5 Strategies to Manage Pain Today

Disclaimer: This information is not medical advice and should not be treated as such. This post is for general educational purposes only and you should consult with a licensed healthcare provider for specific guidance.

I get asked quite often “I have this ache or pain, what do I do?” While specific aches and pains need a bit more assessment*, there are general strategies that you can implement today for musculoskeletal pain. We are focusing on strategies that are efficient in terms of time and money, as well as, have minimal side effects.

1. Improve sleep hygiene.

Sleep not only influences our body’s ability to recover after injury, but also influences our perception of pain. Studies demonstrate a connection between poor sleep and perception of pain [1, 2]. Furthermore, sleep disturbances are considered a risk factor for developing chronic pain [3]. Here are a few simple tips from the Centers for Disease Control and Prevention (CDC), that require minimal initial investment (<$10):

-Have a consistent bedtime and wake up time
-Keep your bedroom dark, quiet, relaxing and at a cool, comfortable temperature
-Avoid caffeine, alcohol, large meals or lots of fluid intake before bed
-Don’t use electronic devices in the bedroom-it should be for sleep and sex only
-Exercise daily

If you still have sleep difficulties even with implementing these steps, consult a licensed practitioner who can help further with issues such as sleep apnea.

2. Exercise daily, especially aerobic exercise

Research shows that aerobic exercise performed at least 75% of VO2 Max [4] or roughly at an intensity where you can talk, but not sing, decreases sensitivity to pain. Aerobic exercise has been recommended as part of a treatment approach for chronic pain [5]. This can take a variety of forms such as walking, swimming, biking, rowing, dancing, and more.  

3. Manage stress levels

Stress and our emotional state influences our perception and response to pain. Research shows that cognitive stressors can significantly impact our perception of physical pain [6]. Beyond that, stress has real physiological effects (such as elevating cortisol levels and increasing inflammatory markers) that directly affect whatever tissue may be irritated [7]. Ideally, we want to remove chronic stressors, however this is often not possible. Fortunately, there are tools that you can use today, recommended by the American Psychological Association (APA), that can help mitigate the effects of chronic stress:

-Eat a well-balanced diet
-Perform muscle relaxation exercises-Perform mindfulness based meditation
-Sleep well
-Get regular physical activity
-Spend time in nature
-Take time for pleasurable leisure activities

If you chronically struggle to manage stress, even with interventions like the ones described above, consult a licensed practitioner for further guidance.

4. Try thermal modalities like ice packs, heating pads/hot packs/hot baths

For acute injuries, I recommend the updated guidelines of “PEACE & LOVE” (the updated version of “RICE”) and consulting a licensed medical provider. However, after the acute injury phase, the response to hot or cold varies by individual. Some people swear by ice packs. Others love hot Epsom salt baths. Overall, I feel comfortable recommending trying hot or cold since they typically have no side effects and are highly accessible.  

5. See a qualified physical therapist or other musculoskeletal provider

If the first four steps don’t work, I’d recommend a formal consult with a clinician (like myself or others)* who is familiar with the biopsychosocial model and promotes a proactive, independent approach to rehab.

What is the biopsychosocial model? This is an emerging model that views pain as a multifactorial experience. Many factors such as your stress levels, sleep quality, emotional state, and what is happening at a tissue level play a role in your experience of pain and your response to it. The experience of pain can occur with or without actual tissue damage. In contrast, older models of rehab viewed pain through a purely “biomechanical” lens, meaning that pain only occurs because a tissue is damaged e.g. your back pain hurts only because you didn’t “lift with your legs”. A good clinician can help you determine what factors to focus on and how, in order to maximize your recovery.  

So there we have it, some general strategies for managing musculoskeletal pain. In another post we’ll cover exercise modification in the presence of pain!

*I recommend a formal consult because:

  1. Without more information (i.e. pain/injury history, beliefs about pain, lifestyle factors, medical history, etc.), a clinician cannot accurately determine what factor relate to someone’s pain. I cannot responsibly recommend specific solutions without further assessment.  
  2. Interventions for pain and returning to activity tend to work best with coaching and feedback, rather than a one off answer. For example, if someone has knee pain during a squat, we might try different ranges of motion to find a squat that doesn’t exacerbate symptoms. Then we might examine their symptoms after 24 hours and over weeks of training and adjust accordingly. There is simply too much feedback to be encapsulated in a “just do this one thing” recommendation.

