Physiol. 2017;595(1):7-8. find original ↗
  3. [Ch 5·2] Vaegter HB, Jones MD. Exercise-induced hypoalgesia after acute and regular exercise: experimental and clinical manifestations and possible mechanisms in individuals with and without pain. Pain Rep. 2020;5(5):e823. Published 2020 Sep 23. find original ↗
  4. [Ch 5·10] Lima LV, Abner TSS, Sluka KA. Does exercise increase or decrease pain? Central mechanisms underlying these two phenomena. J Physiol. 2017;595(13):4141-4150. find original ↗
  5. [Ch 5·11] Grooten WJA, Boström C, Dedering Å, et al. Summarizing the effects of different exercise types in chronic low back pain—a systematic review of systematic reviews. BMC Musculoskelet Disord. 2022;23(1):801. find original ↗
  6. [Ch 5·12] Sluka KA, Frey-Law L, Hoeger Bement M. Exercise-induced pain and analgesia? Underlying mechanisms and clinical translation. Pain. 2018;159 Suppl 1(Suppl 1):S91-S97. find original ↗
Also cited by the book on these pages:
  1. [Ch 5·13] Støve MP, Hirata RP, Palsson TS. Muscle stretching—the potential role of endogenous pain inhibitory modulation on stretch tolerance. Scand J Pain. 2019;19(2):415-422. find original ↗
  2. [Ch 5·15] Halbertsma JP, Göeken LN. Stretching exercises: effect on passive extensibility and stiffness in short hamstrings of healthy subjects. Arch Phys Med Rehabil. 1994;75(9):976-981. find original ↗

Page numbers are those of the uploaded PDF edition. "Find original" opens a PubMed search for the cited study.

6.

Flexibility (stretching) exercises

📖 Rehab Science

Stretching improves flexibility and teaches your nerves to tolerate stretch. Ease in without pain, breathe out to relax a little further, or use contract–relax. In pain: 2–3 sets of 15–30 second holds. When pain-free, longer holds are fine.

  • In pain — 2–3 × 15–30 s
  • PNF — contract 5–7 s, relax-hold 10–15 s, × 2–4
Source: Rehab Science · Ch 5 · PDF pp. 89, 90· 4 original research citationsshow sources ▾
  1. [Ch 5·13] Støve MP, Hirata RP, Palsson TS. Muscle stretching—the potential role of endogenous pain inhibitory modulation on stretch tolerance. Scand J Pain. 2019;19(2):415-422. find original ↗
  2. [Ch 5·14] Marshall PW, Cashman A, Cheema BS. A randomized controlled trial for the effect of passive stretching on measures of hamstring extensibility, passive stiffness, strength, and stretch tolerance. J Sci Med Sport. 2011;14(6):535-540. find original ↗
  3. [Ch 5·15] Halbertsma JP, Göeken LN. Stretching exercises: effect on passive extensibility and stiffness in short hamstrings of healthy subjects. Arch Phys Med Rehabil. 1994;75(9):976-981. find original ↗
Also cited by the book on these pages:
  1. [Ch 5·12] Sluka KA, Frey-Law L, Hoeger Bement M. Exercise-induced pain and analgesia? Underlying mechanisms and clinical translation. Pain. 2018;159 Suppl 1(Suppl 1):S91-S97. find original ↗

Page numbers are those of the uploaded PDF edition. "Find original" opens a PubMed search for the cited study.

7.

Relaxation, breathing and meditation

📖 Rehab Science

Stress makes us breathe with our chest and neck, which raises tension. Slow belly breathing, box breathing (in 4 · hold 4 · out 4 · hold 4, at least three rounds) and meditation calm the system.

Source: Rehab Science · Ch 5 · PDF pp. 91, 92· 5 original research citationsshow sources ▾
  1. [Ch 5·16] Busch V, Magerl W, Kern U, Haas J, Hajak G, Eichhammer P. The effect of deep and slow breathing on pain perception, autonomic activity, and mood processing—an experimental study. Pain Med. 2012;13(2):215-228. find original ↗
  2. [Ch 5·17] Jafari H, Gholamrezaei A, Franssen M, et al. Can slow deep breathing reduce pain? An experimental study exploring mechanisms. J Pain. 2020;21(9-10):1018-1030. find original ↗
  3. [Ch 5·18] Hilton L, Hempel S, Ewing BA, et al. Mindfulness meditation for chronic pain: systematic review and meta-analysis. Ann Behav Med. 2017;51(2):199-213. find original ↗
  4. [Ch 5·19] Cherkin DC, Sherman KJ, Balderson BH, et al. Effect of mindfulness-based stress reduction vs. cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain: a randomized clinical trial. JAMA. 2016;315(12):1240-1249. find original ↗
Also cited by the book on these pages:
  1. [Ch 5·4] Bishop MD, Torres-Cueco R, Gay CW, Lluch-Girbés E, Beneciuk JM, Bialosky JE. What effect can manual therapy have on a patient’s pain experience? Pain Manag. 2015;5(6):455-464. find original ↗

Page numbers are those of the uploaded PDF edition. "Find original" opens a PubMed search for the cited study.

