Bibliografic reference
Malfliet A, Marnef AQ, Nijs J, Clarys P, Huybrechts I, Elma Ö, et al. Obesity Hurts: The why and how of Integrating Weight Reduction with Chronic Pain Management. Phys Ther [Internet]. 2021 Aug 14;
Overweight and obesity are highly prevalent in individuals with chronic pain. In people with overweight or obesity who are suffering from chronic pain, a multi-modal approach targeting both pain and weight seems appropriate.
Background
Overweight and obesity are identified as risk factors for pain development. Pain intensity and disability show a dose-response relationship with BMI, waist cir-cumference, body fat and fat mass. Conservative pharmacological treatment of chronic pain is often limited to the short-term and has minimal effects. When compared to either intervention on its own, weight loss treatments combined with physical therapy have resulted in reductions of pain and disability for pa-tients affected by knee osteoarthritis, fibromyalgia and chronic low back pain.
The characteristics of the study
The study by Malfliet et al. provides an explanation of the possible underlying mechanisms behind the interaction between overweight or obesity and chronic pain in an adult population. The authors suggest a conservative approach to body weight management within a physical therapy setting. They also provide clinical guidelines for assessing and treating overweight and obesity in patients with chronic. These recommendations are based on the available scientific evi-dence as well as the authors’ clinical expertise.
Results
The association between chronic pain and overweight is subject to several expla-nations, including increased biomechanical load, changes in the gut microbiome, and low-grade (neuro)inflammation. The medical history of a person with chronic pain and overweight or obesity should, therefore, also include: BMI, muscle mass and fat distribution, waist and hip circumference, skin fold measurements and/or body composition assessment using a bio-electrical impedance analyzer, dietary intake and habits, and energy-balanced behavior.
Furthermore, the relationship between overweight, obesity and chronic pain should be assessed in light of other lifestyle factors, including physical activity, sleep disturbances, and stress. Insufficient physical activity leads to energy im-balances and (neuro)inflammatory mechanisms, while also affecting the health of the intestine. Obesity-induced sleep apnea results in frequent sleep interruptions and, thus, a reduction in sleep quality. Sleep disturbances are known to increase pain severity. On the other hand, stress can impact food intake, affect energy ex-penditure, and maintain and worsen chronic pain through threat learning. In clin-ical practice, physical therapists should consider encouraging patients to have a healthier lifestyle, integrate a healthy diet, and incorporate a lifestyle approach. Such an approach should aim at addressing sleep problems and stress, increasing physical activity, and reducing sedentary behavior. Physical activity is not only essential for effective weight reduction but is also a key factor in chronic pain management.
Limits of the study
The study is limited to giving advice related to the physical therapist setting. Likely, similar guidelines may be relevant for other health care providers.
What is new?
People with chronic pain who are also overweight or obese are more likely to have more complex health needs that require attention to lifestyle behavioral fac-tors, such as physical activity and diet. The authors suggest integrating conserva-tive, traditional physical therapy with lifestyle strategies in order to manage chronic pain in this adult population.
Perspectives
Addressing important comorbidities within a lifestyle approach could be the next step towards precision medicine for patients. Physical therapists spend a lot of time with their patients and can, therefore, intervene as first line consultants for different aspects, such as diet. That said, physical therapists planning to integrate nutritional interventions into their practice should engage in lifelong learning on this subject. Furthermore, they should be aware of their limitations in skills and knowledge and refer to other specialists for more complicated cases.
Edited by Elisabetta Bravini and Carmela Rinaldi
