Are Physical Therapy Exercises Supposed to Hurt?

If you are currently in physical therapy or have been in physical therapy before, you may wonder, “Are physical therapy exercises supposed to hurt?”.

The answer is usually, but in a good way.

Phsycial Therapy: A Good Pain

First, it’s important to differentiate between “good” and “bad” pain. Good pain occurs when you achieve a high level of therapeutic benefit, such as during strengthening or endurance exercise.

Are Physical Therapy Exercises Supposed to Hurt

When performed properly, therapeutic exercise creates a gradual increase in “burning” discomfort within muscles due to stored carbohydrate being used for fuel more rapidly than created, producing lactic acid. This burning/lactic acid usually dissipates within a few seconds after the exercise is stopped, as your blood stream carries the lactic acid away.

Good pain also occurs during stretching exercises or manual techniques (i.e., hand techniques) used by your physical therapist at the end of your range of motion. This occurs due to stretch receptors (golgi tendon organs, muscle spindles) within your tendons/muscles sending signals to your brain that you are nearing the end of range of motion and should stop stretching further to avoid injury.

For example, when stretching your right hamstrings, you can increase stretch by turning your pelvis to the right. Once you feel the stretch to your desired level, you should stop and hold this position for the prescribed time frame.  The longer you hold a stretch, good pain will likely increase because tissues are deforming into a new elongated position.

Scale of Discomfort in Physical Therapy

In physical therapy, we use a 0 to 10 scale in order to gauge how much discomfort you’re feeling during exercise, which also correlates to how hard you are working. This scale is called the Rate of Perceived Exertion Scale (RPE), where 0 is “no discomfort”, 5 is “strong discomfort” and 10 is “maximum discomfort” (Journal of Applied Physiology 2003).

In order to receive benefit from strengthening exercise, you should be working at a minimum of 6 out of 10 on the RPE scale, or feeling “significant discomfort” that will rapidly go away after the exercise is done.  

Therefore, the “hurt” you feel doing physical therapy exercises should come on gradually, occur within the intended muscles you’re working and dissipate within a few seconds after stopping.

If you feel little to no discomfort doing your physical therapy exercises, you should question the benefit of the exercises.

When Physical Therapy Hurts

On the other hand, “bad” pain is something that should not occur in physical therapy because it suggests that sensitive tissues are being irritated and/or damaged.

Bad pain usually happens near or within a joint (e.g., knee or shoulder joint) and because you move too quickly, into an extreme range of motion and/or use too much resistance.

Probably the most common area patients experience “bad” pain is the low back due to inappropriate technique. If you are experiencing low back pain during exercise, notify your physical therapist so adjustments can be made.

Bad pain can also occur due to nerve irritation. An example is the upper arm, where if you over stretch your chest and/or arm muscles the nerve bundle supplying your arm (called the brachial plexus) can get irritated from being over stretched. This bad pain usually takes the form of numbness and tingling into your fingers and should dissipate within 5 to 15 seconds.

Pain from Physical Therapy: It May Be All In Your Head

Remember that any time you “hurt”, it’s your brain perceiving a stress in an unpleasant way. Those who have had chronic pain for years have brains that perceive discomfort differently than those without chronic pain. For example, those with fibromyalgia struggle with tender points on their bodies and usually need medication to help regulate their perception of pain.

What is truly amazing is that “good” pain can overcome “bad” pain. For example, those with fibromyalgia, chronic spine pain and knee pain usually experience positive results from performing physical therapy exercises, but only if the exercises are performed correctly, with enough intensity and consistently enough (Archives of Physical Medicine & Rehabilitation 2007, 2012; Physical Therapy 2000, 2006, 2010).

Don’t Quit Physical Therapy

The top reasons people quit physical therapy are due to lack of attention and treatment ineffectiveness (Journal of Physiotherapy 2007). These problems may be due to physical therapists prescribing ineffective exercises, not adequately monitoring patients during exercises and/or lack of formal training in exercise prescription (please see prior Blog post).

If you believe the pain you feel in physical therapy is excessive, in the wrong area and/or of the wrong kind, it may be time to have a talk with your physical therapist about changing your program.

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