Effects of Weight and Pain on Physical Activity: Insights from the Lived Experiences of Youth with Co-Occurring Chronic Pain and Obesity

Abstract

Objective:

Pediatric obesity and chronic pain are each associated with an increased risk for numerous poor physical and mental health outcomes. Co-occurring chronic pain and obesity (CPO) result in greater functional disability compared with either condition alone. The aim of the present study was to use qualitative methods to better understand the challenges experienced by adolescents with CPO, with a specific focus on physical activity.

Methods:

Semistructured interviews were conducted with 13 youth with CPO. Participants were questioned about pain, physical activity, coping strategies, and the perceived relationship between weight and pain. Interviews were audiorecorded, transcribed, and analyzed according to Interpretative Phenomenological Analysis.

Results:

Superordinate themes expressed by youth included: Impact of Chronic Pain on Relationships, Impact of Pain on Self-Perception, Using Food to Cope with Pain, Perceived Relationship between Pain and Weight after Onset of Pain, Attitudes toward Physical Activity, Barriers to Physical Activity, and Supports to Physical Activity.

Conclusions:

Participants identified challenges associated with CPO. Notably, participants identified pain as a greater barrier to exercise than weight, implicating the salience of chronic pain in the lives of youth with CPO. Furthermore, participants identified a desire to be more physically active, yet discussed struggles and concerns about attempts to increase their physical activity and indicated a desire for guidance about being more active. This study highlights the complexities of the relationship between CPO and underscores the importance of providers collaboratively working with patients to develop a practical plan to resume movement and physical activity.

Introduction

Both pediatric chronic pain and obesity (CPO) have individually, well-established poor outcomes.^1,2 Although youth with the combination of CPO likely have unique concerns, little is known about these combined effects of CPO on health outcomes, particularly related to physical activity. While research has documented effects of each individual condition on physical functioning, little is known about the patients' own insights on ways that chronic pain and weight affect their ability to be active. Given the rehabilitation focus of pediatric chronic pain programs, it is imperative that we understand the impact of dual CPO, and their effects on the lived experience for youth with CPO.

Individually, CPO are associated with impaired physical functioning,^3,4 a multidimensional construct that encompasses related constructs, such as physical activity and functional disability.⁵ These associations are amplified for youth with both CPO. The likelihood of experiencing impaired physical functioning is more than two times greater for youth with CPO, when compared with youth with chronic pain alone and more than six times greater when compared with youth with obesity alone.³ Studies have shown that functional disability in youth with CPO is more impaired than in those with chronic pain without obesity.^6,7 Furthermore, despite active treatment in a multidisciplinary pain program, youth with CPO fail to demonstrate improvements in functional disability over time compared with peers with chronic pain and healthy weight.⁸

Youth with chronic pain experience a reduction in their physical activity after the onset of their pain.^5,9,10 Similarly,^5,11 obesity is associated with decreased physical activity and increased sedentary behavior.^12,13 Although increased sedentary behavior may temporarily decrease pain symptoms, long-term reduction in physical activity is associated with weight gain, which may further exacerbate symptoms of both CPO.^12,14,15 Additionally, musculoskeletal system changes associated with obesity (e.g., muscle weakness and tightness, decreased aerobic capacity, inflammatory biomarkers, and increased pressure on joints, muscles, and nerves) can further exacerbate chronic pain.^4,16–20

The current study aimed to gather information about chronic pain, weight, and their combined impact on physical activity in youth with CPO. Examining qualitative data from youth with CPO is necessary to address the documented treatment failure for this understudied population.

Materials and Methods

Participants

Participants included 13 youth between the ages of 13 and 17 years. Youth self-reported their age, gender, and ethnicity/race (Table 1). The majority of the sample was female and included participants that identified as White/Caucasian, African American/Black, multiracial, and Native American.

Table 1.

Sample Demographics

Age	M = 15.54	SD = 0.88
Gender
Male	2	15%
Female	11	85%
Race
White/Caucasian	4	31%
African American	5	38%
Multiracial	3	23%
Native American	1	8%

SD, standard deviation.

