Motion is Lotion - Exercise over Pharmaceuticals

Aotearoa has a growing elderly population. Poor health, pain and dysfunction compounds as we age. Exercise prescription that promotes cardiovascular fitness, strength, and mobility should be our front line intervention - NOT just medication.

As the global population ages, managing chronic pain in the elderly has become a critical public health issue. In Aotearoa we will have 1 million people over 65 years of age by 2028.  Traditionally, medication has been the go-to solution for pain relief. However, growing evidence suggests that exercise offers a superior alternative for managing pain in older adults. I want to explore why exercise is often better than medication for pain management in the elderly, highlighting its multifaceted benefits and lower risk profile.

The Problem with Medication

Pharmacological treatments, such as nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and paracetamol, are commonly prescribed to manage pain in older adults. While these medications can provide temporary relief, they come with a host of potential side effects. NSAIDs, for example, can cause gastrointestinal bleeding, renal impairment, and cardiovascular issues (American Geriatrics Society, 2009). Opioids, though effective for severe pain, carry a high risk of dependency, and a range of side effects including dizziness, constipation, and respiratory depression (Chou et al., 2009).

In addition, the efficacy of these medications tends to diminish over time, necessitating higher doses and further increasing the risk of adverse effects. For elderly patients, who often have multiple comorbidities and take several medications concurrently, the risk of drug interactions and complications is significantly heightened (Pergolizzi et al., 2008). Given these challenges, the medical community needs to look towards non-pharmacological interventions for pain management. The barrier is this approach takes more time and effort than writing a prescription for a rushed GP. Having better networks and funded groups to refer to will help with this.

The Benefits of Exercise

Exercise stands out as a holistic and effective approach to pain management in the elderly. Unlike medication, which primarily aims to mask pain symptoms, exercise addresses the underlying causes of pain and promotes overall health and well-being. Listed below are several key reasons why exercise is a superior option:

1) Natural Pain Relief

Physical activity stimulates the release of endorphins, which are natural painkillers produced by the body. These endorphins interact with receptors in the brain to reduce the perception of pain, providing a natural and effective form of pain relief (Geneen et al., 2017). For many of my osteoarthritic knee clients I have prescribed gentle indoor cycling for 5-10min morning and night with excellent pain-relieving results. Over time, regular exercise can lead to a sustained reduction in pain levels while increasing general fitness, improving the quality of life for elderly individuals.

2) Improved Physical Function

Exercise enhances muscle strength, flexibility, and joint mobility, which are crucial for maintaining physical function and independence in older adults. Strengthening exercises can help alleviate pain by reducing the strain on joints and improving posture, while flexibility exercises can reduce stiffness and increase range of motion (Cochrane Database of Systematic Reviews, 2017). Enhanced physical function not only helps in pain management but also reduces the risk of falls and injuries, which are common concerns in the elderly population.

3) Mental Health Benefits

Chronic pain is often associated with mental health issues such as depression and anxiety. Exercise has been shown to have significant mental health benefits, including reducing symptoms of depression and anxiety, improving mood, and enhancing overall psychological well-being (Mather et al., 2002). These mental health benefits can further alleviate the perception of pain and improve the overall quality of life for elderly individuals.

4) Lower Risk of Adverse Effects

Unlike medications, exercise carries a much lower risk of adverse effects. While it is essential to tailor exercise programs to the individual’s capabilities and medical conditions, the risks associated with physical activity are generally minimal compared to the potential side effects of pharmacological treatments. Especially when you start to increase the number of medications.  Furthermore, exercise can be adjusted and scaled to suit the individual’s fitness level, making it a versatile and adaptable option for pain management (Geneen et al., 2017).