References:

  1. Finan, P. H., Goodin, B. R., & Smith, M. T. (2013). The association of sleep and pain: an update and a path forward. The journal of pain14(12), 1539–1552. https://doi.org/10.1016/j.jpain.2013.08.007
  2. Wei Y, Blanken TF, Van Someren EJW. Insomnia Really Hurts: Effect of a Bad Night’s Sleep on Pain Increases With Insomnia Severity. Frontiers in Psychiatry. 2018 ;9:377. DOI: 10.3389/fpsyt.2018.00377. PMID: 30210367; PMCID: PMC6121188.
  3. Generaal, E., Vogelzangs, N., Penninx, B. W., & Dekker, J. (2017). Insomnia, Sleep Duration, Depressive Symptoms, and the Onset of Chronic Multisite Musculoskeletal Pain. Sleep40(1), 10.1093/sleep/zsw030. https://doi.org/10.1093/sleep/zsw030
  4. Jones, M. D., Booth, J., Taylor, J. L., & Barry, B. K. (2014). Aerobic training increases pain tolerance in healthy individuals. Medicine and science in sports and exercise46(8), 1640–1647. https://doi.org/10.1249/MSS.0000000000000273
  5. García-Correa, H. R., Sánchez-Montoya, L. J., Daza-Arana, J. E., & Ordoñez-Mora, L. T. (2021). Aerobic Physical Exercise for Pain Intensity, Aerobic Capacity, and Quality of Life in Patients With Chronic Pain: A Systematic Review and Meta-Analysis. Journal of physical activity & health18(9), 1126–1142. https://doi.org/10.1123/jpah.2020-0806
  6. Marie Hoeger Bement, Andy Weyer, Manda Keller, April L. Harkins, Sandra K. Hunter, Anxiety and stress can predict pain perception following a cognitive stress, Physiology & Behavior, Volume 101, Issue 1, 2010, Pages 87-92, ISSN 0031-9384, https://doi.org/10.1016/j.physbeh.2010.04.021.
  7. Hannibal, K. E., & Bishop, M. D. (2014). Chronic stress, cortisol dysfunction, and pain: a psychoneuroendocrine rationale for stress management in pain rehabilitation. Physical therapy94(12), 1816–1825. https://doi.org/10.2522/ptj.20130597

Beyond “Just Walk More”– Cardio for the Older Adult

For the older adult, common cardiovascular exercise advice is to just perform activities like walking or biking. This is a great start for sedentary individuals, but for those who want to play sports, be fit and perform at a higher level, this isn’t enough.

A commonly used measure of cardiovascular health and performance is VO2 Max, which is a measure of a person’s ability to take in oxygen and deliver it to working tissues (i.e. skeletal muscle during exercise). A person with a higher VO2 Max is able to take in more oxygen and deliver it to their muscles which means:

 1. They can better perform short bursts of high intensity activity. For example, when sprinting during soccer, an athlete with a higher VO2 Max can better create energy to support that sprint.

2. They can perform longer duration activities with an increased intensity. For example, if a runner increases their VO2 Max, they should be able run 1 mile at a faster pace, since they can create more energy to sustain that longer duration activity. 

Like strength, VO2 Max starts to decrease around 40 years of age (1). However, research shows that athletes who maintain high training intensities experience smaller decreases in VO2 Max compared to those who decrease their training intensity (1). This means that with age, performing high intensity cardiovascular exercise is vital to maintain high levels of cardiovascular fitness. Another benefit of high intensity training, is that it recruits more type II muscle fibers and helps maintain muscle mass, both of which tend to decrease with age (1).

So where does one start with cardiovascular training?

