Lifting weights can be a very effective way of improving pain despite what a lot of people may believe. I am going to lay out what I have learned about pain through research and experience and provide some evidence and reasons for why lifting weights can be a way to improve pain.

Pain is typically thought of as a protective mechanism: a signal that indicates harm with the reaction resulting in self preservation. Example: touching a hot surface creates a pain signal which results in pulling your hand away = self preservation. Pain is also thought of as a signal that equals damage. While these statements are true to some extent, they do not come close to encapsulating the entire nature of pain, which we are still learning more about. How do you explain pain in the absence of injury, pain without any obvious pathology on imaging, pain severity that is not consistent from person to person with the same injury, nor the same severity with the same repeated injury, or the absence of pain in the presence of abnormal or pathological imaging findings? Pain is incredibly complex and there are way more factors at play than simply a signal from the source of pain to your brain. Take a look at the image above the article. This is an example of all the many, many known factors that affect pain, of which we are continuing to learn and discover more.

If you look at all the dots, an injury such as tissue damage is only one of those dots. There are factors beyond the physical body that influence and affect pain. Some of these include psychological (anxiety, depression, emotional state, positive or negative outlook, etc), lifestyle (sleep, nutrition, diet, smoking, drinking, life demands, etc), social and work, your cultural and family views and responses to pain, how you learned to deal with pain, your previous experiences with pain, and even further factors beyond this.

a number of factors, including genetics, sensitization, mood, coping, catastrophizing, and the social context, among others, influence the pain experience. Unless such factors are appropriately controlled for, the true magnitude of effect of structural pathology on pain cannot be validly determined. (6)

The perception of pain occurs by the activation of a network of connections within the cerebral cortex. Because of this, nociceptive input is not required for the perception of pain, and a painful experience can be elicited by brain stimulation directly. Furthermore, within the brain, the experience of pain is created and shaped by past experiences, context, cognitive and emotional input. (5)

Physical and tissue injury is certainly a big part of the pain experience when these are present, but the degree to which the pain is experienced, the duration of it, etc can be heavily influenced by several factors outside of the actual tissue damage.

Here is how I have come to think about pain: you have a certain threshold of tolerance where the sum of all the pain factors (from the image above) is either above or below this. Above = pain, below = little or no pain. The threshold itself can also be affected and altered. To simplify this, life factors that cause increased stress and negative previous experiences with pain, even chronic pain states can alter the threshold as well as your physical and tissue tolerance to stressors.

Another way I view pain is through the concept of sensitivity. If you experience pain with a certain movement, position, etc. then you are “sensitive” or “sensitized”  to that stimulus. So, to improve this we want to decrease how sensitive you are to that given stimulus, thus “desensitize” you to that. 

Definitions: Nociception is the activation of sensory organs by means of various forms of energy - such as mechanical, chemical, or thermal - at a level that suggests a risk of tissue injury. When sensitization is present, the energy level required to activate nociceptors is decreased leading to increased pain perception. In addition to lowered nociceptive thresholds, increased pain perception can also result from prolonged activation of receptors, and/or activation of polymodal receptors. This broadening of nociception results in pain perception during activities or movements that would not normally be painful, and is called peripheral sensitization. Peripheral sensitization indicates that the expansion of nociception occurs in tissues innervated by the peripheral nervous system. With prolonged peripheral sensitization, central nervous system changes can also occur and result in central sensitization. Central sensitization refers to altered neural thresholds in the spinal cord and/or reduced cortical inhibition of pain. (7)

Now that we have (lightly) scratched the surface on the complexities of pain, how can we improve pain by lifting weights?