Procedure

Institutional Review Board approval for Human Subjects was secured before recruitment and data collection (IRB Approval No. 951169). Consecutive patients in a multidisciplinary pediatric pain and headache clinic were screened for eligibility before their appointment. Eligible participants were patients presenting to their initial outpatient evaluation and were English speaking, between the ages of 13–17 years, and with a BMI classified as obese. The latter criterion was consistent with the classification determined by the American Academy of Pediatrics²¹ and is defined as a BMI at or above the 95th percentile for gender and age.²² BMI percentiles were extracted from patient medical records and calculated using age- and gender-specific norms published by the CDC.²³

Eligible participants (n = 24) were excluded if parents did not speak English fluently (n = 2), the patient had a previous diagnosis of cognitive/developmental delays (n = 1), BMI was no longer above the 95th percentile (n = 2), or their parent was not present for the appointment (n = 1). Eighteen families were approached at the end of their initial pain clinic evaluation, and 15 provided assent and consent to participate in the study after thoroughly reviewing documents, asking any questions with the research team. Three families said they were not interested in participating in research. Two families were unable to be reached after consent/assent to complete the study. Participants were scheduled for a telephone interview with a trained clinical/counseling psychology graduate student (BS and MA, respectively) or psychologist (PhD; the first author). All interviewers were female. Graduate student interviewers had no contact with participants before the interview. The psychologist obtained consent from all families during their initial in-person evaluation and was part of the treatment team for seven participants.

Youth completed a 20- to 40-minute, semistructured phone interviews independently and were compensated $30 for their participation. Parents were available (e.g., at home) but not present during the phone interview. Phone interviews were recorded on hospital computers with Audacity software (used on encrypted hospital computers) and transcribed verbatim by undergraduate research assistants with checks for fidelity conducted by the interviewers. No field notes were taken during the interviews. Participants did not review or provide feedback on final transcriptions.

Qualitative Interviews

The semistructured phone interview script was designed specifically for the purposes of this study, by study team members with expertise in pediatric pain and obesity, psychology, and qualitative methods (Table 2). All interviews began with a reiteration of the reason for doing the research study. Interviewers were trained in semistructured interview techniques, such as utilizing open-ended questions and follow-up questions, as needed, to encourage elaboration or clarification by the participants. Interviews consisted of questions related to coping skills, interpersonal factors, physical activity, and perspectives about the relationship between pain and weight.

Table 2.

Semistructured Interview Script

1.	How long have you had your pain condition? Could you describe how it developed?
2.	How do other people, including family, friends, doctors, or teachers, react to your paina. Was anyone particularly understanding or supportive?b. Was anyone particularly unsupportive?
3.	How do you cope with your pain condition?
4.	Do you ever use food to cope with your pain condition?
5.	How has your body shape or weight changed since your pain condition started?a. How have you reacted to these changes?
6.	In what way do you think your weight and your pain condition might be related? In other words, do they influence each other?a. Does your pain make it harder to be active?b. Does your weight make it harder to be active?
7.	What does being physically active mean to you?
8.	What is your opinion of your current physical activity? In other words, do you feel like you are getting enough physical activity?
9.	How has your pain condition affected your physical activity or your expectations of physical activity?a. How do you feel about these changes?
10.	What kinds of physical activity were you doing before your pain condition started?
11.	What kinds of physical activity have you tried since your pain condition began?a. If you stopped physical activity, why did you stop? How long did you stop engaging in physical activity?b. If you have not tried physical activity, why?
12.	What is the hardest part about being physically active or exercising now?
13.	Currently, how confident or comfortable do you feel about your ability to exercise?
14.	How confident did you feel before your pain started?
15.	What kinds of things are helpful in getting you to engage in physical activity now?a. In the past?
16.	What kinds of things make it difficult for you to engage in physical activity now?a. In the past?

