2. Activity

Based on a systematic review of randomized controlled trials (RCTs), aerobic exercise of low to moderate intensity, such as walking and pool exercise, can improve symptoms and distress in patients with chronic widespread pain and fibromyalgia [Mannerkorpi]. Another review concluded that physical activity significantly improves pain and related symptoms. For chronic pain, strict guidelines for physical activity are lacking, but frequent movement is preferable to sedentary behavior. This gives considerable freedom in prescribing physical activity treatments, which are most successful when tailored individually, progressed slowly and account for physical limitations, psychosocial needs and available resources [Ambrose].


If you are concerned about the danger of hurting yourself as you add activities, you might want to consider “Graded Motor Imagery” from Neuro Orthopaedic Institute, NOI, which was originally developed by pain experts, such as Prof. Lorimer Moseley for pain experts. Recently, however, apps for cell phones and a handbook on Graded Motor Imagery have become available to you. You could start with a YouTube video called “What is Graded Motor Imagery?” by the Neuro Orthopaedic Institute, NOI. Next, you could look at their great handbook aimed at pain specialists, but accessible to the rest of us.

The “Graded Motion Imagery Handbook” presents many tested techniques for safely reversing the downward spiral of pain/inactivity. It even has movie recommendations for retraining the brain! In chapter two, the editor, Prof. Lorimer Moseley recommends “Oscar Peterson, Music in the key of Oscar.” And “Shine.” These movies are recommended because they use the brain’s own motor neurons to help with retraining the brain.

There is also a chapter by David Butler on using metaphors such as “Motion is Lotion,” which can be really helpful in motivating us to reap the benefits of motion, and “Though I am sore, I am safe,” which I used for several days after some vigorous gardening that resulted in some lower back soreness. Just saying that like a mantra (also the shorter form “sore but safe”) minimized fear that the soreness I felt might persist. I took some ibuprofen so my brain would experience as little pain as possible. Two days later it was gone.

The chapter by Timothy Beames includes examples of useful images, mental visualization of motion and mirror box techniques. The final chapter, by Thomas Giles, introduces the noigroup, which you can join for free at noigroup.com. The noigroup website has links to many, many helpful resources for retraining your brain. These include new apps for iPhones and Android such as “Recognise Shoulder” and “Recognise Back” for dealing with specific chronic pain conditions. You also find these apps by entering “noigroup” in a search on Google Play or the iPhone AppStore. Another website, gradedmotorimagery.com, tells about Graded Motor Imagery courses you can take with a professional.

The method of Graded Motor Imagery (the method of Lorimer Moseley and associates in the Neuro Orthopaedic Institute, NOI) is based on imagining or seeing moving without pain. For example, a mirror box can be used to see a pain free right hand and its image that looks like a left hand. As the right hand moves, pain free, it appears to the brain that the left hand is moving pain free.

Mirror box

Mirror box therapy was invented by Prof. Vilayanur S. Ramachandran to help patients with phantom limb pain. A recent peer-reviewed paper, “The Effects of Graded Motor Imagery and Its Components on Chronic Pain: A Systematic Review and Meta-Analysis” [Bowering et al.], concludes that positive effects were observed for mirror therapy. Mirror therapy is effective for overcoming phantom limb pain [Chan].

This mirror box is offered on the Noigroup website with the description: “Mirrors may be used for a variety of pain and disability states especially involving the hands and feet. In particular, mirror therapy may be appropriate for problems such as complex regional pain syndrome, phantom limb pain, stroke and focal dystonia. Many people gain pain relief and better movement by using a mirror. The Mirror Box has had much success as a patient take-home resource.”

There is peer-reviewed evidence for the usefulness of Graded Motor Imagery, especially mirror box therapy, which is sometimes included in Graded Motor Imagery, as in the Graded Motor Imagery workbook, but sometimes treated as a separate technique. There has even been a meta analysis of six randomized controlled trials [Bowering et al.].

Qigong and Tai Chi

There is very strong clinical evidence for the effectiveness of Qigong and Tai Chi for overcoming chronic pain. A systematic review found that all randomly controlled studies (RCTs)
of Qigong demonstrated greater pain reductions in the qigong groups compared with
control groups. Meta-analysis of 2 RCTs showed a significant effect of external qigong compared with general care for treating chronic pain [Lee]. Another randomly controlled clinical trial demonstrated statistically significant results of immediate reductions in pain intensity in persons with chronic pain after the 2nd, 3rd, and 4th Qigong sessions. This finding is especially impressive given the long duration of pain (> 5 years), in most of the participants [Vincent].

A randomized controlled trial found that a 12-week course of Tai Chi appears to reduce pain and improve physical function, self-efficacy, depression, and health status for knee osteoarthritis [Wang]. Tai chi, yoga, hypnosis, and progressive muscle relaxation were significantly associated with pain reduction in several studies [Morone]. The primary finding of another systematic review and meta-analysis was that Tai Chi gave improvements in chronic pain for patients with osteoarthritis, OA, lower back pain, LBP, and osteoporosis.