We have discussed how all the multitude of factors contributing to pain can add up and once they surpass a threshold, pain can ensue putting you into a sensitized state. So, to improve pain, we need to address enough factors to lower the overall stress below the threshold and/or raise the threshold. Notice I did not say we need to address all the factors. Some factors we cannot address nor change, such as your genetics, certain life circumstances (job situations, family, etc) and factors beyond your control. Some factors we can address, however, and as long as we address enough of them, we can improve pain. We can even improve pain and function in the presence of structural damage and abnormalities because remember, there are other factors that play into pain outside of physical structure and tissue issues. This is where lifting weights can help. Lifting weights can improve tissue tolerance to physical stress which can raise the pain threshold, giving more tolerance and capacity to handling pain factors. Lifting weights can also give you a sense of mental resiliency where you feel you are stronger, tougher, and can handle more which can also raise the threshold. Understanding and feeling that you can do something for yourself such as train and lift weights to help control and improve pain gives you a sense of autonomy over your situation which also can help raise the threshold and/or lower contributory stressors. Lifting weights can give you a sense of purpose which can help decrease the stress of not feeling purpose in your career or life situation. If you are interested enough in improving your strength as much as possible, you will also work to improve your sleep, nutrition, limit or avoid drinking, and similar factors that affect recovery which also improve and reduce these overall stresses to below the pain threshold. Once you experience how your body will adapt and improve through strength training and also experience how loading an injured area to make it stronger and more resilient, also improving pain, you likely will develop a more positive outlook on improving pain which helps to reduce this contributing factor to pain. There are further factors and examples that likely can also be at play here, but this gives an idea of how lifting weights can improve pain through more than the physical improvement that occurs. 

We don’t have to nor need to “fix” structural issues or findings on Xray and MRI to improve pain

Here is research cited evidence to support improving pain through lifting weights:

-there is considerable evidence that appropriate resistance training reduces low back pain, arthritic discomfort, and pain associated with fibromyalgia (1)

-The evidence for RT in musculoskeletal rehabilitation demonstrates greater effectiveness than aerobic, coordination, mobilization or Pilates training (2)

-strength training seems to relieve pain by accelerating protein synthesis and degradation, leading to reconstruction of abnormal or painful muscle tissue or by reducing the relative workload due to strength improvement (3)

-Strength training is thought to reduce functional instability and pain in older osteoarthritic patients by preventing sarcopenia and by improving the strength and function of the surrounding connective tissue. Several studies support that strength training can significantly reduce pain in elderly patients with OA (osteoarthritis). Combination exercise programs (aerobic and strength) as well as long-term exercise programs are also seen as effective for improvement of knee pain in individuals with osteoarthritis. (4)

-Other medical conditions such as rheumatoid arthritis (RA), back pain, and osteoporosis have also been shown to benefit from exercise programs. (4) 

-Improved strength in the training group was associated with lower pain values (4)

-The lower PRIT (pain rating index total) in the training group suggests that progressive resistance training of all major muscle groups, when performed three times per week for eight weeks, had a positive impact on perception of overall pain. (4)

-The overall perceived pain level in the present study was reduced by 50% after strength training. (4)

-The self-reported sensory aspects of pain were reduced by 49% after high resistance weight training. (4)

-Maintaining sufficient muscle strength around the joints is important in reducing pain and maintaining function, and if you require an operation will benefit both pre and post operate periods of your treatment (8)

-the management of tendon pain via progressive loading is well documented and appears to be one of the best interventions currently available.(9) 

-pain is multidimensional and is more indicative of sensitivity as opposed to damage or joint dysfunction. Therefore, the rationale to patients for using exercise could include an explanation of how sensitive tissues respond well to physical load (as seen in, eg, the management of knee and hip osteoarthritis)(10)

Lifting weights and acute pain:

Acute pain occurs suddenly, usually in the event of an injury. Pain is typically sudden and more severe. When this occurs, the primary goal is to get the pain to calm down, then very gradually load and progressively return back to normal as pain and tolerance allows. 