5) Evidence Supporting Exercise for Pain Management 

Numerous studies have demonstrated the efficacy of exercise in managing pain among older adults. A review of Cochrane Reviews found that physical activity and exercise are effective for chronic pain management in adults, including the elderly (Geneen et al., 2017). The review highlighted that exercise interventions led to significant improvements in pain levels, physical function, and overall quality of life. Another study published in the Journal of the American Geriatrics Society emphasized the benefits of exercise for reducing persistent pain in older persons. The study found that tailored exercise programs, including strength training, aerobic exercises, and flexibility exercises, significantly improved pain management outcomes and reduced the reliance on medications (American Geriatrics Society, 2009). Additionally, a Cochrane review on exercise for reducing fear of falling in older people living in the community found that exercise interventions not only reduced the fear of falling but also improved physical performance and reduced pain (Cochrane Database of Systematic Reviews, 2017). This is particularly important as the fear of falling can exacerbate pain and limit physical activity, creating a vicious cycle that further impairs the individual’s quality of life.

Implementing Exercise Programs for the Elderly

To maximize the benefits of exercise for pain management in the elderly, it is crucial to implement well-designed and individualized exercise programs. These programs should be tailored to the individual’s specific needs, capabilities, and medical conditions. Here are some key considerations for implementing effective exercise programs for elderly individuals:

Professional Guidance

Engaging healthcare professionals such as physical therapists, exercise physiologists, or geriatricians can ensure that exercise programs are safe, effective, and tailored to individual needs. These professionals can assess the individual's physical condition, recommend appropriate exercise types, and monitor progress to adjust the regimen as needed.

Variety and Balance

A well-rounded exercise program should include the three pillars of physical fitness, aerobic exercises (such as walking, swimming, or cycling) to improve cardiovascular health, strength training exercises (using weights or resistance bands) to enhance muscle strength, and flexibility exercises (such as yoga or stretching) to improve range of motion and mobility. Balance exercises (such as tai chi, slower forms of yoga, and body balance classes) can also be particularly beneficial for reducing the risk of falls.

Gradual Progression

Starting slowly and gradually increasing the intensity and duration of exercise can help prevent injuries and ensure that the body adapts positively to the new activity levels. This approach is especially important for elderly individuals who may have been sedentary or have underlying health conditions. Building consistency to entrench habitual behaviours is key for success.

Social and Emotional Support

Encouraging participation in group exercise classes or community-based physical activity programs can provide social interaction and much needed emotional support, which are crucial for maintaining motivation and adherence to exercise routines. Social connections can also play a major role in improving mental health and reducing the perception of pain.

Education and Empowerment

Educating elderly individuals about the benefits of exercise and empowering them with the knowledge and skills to perform exercises safely can enhance their confidence and willingness to engage in physical activity. Providing appropriate resources such as instructional videos, printed materials, or access to online exercise programs can be helpful.

While medication has traditionally been the cornerstone of pain management in the elderly, the growing body of evidence supporting exercise as a superior alternative should not be ignored. Exercise offers a holistic approach to pain management by addressing the underlying causes of pain, enhancing physical and mental health, and minimizing the risk of adverse effects associated with long term pharmacological treatments. By implementing well-designed, individualised exercise programs, healthcare providers and caregivers can help elderly individuals achieve better pain management outcomes, greater independence, and an improved quality of life. By moving towards exercise-based pain management strategies, we can help elderly individuals lead more active, fulfilling lives free from the constraints and risks associated with chronic medication use.

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References

1. Geneen, L. J., et al (2017). Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database of Systematic Reviews, (4).

2. American Geriatrics Society. (2009). Pharmacological management of persistent pain in older persons. Journal of the American Geriatrics Society, 57(8), 1331-1346.

3.Cochrane Database of Systematic Reviews. (2017). Exercise for reducing fear of falling in older people living in the community. Cochrane Database of Systematic Reviews, (12).

4. Mather, A. S., et al (2002). Effects of exercise on depressive symptoms in older adults with poorly responsive depressive disorder: randomized controlled trial. The British Journal of Psychiatry, 180(5), 411-415.

5. Pergolizzi, J. V., et al  (2008). The pharmacological management of pain in older persons: a review of the current literature. Journal of Pain Research, 1, 123-134.

6. Chou, R., et al(2009). Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. The Journal of Pain, 10(2), 113-130.