Data Analyses

Qualitative interviews were analyzed from transcriptions with Interpretive Phenomenological Analysis (IPA),²⁴ a burgeoning, robust qualitative framework that is frequently used in the field of health psychology.^25,26 The three interviewers contributed to the thematic analysis process using IPA guidelines. IPA utilizes inductive analytic techniques, which emphasizes data interpretation at multiple levels. The first step of analysis required coders to read and reread transcripts to gain familiarity with child interviews. Second, the coders independently generated initial codes intended to be short, exploratory comments that were descriptive, linguistic, or conceptual in nature.²⁴ Next, coders independently and then collaboratively identified emergent themes based on initial codes, effectively moving away from the transcripts and toward the development of broader themes. Emergent themes aimed to be succinct and interpretative.

In a collaborative group process, the research team discussed the emergent themes to ensure that they accurately reflected participant data. Following the development of emergent themes, coders identified superordinate themes, essentially grouping emergent themes through abstraction and subsumption. With abstraction, related emergent themes were clustered, and the group was labeled with a new superordinate theme. With subsumption, an emergent theme became a superordinate theme, and relevant, related emergent themes were subsumed under the new superordinate theme. Emergent and superordinate themes were only acceptable if they accurately reflected the insights provided by over half of the sample.

Results

Primary diagnoses included: headaches (n = 7), generalized pain (n = 3), abdominal pain (n = 1), back pain (n = 1), and lower extremity pain (n = 1). Approximate pain onset was reported during the participant interview, ranging from 4 months to over 7 years before participation (modal onset = 2 years). Participants rated average pain over the past 2 weeks on a 0 to 10 scale as moderate (M = 5.92, SD = 1.12) and worst pain intensity as severe (M = 8.40, SD = 1.45). All participants were classified as obese (BMI percentile: M = 97.75, SD = 1.60).

Qualitative Results

The following results reflect superordinate and emergent themes from the qualitative analysis of youth interviews. Each superordinate theme characterized the majority of the sample (bolded headers below); illustrative participant quotes for each theme are presented in Table 3.

Table 3.

