Exercise%20in%20Chronic%20Pain

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Exercise in Chronic Pain

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Why Exercise?

• Decrease pain
• short-term, exhaustive physical exercise can
  evoke a transient elevation in pain thresholds.
  This exercise-induced elevation in pain threshold
  does not, however, appear to be directly related
  to plasma endorphin levels.Med Sci Sports Exerc.
  1991 Mar23(3)334-42
• Increase ability to participate in life
• systematic increases in both exercise levels and
  expectancies of capability while reducing worry
  and concern about exercising. Pain. 1986
  Mar24(3)365-72

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Anti-inflammatory Benefits of Exercise

• Regular aerobic exercise can decrease risk of
  having elevated CRP.
• Most significant drop in CRP is when sedentary
  adults move from sedentary lifestyle to regular,
  low to moderate intensity exercise program.
• As exercise intensity, frequency, and duration
  increase, the CRP continues to drop.
• Anaerobic high intensity training (interval
  training) may elevate CRP temporarily.
• \Colbert LH et al J Am Geriatr Soc. 2004
  Jul52(7)1098-104.
• Tomaszewski M et al Arterioscler Thromb Vasc
  Biol. 2003 Sep 123(9)1640-4.

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Which Conditions Benefit?

• Osteoarthritis
• Low Back Pain
• Rheumatoid Arthritis
• Fibromyalgia
• Etc.

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Osteoarthritis

• Wear and tear arthritis is not benefited by
  resting the joints completely
• Older disabled persons with osteoarthritis of the
  knee had modest improvements in measures of
  disability, physical performance, and pain from
  participating in either an aerobic or a
  resistance exercise program. JAMA. 1997 Jan
  1277(1)25-31.
• At 24 months, highly significant reductions in
  knee pain were apparent for the pooled exercise
  groups compared with the non-exercise groups
  (mean difference 0.82, 95 confidence interval
  1.3 to 0.3). Similar improvements were observed
  at 6, 12, and 18 months. Regular telephone
  contact alone did not reduce pain. The reduction
  in pain was greater the closer patients adhered
  to the exercise plan. BMJ. 2002 October
  5 325(7367) 752

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Low Back Pain

• A controlled trial of transcutaneous electrical
  nerve stimulation (TENS) and exercise for chronic
  low back pain The 95 percent confidence
  intervals for group differences excluded a major
  clinical benefit of TENS for most outcomes. By
  contrast, after one month patients in the
  exercise groups had significant improvement in
  self-rated pain scores, reduction in the
  frequency of pain, and greater levels of activity
  as compared with patients in the groups that did
  not exercise. The mean reported improvement in
  pain scores was 52 percent in the exercise groups
  and 37 percent in the nonexercise groups (P
  0.02). Two months after the active intervention,
  however, most patients had discontinued the
  exercises, and the initial improvements were
  gone. N Engl J Med. 1990 Jun 7322(23)1627-34

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Low Back Pain

• Specific training of muscles surrounding the
  spine (deep abdominal muscles and lumbar
  multifidus), considered to provide dynamic
  stability and fine control to the lumbar spine.
  Found to be effective in the treatment of
  spondylolysis and spondylolisthesis. Spine. 1997
  Dec 1522(24)2959-67
• The primary treatment was intensive, specific
  exercise using firm pelvic stabilization to
  isolate and rehabilitate the lumbar spine
  musculature. Patients were encouraged to work
  hard to achieve specific goals.Seventy-six
  percent of patients completing the program had
  excellent or good results. At 1-year follow up
  94 of patients with good or excellent results
  reported maintaining their improvement. Results
  in the control group were significantly poorer in
  all areas surveyed except employment.Orthopedics.
  1995 Oct18(10)971-81.

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Low Back Pain

• 1) modern active physiotherapy,2) muscle
  reconditioning on training devices, or 3)
  low-impact aerobics.After therapy, significant
  reductions were observed in pain intensity,
  frequency, and disability Fear-Avoidance Beliefs
  about physical activity (FABQ activity) and
  "praying/hoping,""catastrophizing," and "pain
  behavior" coping strategies--each with no group
  differences in the extent of the response. These
  effects were maintained over the subsequent 6
  months Spine. 1999 Dec 124(23)2435-48

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Rheumatoid Arthritis

• Home exercise in rheumatoid arthritis functional
  class II goal setting versus pain attention. J
  Rheumatol. 1994 Apr21(4)627-34.

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Fibromyalgia

• Exercise is helpful in the management of FM in
  the short term. It also shows that FM patients
  can undertake an exercise program which includes
  aerobic, flexibility, and strength training
  exercises without adverse effects. J Rheumatol.
  1996 Jun23(6)1050-3.
• AE was the overall most effective treatment,
  despite being subject to the most sceptical
  patient attitude prior to the study. At follow
  up, there were no obvious group differences in
  symptom severity, which for AE seemed to be due
  to a considerable compliance problem. Scand J
  Rheumatol. 199625(2)77-86.

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General Guidelines for Safe Exercise in People
with Chronic Pain

• Stretch before and after exercise
• Gentle stretches no bouncing!
• Start Low, Go Slow
• Emphasize Concentric Exercise, avoid Eccentric
  Exercise

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Emphasize Concentric Exercise, avoid Eccentric
Exercise

• Concentric muscle contraction as muscle is
  shortening
• Eccentric muscle contraction as muscle is
  lengthening, such as slowing yourself down coming
  down a hill

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Delayed Pain After Exercise

• Deconditioning
• Improper body mechanics

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Post-Exertional Fatiguein CFS and Fibromyalgia

• Exacerbations of fatigue lasting a day or more
  after exercise may indicate
• Neurally Mediated Hypotension
• Adrenal Insufficiency
• Mitochondrial dysfunction
• If these conditions are treated, exercise
  tolerance will improve

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Motivation and Adherence

• Solitary vs. Group vs. Buddy
• Keeping it interesting
• Conversation
• Books on tape
• Moving meditation
• Exercise equipment and television/VCR

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Specific Forms of Exercise

• Water Exercise
• Walking
• Low-impact
• Elliptical Trainers
• Nordic Track

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Guidelines for Walking

• Stretch before you begin your walk
• During the first three minutes, go about half the
  speed you will be walking
• Tell someone where you are going and when you
  expect to return
• Consider safety if you will be away from
  populated areas

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Walking Guidelines Contd

• Wear at least one brightly colored article of
  clothing
• Always carry water with you
• Walk during daylight and check weather forecast
  before you start
• Carry a police whistle
• Breathe as normally as possible when you walk
• After your walk, stretch again