The first step is in developing a strong aerobic base with moderate intensity training for longer intervals. Moderate intensity, steady state cardio helps build the aerobic energy base that supports recovery from higher intensity training. For older adults, the minimum recommended intensity is about 75-80% of one’s age predicted maximum heart rate (calculated as 220-age). Another way to roughly estimate this, is to perform exercise at an intensity where one can still talk, but not sing (also known as the “Talk Test”) (2). As far as duration, the Center for Disease Control (CDC)’s “Physical Activity Guidelines for Americans”, recommends 150-300 minutes of moderate intensity exercise weekly (3). This includes a range of activities such as walking, swimming, dance, or cycling. A sample program could be starting with 30 minutes, 5 days per week and increasing your total weekly duration by 10% (about 15 minutes) until reaching 300 minutes per week. Note that these recommendations serve not only as a base for higher intensity training, but also promote cardiovascular health (3).

After several weeks of lower intensity aerobic exercise, then we can start with high intensity interval training (HIIT). While a completely sedentary individual will see an increase in VO2 Max with low intensity training, more active individuals will need to incorporate high intensity training to further improve their VO2 Max. Typically, this intensity range is defined as 80-95% of age predicted max heart rate (4). Another estimation method is to perform an exercise with sufficient intensity that you can only say a few words at a time (3).

Many HIIT protocols exist, however my preferred is as follows:

  • 5 minutes of low intensity warmup
  • 60 seconds of high intensity work, followed by 60 seconds of low intensity work. This would be repeated 6-10 times.
  • 5 minutes of low intensity cool down

As for exercise selection, HIIT is ideally performed with activities that:

  1. Require little skill to perform well
  2. Have minimal eccentric muscle loading, which produce more muscle soreness and fatigue*
  3. Can be easily increased/decreased in intensity

Thus activities like an assault bike, stationary bike, or rower are ideal for HIIT. While many popular fitness programs use bodyweight exercises such as burpees and other jumping exercises, I don’t recommend these for HIIT, unless they are the only option one has. These movements are not bad, per se, but they require some degree of skill to perform well, have higher eccentric muscle loading demands, and the intensity of them cannot be easily adjusted.

So to summarize here is a sample training program to improve cardiovascular health and performance in the older adult:

 Moderate Intensity TrainingHigh Intensity Interval Training
Intensity via Heart Rate75-80% of max heart rate80-95% of max heart rate
Intensity via Talk TestCan talk, but not singCan only say a few words at a time
Warm Up/Cool DownNone needed5 min warmup, 5 min cool down
Duration30-60 min per session, for a total of 150-300 min per week60:60 sec, work: rest interval, repeated 6-10 times
Frequency5-7x/week1-2x/week
Example Recommended ActivitiesWalking, cycling, rowing, light dance, swimming, ellipticalCycling, rowing, elliptical

Much like with strength training, the exact program varies by the medical history, needs, wants, abilities and response of each person.

*An eccentric muscle contraction is the part of a movement where the muscle is stopping motion, whereas a concentric muscle contraction is when the muscle is creating motion. For example, during a squat, the lowering down portion of the movement is the eccentric phase and the rising up part is the concentric phase. Exercises like biking, mostly involve concentric muscle contractions since your limbs primarily encounter resistance when they contract to create motion e.g. when your foot is on a bike pedal, you don’t have to control/stop the motion, you only experience resistance when you actively push the pedal.

References:

  1. Foster, C., Wright, G., Battista, R. A., & Porcari, J. P. (2007). Training in the aging athlete. Current sports medicine reports6(3), 200–206. https://doi.org/10.1007/s11932-007-0029-4
  2. https://www.acsm.org/docs/default-source/files-for-resource-library/exercise-intensity-infographic.pdf?sfvrsn=f467c793_2
  3. https://health.gov/sites/default/files/2019-10/PAG_ExecutiveSummary.pdf
  4. Roy, Brad A. Ph.D., FACSM, FACHE High-Intensity Interval Training, ACSM’s Health & Fitness Journal: May/June 2013 – Volume 17 – Issue 3 – p 3 doi: 10.1249/FIT.0b013e31828cb21c

Should Older Adults Only Lift Light Weights?

Many exercise programs for older adults recommend lifting light weights, for high reps. But is this really the best recommendation?

To answer that question we first need to ask, why are we training? For older adults, we should prioritize strength (the ability to produce high amounts of force) and hypertrophy (an increase in muscle mass). As discussed here, these qualities tend to decrease with age, so resistance training should develop and maintain them.

How we develop strength and hypertrophy depends on the weight of the load and the number of reps performed.