Superordinate and Emergent Themes

Themes	Supporting Quotes
Impact of chronic pain on relationships
Experienced pain dismissal from others	“My teachers, they don't really understand when I miss school.… Sometimes the pain is so bad I can barely get out of bed, and they don't understand that. I feel like they think I'm faking.”
Discomfort in sharing story of pain with others	“I just felt uncomfortable telling [my teachers].… They make me feel uncomfortable about it. Some of them roll their eyes.… It was just really stressful.”
More empathy from people who had a pain condition	“My mom is really understanding because she has fibromyalgia, and she has a lot of pain too.… I have a friend who has a lot of medical problems, and she's in a lot of pain as well. She can relate to this.”
More empathy from people who had a pain condition	“My mom gets migraines too, so she knows how it is. She can really understand. But with my teachers and other people, it's kind of hard because they don't know what it's like to experience that.”
Impact of pain on self-perception
Self-identity changed after pain condition	“It has affected a big part of [my identity]. I stopped playing basketball, like completely stopped playing. Every time I did something that involved running to pump up my body, the headaches would occur.… I see my sister playing, and I want to do it, but sometimes I just have to take a break from watching the game. It just makes me sad. Everyone around knew that I used to play, and they are like, ‘Why are you not playing?’ And I have to constantly tell everyone what happened. Just from that I get a headache, going over something that I just don't want to talk about.”
Negative self-perceptions about weight	“It makes me a little bit upset because I'm already trying to lose weight and in general become a healthier person even if I just maintain the same body weight.… Since all this pain, it's become harder, and I know I have to keep going, but it's just frustrating.”
Using food to cope with pain
Food generally not used as a coping skill	“When I first got my concussion and I couldn't really do anything, I did like eating.… That was my way to cope with headaches.… I was trying to eat less, but the more headaches I got, the more depressed I got and that is why I ate. I didn't want to starve myself, but … the more I eat, the more I get overweight. I didn't know what to do.”
Food generally not used as a coping skill	“I get nauseated, so I don't eat much when I have a migraine at all.”
Perceived relationship between pain and weight after onset of pain
Physical activity important part of this relationship	“I was a very athletic kid. I played a lot of football and hockey, but since [the concussion and start of headaches], I have had to not play those sports, and I have gained weight. I have gained a lot of weight since I have been having the headaches. Whether it was stress or eating too much, I am not really quite sure.”
Limited impact of weight on psychosocial outcomes	“I can do a lot [despite] my weight, so I don't think my weight influences my active wellness.”
Stress and fatigue, resulting from pain, decreases engagement in physical activity	“I think because of the stress and anxiety I have and because of the pain, I did gain some weight, but not being able to play [sports] has been a huge bummer.”
	“When I'm in constant pain and it doesn't go away, I can't even explain what happens. I get really tired really quick when I'm in a lot of pain. But if I'm in mild pain, I can do more.”
Attitudes toward physical activity
Physical activity viewed as challenging	“I think the only time I am getting physical activity is when I am in gym, and that is not enough to me. I want to do more, but I don't know if I can do more.”
Physical activity viewed as challenging	“I don't think that I am getting enough physical activity. I do feel like I should be doing more. I just can't though. Walking is the biggest physical activity I can do now.”
Negative feelings about limited physical activity	“I know I expect to be able to do a lot more than I am able to do. I expect to be able to lift more, but it just hurts too much when I do. It makes me feel weaker than I actually am. I know I could be doing more if I really pushed myself, but it hurts too much.”
Barriers to physical activity
Largest barrier to physical activity is pain, not weight	Pain is kind of preventing me a lot of the time from going out and exercising.… When I work out, it's hard because I'm overweight, and it's not just my pain, but I know the difference, and I push through it when it's just my weight.”
Difficulties with poor motivation	“There's absolutely no motivation to walk or do anything when I have a migraine because of the fact that my head hurts so much, and it's like the ‘only thing I can think about’ type thing. So, it's hard to think about doing any kind of physical activity when I'm in pain in that way.”
Practical barriers to physical activity	“The hardest part is trying to contain the workout or the activity without the noise or the light affecting me … or the headache will come on.”
Supports to physical activity
Helpfulness of social support	“At dance, I have plenty other friends to help me there.… My mom and my granny [support me]. They push me … so I won't have health problems again.”
Helpfulness of social support	“I literally have to be dragged out of bed [by my friends]. There's not really much else that motivates me.”
Fun activities encourage exercise	“Dance Central—that was where I got most of my exercise. Dance Central, it was fun and competitive, and when I'm playing a game, even if it was just do however many push-ups, as long as it's fun and competitive, that really helps me because I'm not thinking ‘ow, ow, ow.’ I'm thinking, ‘gotta go, gotta [sic] beat this, come on.’”
Structural support increases engagement	“Right now, the only thing that is making me do physical activity is gym.”

Superordinate themes are in bold; emergent themes are italicized.

Impact of Chronic Pain on Relationships

Youth described the negative impact of pain on interpersonal relationships in their lives, as well as the importance of interpersonal relationships for coping with chronic pain. For this sample, interpersonal difficulties resulted in part from the experience of pain dismissal for more than half of the sample. Of those reporting pain dismissal, almost all identified teachers as not believing or validating their pain experiences. Participants also expressed difficulty or discomfort in sharing their pain story with those outside their families. Participants endorsed support from friends or family members who had their own personal experience with chronic pain, describing them as better at empathizing with the participants' challenges.

Impact of Pain on Self-Perception

For many of the participants, self-identity changed after the onset of the pain condition. Those who had considered themselves athletes had particular trouble adjusting to a lack of involvement with sports since their pain onset. In addition to the challenges associated with their chronic pain, participants also reported negative perceptions about difficulty losing weight and frustrations about how pain further interferes with weight loss.

Using Food to Cope with Pain

Participants were explicitly asked about their use of food as a coping tool for their pain condition and reported that food was generally not a current coping tool for them. However, participants reported using food as a coping tool early in the pain course, during times of severe pain, and when they were “younger.” For certain pain conditions, like migraines and abdominal pain, participants would avoid eating any food for fear of increasing pain and nausea.

Perceived Relationship between Pain and Weight after Onset of Pain

Participants identified a complex relationship between pain and weight, with multiple other factors indirectly affecting this relationship. Physical activity was identified as an important factor that was often limited due to their pain experience. Participants' weight gain post-pain onset was often attributed to their decreased physical activity, particularly with student athletes. Participants identified multiple potential mediating factors, such as stress, anxiety, and fatigue that may influence the identified relationship between weight, pain, and physical activity.