 When an acute or sudden injury or pain episode occurs, the primary goal initially is to lower the pain response and calm tissues down. This can be accomplished through movement variation such as adjusting lifting technique or using variations of lifts that alter movement patterns enough to pull stress off the injured and painful area and allow it to calm down while still training around it as much as possible.(6) If you are able to train around an acute injury, you may be able to alter the inputs that contribute to pain and positively affect the pain response. (7)

 In this scenario, we would want to determine what movements and positions, etc are highly pain provoking and see how movements, load, volumes, etc can be altered to allow for training around the injury. This will allow us to continue to train unaffected areas to prevent regression while also allowing the sensitive area to desensitize and heal to the point where it can begin to be gradually loaded. As mentioned above, continuing to lift in a way that does not aggravate pain symptoms can actually help the pain response to dampen and improve. Thus, lifting weights can help with acute pain.

When you become injured, part of the pain response is the fearful thoughts of how badly you damaged something, how much strength you’re going to lose because you think you’re done lifting, maybe thinking you’ll never be able to lift or do certain things again, etc, etc. This is called catastrophizing. If you can get back to lifting in some form, even if it is not directly loading the injury, this can help you to feel more normal and more capable than you thought. You start to realize maybe things aren’t as bad as you thought or that you can still do something you thought you couldn’t. You likely will also realize you can load the area to some extent, maybe not right away but relatively soon, and this starts to restore some trust in the injured area. This might be the most important way lifting can help in an acute pain scenario.

Lifting weights and chronic pain:

When pain occurs over a longer period of time, typically 3 months or more, it is classified as chronic. Chronic pain can result from acute pain that does not resolve or from pain that gradually appears and won’t go away. In this situation, oftentimes the pain signal and perception has become distorted as there is likely not actual tissue damage occurring. There is evidence of changes in the brain in chronic pain states

Even though no bodily signs of injury or dysfunction may be observed in the patients, neurological differences have been observed in brain structure and function in patients across a wide variety of chronic pain conditions as compared with healthy individuals. (5) 

In this case, we are wanting to alter the pain response by challenging it. In contrast to an acute pain setting where we are looking to calm things down, with chronic pain the response is disproportionate to any actual damage so we are looking to get this back in check. We can do this by intentionally moving into symptomatic positions as long as they are within tolerance. We are looking to expose vs protect. An example would be chronic back pain that increases with bending movements. If this was an acute instance, we would look to utilize lifts and movements that do not involve bending to allow this to calm down and desensitize. In the chronic pain scenario, the stimulus and response to bending is sensitized and heightened, thus we want to gradually expose to this by using lifts with more bending movements that can be tolerated even with some pain occurring and then gradually progressing. We can use lifting to intentionally challenge and work into pain sensitized movements and positions in chronic pain situations to actually get this change and improve the pain response. An example of how lifting can be very effective at helping someone in this situation: An individual has had low back pain with bending movements for 2 years and has learned to avoid any bending movement at all. They are eventually convinced to try and deadlift as they have heard of all the awesome benefits of lifting weights and they are tired of always hurting and being afraid of moving. Through some help and encouragement they discover they can deadlift a loaded barbell from the floor, and although there was some pain, it was tolerable, much less than they thought it would be, and their spine didn’t explode! This has violated their expectancy of pain and their fragile view of their back. They have just started the amazing process of altering chronic pain through lifting weights and developing a more resilient mindset and view of themselves and their back.

Lifting weights and arthritis:

Osteoarthritis has been typically thought of as “wear and tear” on your joints over the years, thus lifting weights is viewed as something that would potentially exacerbate this and wear out your joints faster. Well, this is in fact wrong. Our understanding of osteoarthritis is changing and we are discovering we do not understand it as well as we thought and it is not simply “wear and tear”. There are multiple other factors that play into pain associated with osteoarthritis (remember all the dots in the diagram above?) as well as other systemic factors outside the joints themselves.

The determinants of pain in OA are not well understood, but are believed to involve multiple interactive pathways that are best framed in a biopsychosocial framework (posits that biological, psychological and social factors all play a significant role in pain in OA). Psychosocial factors that can predispose to symptoms include self-efficacy and pain catastrophizing, and the social context of arthritis (social support, pain communication) are all important considerations in understanding the pain experience. (6)

Joint damage on an x-ray does not indicate how much your osteoarthritis will affect you (8)

Lifting weights can actually improve your function and pain that is associated with arthritis, thus the “wear and tear” belief falls flat.