Broadly speaking, we can classify loads as heavy (5-10 reps), moderate (10-20 reps), and light (20-30 reps) [1].

So what loads maximize strength?

Research indicates that maximal strength comes from lifting heavier loads [2]. This makes sense as the ability to produce high amounts of force is a skill that our nervous system needs to practice. So lifting heavier loads in the 5-10 rep range is ideal for maximizing top end strength. Interestingly, research shows, that we don’t have to go all the way to muscle failure to maximize strength and it actually might produce worse strength gains if you take sets to failure [3].

Next, what loads maximize hypertrophy?

Unlike strength, hypertrophy can be achieved well with a wide variety of rep ranges from 5-30 reps. However, hypertrophy requires getting closer to muscle failure, especially with higher rep sets [3]. For example, if you perform a biceps curl for 30 reps, it should be sufficiently heavy that you can only perform 31 or 32 reps total i.e. only having 1-2 repetitions in reserve.

So, should older adults lift heavy or light weights?

The answer is both, since both strength and muscle mass are important.

When deciding the weight/reps of an exercise we need to consider:

  1. How fatiguing the lift is: Generally compound, barbell lifts, such as barbell squats and deadlifts, are more fatiguing because they involve many muscle groups and require more spinal stabilization. If an exercise is more fatiguing it should be done for heavier loads. On the other hand, single joint exercises, such as a biceps curl, use few muscle groups and place little stability demands on the spine. Similarly, machine based exercises don’t require much spinal stabilization, so are not as fatiguing. These less fatiguing exercises should be done for lighter loads.

So, for compound, barbell lifts we should focus on heavier loads. At the other end of the spectrum, single joint and/or machine based lifts should be done at lighter loads.

2. How much technique is needed for the lift: Compound, free weight lifts such as squats, deadlifts and bench presses, require more technique and coordination to perform well. On the other hand, single joint exercises and/or machine based exercises require little technique to execute correctly.

If a lift requires more attention to technique we should perform it at lower rep ranges (with heavier loads). Conversely, if a lift requires less focus on technique, we should pick higher rep ranges (with lighter loads).

Finally, let’s get into recommendations for specific exercises. Note, these are general recommendations to serve as a starting point.

ExerciseRecommended Reps
Barbell deadlifts & squats5-10
Pullups & chin ups*5-10
Barbell presses (bench & overhead)5-10
Compound dumbbell lifts (bench press, overhead press, row)**10-20
Lunges & split squats**10-20
“Simple” squat variants (e.g. goblet squat)*10-20
Compound machine (e.g. leg press, chest press)***10-20
Single joint-free weight or machine (e.g. bicep curl)10-30

Finding your optimal weight/rep combination for a given exercise takes experimentation, ideally with a coach to guide that process.

A few notes on some of these recommendations:

*Pullups and chin-ups require some degree of technique and also demand more spinal stabilization than a machine exercise, like a lat pull down. Similarly, squat variants, like goblet squats, require less technique than a barbell squat, as well as, are difficult to load with heavy weights i.e. it is cumbersome to hold up a heavy dumbbell.

**Compound dumbbell lifts and lunges/split squats are more unstable then barbell lifts, so are difficult to load with heavy weights.

***Compound machine lifts are not technically demanding, but they are somewhat fatiguing since many muscle groups are being used at once.

References:

  1. https://renaissanceperiodization.com/chest-training-tips-hypertrophy/
  2. Schoenfeld BJ, Grgic J, Ogborn D, Krieger JW. Strength and Hypertrophy Adaptations Between Low- vs. High-Load Resistance Training: A Systematic Review and Meta-analysis. J Strength Cond Res. 2017;31(12):3508-3523. doi:10.1519/JSC.0000000000002200 https://pubmed.ncbi.nlm.nih.gov/28834797/
  3. Vieira AF, Umpierre D, Teodoro JL, et al. Effects of Resistance Training Performed to Failure or Not to Failure on Muscle Strength, Hypertrophy, and Power Output: A Systematic Review With Meta-Analysis. J Strength Cond Res. 2021;35(4):1165-1175. doi:10.1519/JSC.0000000000003936 https://pubmed.ncbi.nlm.nih.gov/33555822/

Optimal Protein Intake for Fitness After 50

Optimizing resistance training is crucial for the aging athlete, but we can’t forget about optimizing nutrition, especially protein intake.