Attitudes toward Physical Activity

All participants acknowledged the benefits of physical activity, often endorsing a perceived need to be more physically active, but significant challenges to doing so. Participants also reported negative feelings around activity limits. This was particularly true for those who were involved in sports or other physical activities before the onset of their pain.

Barriers to Physical Activity

Pain was identified as a greater barrier to physical activity than weight, with 12 participants reporting that pain makes physical activity harder and only 4 participants reporting that weight makes physical activity harder. A common barrier reported was low motivation for engaging in physical activity due to chronic pain. Physical activity for this population was also reported to be difficult to engage in due to practical barriers, such as environmental characteristics that affect their pain (e.g., bright lights or loud noises).

Supports to Physical Activity

All participants were able to identify some type of support that encouraged physical activity, despite their chronic pain. Friends and family members were described as primary sources of support for youth with CPO to engage in physical activity. For instance, having someone with whom to participate was reported as helpful in overcoming low motivation. Fun physical activities were also associated with a greater likelihood of engagement. Finally, structural supports, such as mandatory gym class, were identified as supports to increasing engagement in physical activity.

Discussion

Research examining the synergistic effects of CPO on the lives of children and adolescents is limited. The current study adds to this literature by using qualitative methods to characterize the day-to-day impact of chronic pain and weight, and perceptions about physical activity in light of pain and weight concerns. These results highlight potential ways that treatment and management of pain could be improved for this vulnerable population. Four main insights were gained as a result of this study.

First, this population reported frustration over the inability to be physically active, and importantly, reported concern about how best to develop and implement a realistic physical activity plan. Noteworthy was the perception that pain was a primary deterrent to physical activity, but weight was not. These perceptions suggest that while weight status may indeed inhibit engagement in physical activity, pain emerged as the primary perceived barrier to increasing activity. Participants may have perceived a stronger relationship between pain and physical activity rather than between weight and physical activity because the onset of pain directly preceded impaired physical functioning for the subgroup that was previously active or involved in sports. Similarly, some participants may have been able to engage in physical activity before onset of pain, despite having weight concerns, and as a result may not associate the inability to be physically active with weight. An important implication of these findings is that in pain management programs, a focus on physical activity, rather than on weight loss, would likely be most beneficial for patients.

Second, participants' “pre-pain” identity was negatively impacted by their current pain.^27,28 The current study identified subgroups within this population that differed in the impact of pain and pain-related weight on self-identity. For those who saw themselves as an athlete or as very active before pain onset, their identity was negatively affected both by the pain and, for some, the subsequent weight gain. Specifically, these participants had difficulty adjusting to their inability to engage in sports. Participants also identified negative changes in mood and social activity, highlighting the importance of athletics across multiple domains of functioning.²⁹ Assessing pre-pain physical activity and sports engagement may help to reduce weight stigma (including self-stigma as well as stigma from health care providers) and bias, and may help to provide guidance about returning to activity. Equally important is the understanding that even pain providers hold biased views of youth with obesity, which may include the stereotype that those with obesity are extremely sedentary and nonathletic.³⁰ These results underscore the importance of challenging such stereotypes. Youth with CPO can desire to be active, and see themselves as athletes, which is something that should be addressed in pain management programs.

Third, unlike adults with CPO,^31,32 youth reported less use of food as a coping mechanism. Some reported emotional eating as a way to cope with severe pain, but eating as a coping mechanism generally occurred early in the course of their pain and before learning more adaptive coping skills. At either onset of pain or earlier in treatment, evaluating the role of eating as a coping skill and attitudes toward eating may provide important information for treatment planning and reduce the risk of post-pain weight gain.

Finally, in many ways, these patients present similarly to other youth with chronic pain.³³ Specifically, they experienced pain dismissal³⁴ and found social support to be helpful. Participants wanted others to understand and empathize with daily struggles related to their pain condition. For participants feeling unsupported, pain dismissal primarily came from teachers, potentially because participants were not comfortable talking about their pain with them or because they felt pressured to perform at the same academic level as peers (i.e., attending school regularly and/or completing all coursework), despite their pain. Youth viewed individuals with pain conditions as more supportive.³⁵ Finding common ground with others may not only be an important factor related to social support but may also provide a safe space to avoid experiences of pain dismissal.