8.

Mobility exercises — PROM, AAROM, AROM

📖 Rehab Science

Mobility exercises move a joint through its range. Start passive (your healthy arm or a dowel does all the work), then active-assisted (share the effort), then active (your own muscles do it). Hold end positions for a few seconds without pushing into pain.

Diagram · Mobility progression: PROM → AAROM → AROMOriginal illustration
PROMpassiveinjured-side muscle efforthealthy arm / dowel does 100%AAROMactive-assistedinjured-side muscle effortshare the work ~50/50AROMactiveinjured-side muscle effortyour muscles do 100%
Start passive when pain limits movement; progress as pain eases and control improves. Hold end range 2–3 s without pushing into pain. — Based on concepts in Rehab Science Ch 5 (PDF pp. 93–96).
Source: Rehab Science · Ch 5 · PDF pp. 93, 94, 96· 2 original research citationsshow sources ▾
Also cited by the book on these pages:
  1. [Ch 5·20] Usuba M, Akai M, Shirasaki Y, Miyakawa S. Experimental joint contracture correction with low torque—long duration repeated stretching. Clin Orthop Relat Res. 2007;456:70-78. find original ↗
  2. [Ch 5·22] Light KE, Nuzik S, Personius W, Barstrom A. Low-load prolonged stretch vs. high-load brief stretch in treating knee contractures. Phys Ther. 1984;64(3):330-333. find original ↗

Page numbers are those of the uploaded PDF edition. "Find original" opens a PubMed search for the cited study.

9.

Contractures and low-load long-duration stretching

📖 Rehab Science

If a joint feels blocked after a long period without moving, gently hold it at its limit with light force for a long time—2 to 10 minutes, 3 to 5 times a day, for weeks. See a manual therapist if nothing changes after a few weeks.

  • LLLD — 2–10 min holds, 3–5× daily
  • Goal — maximise total end range time (TERT)
Source: Rehab Science · Ch 5 · PDF pp. 96, 97· 3 original research citationsshow sources ▾
  1. [Ch 5·20] Usuba M, Akai M, Shirasaki Y, Miyakawa S. Experimental joint contracture correction with low torque—long duration repeated stretching. Clin Orthop Relat Res. 2007;456:70-78. find original ↗
  2. [Ch 5·21] Flowers KR, LaStayo P. Effect of total end range time on improving passive range of motion. J Hand Ther. 1994;7(3):150-157. find original ↗
  3. [Ch 5·22] Light KE, Nuzik S, Personius W, Barstrom A. Low-load prolonged stretch vs. high-load brief stretch in treating knee contractures. Phys Ther. 1984;64(3):330-333. find original ↗

Page numbers are those of the uploaded PDF edition. "Find original" opens a PubMed search for the cited study.

10.

Joint mobilisation and manipulation

📖 Rehab Science

A physio or chiropractor can move a joint in ways you cannot. It often eases pain and stiffness for a while; combine it with your exercise programme for lasting change.

Source: Rehab Science · Ch 5 · PDF pp. 97, 98· 4 original research citationsshow sources ▾
  1. [Ch 5·23] Slaven EJ, Goode AP, Coronado RA, Poole C, Hegedus EJ. The relative effectiveness of segment specific level and non-specific level spinal joint mobilization on pain and range of motion: results of a systematic review and meta-analysis. J Man Manip Ther. 2013;21(1):7-17. find original ↗
  2. [Ch 5·24] Beattie PF, Arnot CF, Donley JW, Noda H, Bailey L. The immediate reduction in low back pain intensity following lumbar joint mobilization and prone press-ups is associated with increased diffusion of water in the L5-S1 intervertebral disc. J Orthop Sports Phys Ther. 2010;40(5):256-264. find original ↗
  3. [Ch 5·25] Moss P, Sluka K, Wright A. The initial effects of knee joint mobilization on osteoarthritic hyperalgesia. Man Ther. 2007;12(2):109-118. find original ↗
  4. [Ch 5·26] Conroy DE, Hayes KW. The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome. J Orthop Sports Phys Ther. 1998;28(1):3-14. find original ↗

Page numbers are those of the uploaded PDF edition. "Find original" opens a PubMed search for the cited study.

11.

