1. Aerobic Exercise for Chronic Pain: Potential Role in Mood Elevation and Societal Function Matthew N. Bartels, MD, MPH Professor and Chairman Department of Rehabilitation Medicine Montefiore Medical Center Albert Einstein College of Medicine Bronx, NY

2. Disclosures: I have no significant disclosures related to this talk.

3. Goals Review the effects of exercise on mood, memory, societal function, and cognition Review effects of aerobic exercise (AE) on metabolism and hormonal regulation as this contributes to mood Examine evidence in other impaired populations Review the role of AE in in patients with chronic pain Examine possible applications to chronic pain populations

4. Aerobic Exercise and the Body Known benefits of aerobic exercise include: –Improved lean body mass –Lower BP, lower blood sugar, improved lipids –Improved endurance, Stamina –Less fatigue, improved immunity –Less depression, less anxiety –Improved memory and cognition –Less CAD, Stroke, PVD –Lower cancer risk, etc….

5. Chronic Pain and the Body Chronic pain results in: –Less activity, less endurance –Depression and anxiety –Worsened cognition, lower memory and attention –Lower societal engagement –More sleep disorder –Increased risk of metabolic syndrome –Worsened immunity –Higher risk of mortality from CAD/CVD/PVD

6. Aerobic Exercise and Pain Just looking at the two patterns, logic would say: –Need to get patients exercising But: –What is the evidence? –What types of exercise are right? –Where to start? –How to motivate patients?

7. Pain and Obesity Brief discussion: –Patients with chronic pain more likely to be inactive, and on opiates –Low activity and opiates each are associated with obesity –Obesity associated independently with chronic pain and sleep disorders –Sleep disorders and obesity cause decreased mood and worsened societal function –Self fulfilling feedback loop……

8. What is the Evidence for the Loop? Norwegian HUNT study –26896 men and women in Norway Assessed in 1984-86 with no pain or impairments Reassessed in 1995-97 for chronic pain RR for Chronic Pain: –1.3-1.8 for sleep disorder individuals –1.3-1.8 for obese individuals Mork PJ, et al. European Journal of Public Health, Vol. 24, No. 6, 924–929, 2013.

9. Young Hunt Study Similar to HUNT, but with young individuals 13-18 year old adolescents, collected 2006-8 In girls, sedentary behavior assoc. with pain onset Depression and anxiety strongest assoc with pain –4.1 in girls, 3.7 in boys Obesity: 1.8 in girls, 1.3 in boys Smoking: 2.7 in girls, 2.7 in boys Alcohol use: 2.3 in girls, 1.7 in boys Individuals with more than one risk worse off –2 risks: 2.4 girls, 1.6 boys –3 risks: 4.1 girls, 2.3 boys –4 risks: 5.6 girls, 2.9 boys Hoften GB, et al. The Journal of Pain, Vol 13, No. 9: pp 874-883, 2012

10. How to Modify this Loop? Encourage exercise: AE known to have benefits for obese and sedentary individuals Exercise shown to decrease anxiety and depression in a number of populations Trials of combined therapy now underway: STOP trial (Simultaneously Targeting Obesity and Pain) just starting recruitment in 2014 –Integrated behavioral management including exercise and behavior counseling –Unfortunately only counseled, not structured exercise Janke et al. BMC Public Health 2014, 14:621

11. Chronic Pain/Mood/Activity Gatchel RJ: Psychological disorders and chronic pain: cause and effect relationship. In Psychological Approaches to Pain Management: A Practitioner’s Handbook.

12. Exercise/Chronic Pain/Mood A single bout of acute exercise: –Elevates mood acutely –Reduces pain perception acutely Chronic exercise: –Protects from depression –Reduces anxiety –Enhances mood elevation from individual bouts of exercise –Elevates cognition (attention/recall/concentration) Hoffman MD, et al. Current Pain and Headache Reports 2007, 11:93–97