Regular physical activity and individualized exercise programs (including muscle strengthening, cardiovascular activity, and flexibility exercises) can reduce your pain, prevent worsening of your osteoarthritis, and improve your daily function (8)

There are a multitude of other pain and injury scenarios with which lifting weights can help. Some of which I will address more specifically in subsequent writings. This article is to provide some background and overview on what pain is and how it can be affected through lifting weights, as well as some research based evidence that lifting does actually demonstrate improvement. 

I have always felt lifting weights is one of the best things you can do for yourself, especially when it comes to improving pain and injury. This is the beginning of me showing you how and why this is so.

ReTrain: Rehab is Training, Training is Rehab

References:

1. Westcott WL. Resistance training is medicine: effects of strength training on health. Curr Sports Med Rep. 2012 Jul-Aug;11(4):209-16. doi: 10.1249/JSR.0b013e31825dabb8. PMID: 22777332.

2. Welch N, Moran K, Antony J, et al. The effects of a free-weight-based resistance training intervention on pain, squat biomechanics and MRI defined lumbar fat infiltration and functional crosssectional area in those with chronic low back. BMJ Open Sport Exerc Med2015;1:000050. doi:10.1136/bmjsem-2015-000050

3. Knutzen KM, Pendergrast BA, Lindsey B, Brilla LR. The effect of high resistance weight training on reported pain in older adults. J Sports Sci Med. 2007 Dec 1;6(4):455-60. PMID: 24149478; PMCID: PMC3794485.

4. Tataryn, N., Simas, V., Catterall, T. et al. 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 7, 17 (2021). https://doi.org/10.1186/s40798-021-00306-w

5. Hattori, Takafumia,b,*; Ohga, Satoshic; Shimo, Kazuhiroc; Matsubara, Takakoa,c. Pathology of knee osteoarthritis pain: contribution of joint structural changes and pain sensitization to movement-evoked pain in knee osteoarthritis. PAIN Reports 9(1):p e1124, January 2024. | DOI: 10.1097/PR9.0000000000001124

6. D.J. Hunter, A. Guermazi, F. Roemer, Y. Zhang, T. Neogi, Structural correlates of pain in joints with osteoarthritis, Osteoarthritis and Cartilage, Volume 21, Issue 9, 2013, Pages 1170-1178, ISSN 1063-4584, https://doi.org/10.1016/j.joca.2013.05.017.

(https://www.sciencedirect.com/science/article/pii/S1063458413008224)

7. Borstad J, Woeste C. The role of sensitization in musculoskeletal shoulder pain. Braz J Phys Ther. 2015 Jul-Aug;19(4):251-7. doi: 10.1590/bjpt-rbf.2014.0100. Epub 2015 Aug 7. PMID: 26443971; PMCID: PMC4620972.

8. French SD, Bennell KL, Nicolson PJ, Hodges PW, Dobson FL, Hinman RS. What do people with knee or hip osteoarthritis need to know? An international consensus list of essential statements for osteoarthritis. Arthritis Care Res (Hoboken). 2015 May;67(6):809-16. doi: 10.1002/acr.22518. PMID: 25418120.

9. Morrison, S., Cook, J. Putting “Heavy” into Heavy Slow Resistance. Sports Med 52, 1219–1222 (2022).https://doi.org/10.1007/s40279-022-01641-y

10. Palsson TS, Gibson W, Darlow B, Bunzli S, Lehman G, Rabey M, Moloney N, Vaegter HB, Bagg MK, Travers M. Changing the Narrative in Diagnosis and Management of Pain in the Sacroiliac Joint Area. Phys Ther. 2019 Nov 25;99(11):1511-1519. doi: 10.1093/ptj/pzz108. PMID: 31355883.