Resistance exercise — isometric, eccentric, concentric

📖 Rehab Science

Isometric = muscle works without moving (like pausing halfway through a curl); it can ease tendon pain—"natural ibuprofen". Eccentric = muscle works while lengthening (lowering the weight); it builds strength and range. Concentric = muscle shortens (lifting); usually hardest, so it comes last. Strength training reduces tendon pain and knee arthritis pain and helps stop problems returning.

  • Isometric 4–5 × 30–45 s holds
  • Order — isometric → eccentric → concentric
Diagram · Isometric · eccentric · concentricOriginal illustration
Isometriccontracts · no movementEccentriccontracts while lengthening↓Concentriccontracts while shortening↑
Protocols usually progress isometric (phases 1–2) → eccentric (phase 2) → full range including concentric (phase 3). Isometrics often ease tendon pain. — Based on concepts in Rehab Science Ch 5 (PDF pp. 100–101).
Source: Rehab Science · Ch 5 · PDF pp. 100–103· 6 original research citationsshow sources ▾
  1. [Ch 5·27] Rio E, Kidgell D, Purdam C, et al. Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. Br J Sports Med. 2015;49(19):1277-1283. find original ↗
  2. [Ch 5·28] Malliaras P, Barton CJ, Reeves ND, Langberg H. Achilles and patellar tendinopathy loading programmes: a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Med. 2013;43(4):267-286. find original ↗
  3. [Ch 5·29] Cardoso TB, Pizzari T, Kinsella R, Hope D, Cook JL. Current trends in tendinopathy management. Best Pract Res Clin Rheumatol. 2019;33(1):122-140. find original ↗
  4. [Ch 5·30] Rio E, Kidgell D, Moseley GL, et al. Tendon neuroplastic training: changing the way we think about tendon rehabilitation: a narrative review. Br J Sports Med. 2016;50(4):209-215. find original ↗
  5. [Ch 5·31] Turner MN, Hernandez DO, Cade W, Emerson CP, Reynolds JM, Best TM. The role of resistance training dosing on pain and physical function in individuals with knee osteoarthritis: a systematic review. Sports Health. 2020;12(2):200-206. find original ↗
  6. [Ch 5·32] Ferreira RM, Torres RT, Duarte JA, Gonçalves RS. Non-pharmacological and non-surgical interventions for knee osteoarthritis: a systematic review and meta-analysis. Acta Reumatol Port. 2019;44(3):173-217. find original ↗

Page numbers are those of the uploaded PDF edition. "Find original" opens a PubMed search for the cited study.

12.

Graded exposure — "poke the bear"

📖 Rehab Science

Find the movement you are sensitive to, break it into small pieces and gradually expose yourself to more—staying just under your flare-up line. If you flare up, reduce the load or step back a phase. Think "therapeutic exercise", not "corrective exercise": you are calming and strengthening, not fixing a broken part.

Diagram · Graded exposure — move the flare-up lineOriginal illustration
flare-up line (≈ 4/10 pain)step backsessions / weeksdose of sensitive movement
Break a sensitive movement into steps and dose it just under the flare-up line. As the system desensitises, the line moves up. If you flare, step back and rebuild. — Based on concepts in Rehab Science Ch 5 (PDF pp. 103–104) & Ch 12 (PDF pp. 210–212).
Source: Rehab Science · Ch 5 · PDF pp. 103, 104· 4 original research citationsshow sources ▾
Also cited by the book on these pages:
  1. [Ch 5·29] Cardoso TB, Pizzari T, Kinsella R, Hope D, Cook JL. Current trends in tendinopathy management. Best Pract Res Clin Rheumatol. 2019;33(1):122-140. find original ↗
  2. [Ch 5·30] Rio E, Kidgell D, Moseley GL, et al. Tendon neuroplastic training: changing the way we think about tendon rehabilitation: a narrative review. Br J Sports Med. 2016;50(4):209-215. find original ↗
  3. [Ch 5·31] Turner MN, Hernandez DO, Cade W, Emerson CP, Reynolds JM, Best TM. The role of resistance training dosing on pain and physical function in individuals with knee osteoarthritis: a systematic review. Sports Health. 2020;12(2):200-206. find original ↗
  4. [Ch 5·32] Ferreira RM, Torres RT, Duarte JA, Gonçalves RS. Non-pharmacological and non-surgical interventions for knee osteoarthritis: a systematic review and meta-analysis. Acta Reumatol Port. 2019;44(3):173-217. find original ↗

Page numbers are those of the uploaded PDF edition. "Find original" opens a PubMed search for the cited study.

Check your understanding

1. Which is an active strategy?
2. What is the usual isometric prescription for pain relief in the book?
3. Correct mobility progression?
4. Soft tissue mobilisation most likely works by…