The current study provides a foundation upon which to improve how we address physical functioning in youth who present to multidisciplinary pain programs with CPO. One of the most important insights was that anxiety about their perceived limitations seem to be driving physical inactivity for this population.^3,36 Participants desired to be more physically active, but they frequently expressed difficulty in knowing how to engage in physical activity. Often, immediate return to intense athletics is not feasible or beneficial because this may exacerbate pain.³⁷ Therefore, fears about pushing too hard or not doing enough may not be unfounded and may contribute to continued sedentary behavior for this population. Multidisciplinary pain providers, particularly physical therapists (PTs), are uniquely positioned to help youth with CPO due to their abilities to evaluate the patient's musculoskeletal and aerobic systems.

PTs can specifically assist these youth by (1) understanding patients' pre-pain activity levels, (2) evaluating pre-pain activity levels for adequacy to enhance health and physical fitness, (3) formulating realistic expectations about a return to pre-pain physical activity levels or possibly developing a plan for patients to exceed pre-pain activity levels, and (4) developing a long-term, structured plan for age-appropriate, consistent physical activity based on functional abilities (e.g., flexibility, strength, and aerobic capacity).

Research suggests that pediatric PTs, who are specifically trained in assessment of pain, aerobic capacity, and the musculoskeletal system within the growing child, can be helpful with a variety of pain diagnoses, including headaches, back pain, and musculoskeletal pain.³⁸ Youth may find it particularly useful to have a structured activity plan, with exercises tailored to target specific impairments (muscle tightness, muscle weakness, and general deconditioning) and allow for progression under the guidance of a professional who understands the effects of pain on physical activity. Focusing on increasing physical activity, rather than on decreasing weight is critical as it may help with stagnation for youth with CPO, as well as taking a focus off of “weight blame.” Furthermore, identifying pain as the primary barrier to physical activity suggests that youth with CPO should be referred to multidisciplinary pain clinics before referring to weight management clinics, and not the other way around.³⁹

This study provides important insights on living with CPO but is not without limitations. First, the nature of the qualitative framework precludes generalization to the larger population of youth with CPO. Second, this study cannot fully answer the question as to why functional disability does not improve for youth with CPO compared with youth with either chronic pain alone, despite active treatment for chronic pain.

It is important to note that CPO is a complex dialectic of one chronic condition that is typically “invisible” (i.e., chronic pain) with one that is extremely visible and associated with negative biases and stereotypes (i.e., obesity).^40–42 Changes in weight following the onset of pain led participants to feel judged in ways that their peers with healthy weight are not. There is evidence that even parents may see their child's pain differently when their child has obesity versus when their child does not.⁴³ Future research should examine the impact of weight and body type on confidence in engaging in physical activity and stigma associated with activity in youth with excess weight. Finally, future research could examine not only how health care providers present information on weight status and physical activity, but also how youth prefer to receive information about weight during evaluations at a pain clinic.⁴⁴

Conclusions

The current study provides important insight into the perspectives of patients with CPO on the weight and pain relationship and their perceptions of impaired physical activity. Focusing on increasing participation in physical activity and increasing general physical functioning may be better received by patients and their parents and be more productive, given that pain is perceived as the most salient barrier to physical activity engagement. The importance of carefully assessing supports and barriers to youth engaging in physical activity provides a starting point for providers to collaborate with youth to construct a realistic treatment plan.

Footnotes

Authors' Contributions

Drs. K.H., W.H.D., M.G., and S.W. conceptualized and designed the study. Drs. M.G. and K.H. drafted the initial article. Drs. M.G., A.L., and S.E. completed data collection, and conducted analysis and interpretation of data. All authors assisted with interpretation of the data and reviewed and all authors critically revised the article. All authors have approved the final version of the article, and agree to be accountable for all aspects of the study.

Acknowledgment

The authors thank all the participants involved in this study.

Funding Information

No funding was received for this article.

Author Disclosure Statement

No competing financial interests exist.

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