Why such an emphasis on protein?

Protein (along with sufficient overall caloric intake) is critical to maintain muscle mass and strength, especially as one ages. Unfortunately, up to 40% of older adults do not even consume the Recommended Daily Amount (RDA) of protein of 0.8 grams/kilogram bodyweight/day (1). Note that the RDA was originally created based on the needs of young men to merely prevent nutritional deficiency, not to promote optimal health, muscle mass, or strength. Further, older athletes need to manage protein intake more closely than younger athletes because of metabolic changes that promote “anabolic resistance”, which is a decreased muscle protein synthesis (MPS) response to resistance exercise and/or protein consumption. Consuming protein and resistance exercise activate MPS , however with age that MPS response is decreased (1). Fortunately, if we engage in resistance exercise and eat sufficient, well-dosed amounts of protein, we can optimize MPS leading to better muscle mass and strength gains (2).

How Much Protein?

Most research points towards a protein range of 1.2-2.0 g/kg/day for optimal muscle mass and strength in the older adult (1). To track daily protein intake, there are many methods but my preferred is to use the Hand Measure System. This method uses the palm of your hand to roughly equate to 25 g of protein. For example, for a 70 kg woman, to hit 1.2 g/kg/day they would need to consume at least 84 g of protein per day—equating to about 3-4 palms of protein per day. As a side note, most protein powder supplements provide between 20-30 g of protein per serving.

How Often?

While the net amount of protein per day is most important, research indicates that consuming at least 25-30 g per meal maximizes the MPS, as opposed to a more uneven distribution (2). For example, consuming 15 g at breakfast then 15 g at lunch would lead to a lower MPS response as compared to consuming 30 g at breakfast.

Type of Protein?

As long as the total amount of protein is sufficient, the exact type is of little importance. Animal and plant proteins both support muscle mass and strength development, as long as total protein and energy intake are sufficient. For example, research in athletes comparing whey and plant based proteins has found no significant differences in muscle gain, strength development or psychometric measures like perceptions of soreness or readiness to train (3), (4).

So to sum up:

-For optimal muscle mass and strength, older adults should consume 1.2-2.0 g protein/kg bodyweight per day

-Servings of protein should ideally be consumed in doses of at least 25 grams per meal, spread throughout the day

-“1 palm size portion” of protein roughly equals 25 grams of protein

-Animal and plant proteins are effective, as long as one consumes a sufficient amount of protein

References:

  1. Baum JI, Kim IY, Wolfe RR. Protein Consumption and the Elderly: What Is the Optimal Level of Intake?. Nutrients. 2016;8(6):359. Published 2016 Jun 8. doi:10.3390/nu8060359
  2. Deer RR, Volpi E. Protein intake and muscle function in older adults. Curr Opin Clin Nutr Metab Care. 2015;18(3):248-253. doi:10.1097/MCO.0000000000000162
  3. Joy JM, Lowery RP, Wilson JM, et al. The effects of 8 weeks of whey or rice protein supplementation on body composition and exercise performance. Nutr J. 2013;12:86. Published 2013 Jun 20. doi:10.1186/1475-2891-12-86
  4. Banaszek A, Townsend JR, Bender D, Vantrease WC, Marshall AC, Johnson KD. The Effects of Whey vs. Pea Protein on Physical Adaptations Following 8-Weeks of High-Intensity Functional Training (HIFT): A Pilot Study. Sports (Basel). 2019;7(1):12. Published 2019 Jan 4. doi:10.3390/sports7010012

*This information is provided solely as general educational and informational purposes. Always consult your physician or health care provider before undertaking any changes in diet or physical activity.

A Strength Training Blueprint for the Aging Athlete

The older athlete can and should strength train, as we’ve discussed here, which begs the question, how to do it?