13. Exercise Acute Pain Relief in Chronic Low Back Pain Hoffman MD, Med Sci Sports Exerc 2000,32:S71

14. Effects of Exercise on Mood Most intense effects in clinical psychiatric populations, but also in normal individuals. Exercise as effective as medications or psychotherapy for depression* and anxiety~ Peak effect in several months Pain research in fibromyalgia populations –Exercise effective in decreasing anxiety and depression with pool and land exercise# Pain in LBP: –High intensity exercise lowers psychological stress by 35% (depression or anxiety)^ *Brosse AL. Sports Med 2002, 32:741–760 ~Petruzzello SJ. Sports Med 1991, 11:143–182 #Hoffman MD, et al. Current Pain and Headache Reports 2007, 11:93–97 ^ Chatzitheodorou D.Physical Therapy; Mar 2007; 87, 3; ProQuest Central pg. 304

15. Chronic Pain and Neurocognitive Deficits Pain leads to decreased attention* –Leads to impaired task performance Pain impairs learning, explicit memory, and general cognition –All pain impairs these functions, fibromyalgia also has impairment of semantic memory~ Decreased function on the Mini Mental State Exam –Decreased P300 event related potentials –Higher prevalence of MMSE <24 than controls^ *Moriarty O, et al. Progress in Neurobiology 93 (2011) 385–404 ~Glass JM. Rheum. Dis. Clin. NorthAm. 35, 299–311, 2009 # Park DC, et al. Arthritis Rheum. 44, 2125–2133, 2001 ^Rodriguez-Andreu J, et al. BMC Musculoskelet. Disord. 10, 162, 2009

16. Cognitive Impairment in Chronic Pain Impaired reaction times* Impaired executive function –Shorter response times –Decreased accuracy Implication is greater impulsivity~ Mechanism may be the ‘‘division of resource’’ theory# –overlapping of areas of pain and executive function *Lee DM, et al. Pain 151, 30–36, 2010. ~Veldhuijzen DS, et al. Pain 122, 28–35, 2006 #Moriarty O, et al. Progress in Neurobiology 93, 385–404, 2011

17. Cognition and Pain Mechanisms Used from: Moriarty O, et al. Progress in Neurobiology 93, 385–404, 2011 PFC: prefrontal cortex IC: insular cortex Hipp: hippocampus Amy: amygdala PAG: periaqueductal grey ACC: anterior cingulate cortex LTP: long-term potentiation EPSP: excitatory post-synaptic potential BDNF: brain-derived neurotrophic factor ECs: endocannabinoids.

18. Aerobic Exercise and Cognition in Pain Patients Unfortunately very little research exists in pain Exercise improves cognition in normal individuals, and in patients with depression and anxiety Also for patients with schizophrenia Improvement via unknown mechanisms, but maybe through BDNF No reason to not believe that similar effects would be present for pain patients

19. Approaches to Improve the Cognition of Pain Patients Pain Patients treated with narcotics and other analgesics do worse on cognitive and memory tasks Mood also negatively affected by medications Behavioral modification studied very little but may help Exercise not really evaluated at all, but should help as it is known to increase BDNF and improve cognition in normal, depressed, anxious and schizophrenic individuals

20. Social Functioning and Pain Pain patients have decreased social functioning –Withdrawal –Anxiety, depression –Negative body image –Inactivity In other groups with severe illness (cancer, heart failure, diabetes, psychiatric disease) exercise improves social functioning* Some evidence in select pain groups as well# #Arnstein P, et al. Journal of Gerontological Nursing, 39(4), 56-65, 2013

21. Effects of Exercise in Pain Populations Clear benefits to social function in many populations –Fibromyalgia –Back pain patients –Peripheral artery disease patients –Systemic Lupus patients –Cancer patients –Pediatric, adult,and geriatric populations of above No populations with negative effects of exercise on social functioning SO WE NEED TO USE IT!

22. Summary of Data For Mood –Aerobic exercise: beneficial in all pain populations studied –Limited data in all pain populations For Memory –Aerobic exercise: may be beneficial –More pain populations need to be studied For Cognition –Aerobic exercise: may be beneficial –More pain populations need to be studied For Societal Function –Aerobic exercise: beneficial in all pain populations studied

23. Conclusions Since aerobic exercise likely to be beneficial for so many neurocognitive, psychiatric, and social functioning measures: PRESCRIBE IT! Enroll patients in local community exercise groups –Tai Chi, Qui Gong, Walking, Swimming –Whatever it takes to get them moving Aerobic exercise may also help their pain too! –Prevents/lessens obesity and Metabolic Syndrome, improves cardiovascular risk profile