Fortunately, there are evidence based guidelines that form a blue print for strength training in the aging athlete. For older adults, the National Strength and Conditioning Association (NSCA) recommends:

-2-3 sessions per week

-2-3 sets of 1-2 multijoint exercises per major muscle group (with 1.5 – 3 minutes of rest between sets)

-An intensity of 70-85% of 1 repetition maximum (% 1RM)

Of course, this is a rough frame work. A new strength trainee will likely see strength gains with a lower volume and intensity initially (i.e. fewer sets and/or session and a lower % 1RM). However, to continue to see strength gains we’ll have to increase the volume and intensity, since strength follows a “dose-response” relationship. This means that as you increase the intensity and volume of strength training, the strength gains will be larger. Of course, this only happens up to a point – we cannot infinitely add volume and intensity. An excess of volume and intensity could actually lead to decreased strength gains due to poor recovery from the training program. That sweet spot of volume and intensity is highly individualized and can really only be determined by strength training and assessing the athlete’s response.

Given the above parameters, let’s start with the exercises to build the program around. The fundamental strength exercises fall into six buckets of movement patterns:

  • Squat – bending at the knees and hips, such as the barbell squat, leg press, and lunge.
  • Deadlift – bending primarily at the hips, such as the deadlift and hip thrust.
  • Horizontal press – pressing straight out in front of the torso, such as the bench press and pushup.
  • Vertical press – pressing up overhead, such as the barbell and dumbbell “military” press.
  • Horizontal Pull – pulling from straight out in front of the torso, such as the barbell row and seated row machine.
  • Vertical pull – pulling from overhead, such as the pullup or the lat pull down.

To prescribe the intensity of these exercises we’ll gauge that by the number of repetitions in reserve, also known as “RIR”. The RIR of an exercise is the number of repetitions we have left in reserve or “left in the tank”. For example, if you can do a squat at given weight for a maximum of 12 reps, but only perform 10 reps, the intensity would be a 2 RIR, because you have 2 reps in reserve. If you did that squat for 12 reps, the intensity would be 0 RIR, because you have 0 reps in reserve.

RIR is useful because it helps us pick a weight for the day based on our actual strength levels that day. Strength varies day to day based on many factors such as sleep, nutrition, stress, etc. For example, do you think you would lift the same weight at 11 am after a good night of sleep and a solid breakfast versus at 11 pm after a long day of work when you skipped lunch and dinner? If we just try to force the same weight, we will likely over fatigue our body since we are not matching the exercise to our current strength level. Conversely, using RIR helps us take advantage of “good days” in the gym, by letting us lift more weight when we are especially recovered and energized.

There have been conversion charts developed which give a rough guideline to equate %1RM to RIR. My adaptation for the aging athlete is the general recommendation to:

-Perform 5-10 reps, with 4-2 RIR

For example, if you can do a deadlift 9 times at a certain weight and you want to stay at 4 RIR (4 reps left in the tank), you would perform 5 reps. At the other end if you can perform a bench press 12 times and you want to stay at 2 RIR (2 reps in reserve), you would perform 10 reps.

Of course this is not an exact science. We won’t always assess RIR with perfect accuracy and that is OK. Research suggests that over time a trainee gets better at estimating their RIR for an exercise.

To wrap up, here is a summary of the blue print of strength training for the aging athlete. Like with an athlete of ANY age, medical screening and adapting the training program based on their individual physiology and response to the program is vital.

Pick:

  1. Frequency: 2-3 sessions per week
  2. Volume: 2-3 sets per exercise
  3. Movement Pattern (1-2 exercises for each pattern, each session):
    • Squat
    • Deadlift
    • Horizontal Press
    • Horizontal Pull
    • Vertical Press
    • Vertical Pull
  4. Intensity: pick a weight that allows for 5-10 reps per set, leaving 2-4 reps in reserve on each set (choose a lower RIR for heavier weights, choose a higher RIR for lighter weights)

To create your strength training plan, reach out to me and we’ll create an adaptive strength plan customized to you, no matter your age.


References:

1. Fragala MS, Cadore EL, Dorgo S, et al. Resistance Training for Older Adults: Position Statement From the National Strength and Conditioning Association. J Strength Cond Res. 2019;33(8):2019-2052. doi:10.1519/JSC.0000000000003230

2. Helms ER, Cronin J, Storey A, Zourdos MC. Application of the Repetitions in Reserve-Based Rating of Perceived Exertion Scale for Resistance Training. Strength Cond J. 2016;38(4):42-49. doi:10.1519/SSC.0000000000000218