Patients & Visitors

Pain Clinic

A17

Exercise in Pain:
Principles of a Paced Exercise Programme

Stage 1: Preparation

urban runner It is vital that an assessment is made of the patient’s starting position. Their beliefs and attitudes will be fundamentally important to the success or otherwise of any exercise plan. Patients may have inappropriate or inaccurate ideas about their pain, sometimes picked up during consultations.

An example is the patient who believes that their spine is ‘crumbling’. They are unlikely to engage with exercise while they have such a belief. Failure to pace activities during previous attempts to exercise can also lead to later fear of exercise (‘I tried it but it made me worse’).

Patients may be receptive to the idea of starting exercise, or they may be resistant. If they are resistant, they may have a lot of questions to ask, or their reasons for resisting may need to be teased out with questioning of them. Patients may also have accepted the need for exercise as a principle, but not actually be ready to start. Again, time may need to be invested to move them from this position.

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Stage 2: Understanding the cycle of under- and over-activity

People in pain tend to slip easily into this counterproductive behaviour pattern. They may either do as much as they can when feeling well, leading to more pain or exhaustion the next day, or they may push themselves to complete a task in spite of intolerable pain. In either case, the result is increased pain and enforced rest, as well as a sense of failure and disappointment. If this pattern is repeated over and over, the result tends to be increasing disability.

Pacing is a strategy that deals with this unhelpful cycle. A simple way to embark on a paced exercise programme is to measure the time taken during activity to get to a point of significant pain increase. The time should then be reduced by 20% to arrive at a starting point for that activity. The duration of activity is then not increased until some control is gained over the pain. It can then be increased by small increments (5 to 10%, for example).

When patients understand this strategy and its basis, it allows them to understand their previous lack of success, regain control over the pain and safely set an exercise programme.

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Stage 3: Setting the exercise programme

The choice of exercise is important. It should be a form of exercise that the patient will enjoy, as they will need to persist at it for a long period. Common choices are walking, swimming, cycling, aerobics, gym-based exercise, exercises at home, stretching or a combination of exercises. A good programme would include some aerobic work, some element of strength work and stretches, although these need not be on the same day.

In general, exercise should be changed from being pain contingent to being time contingent. Patients will not then stop an activity because of pain, but instead because of time or repetition limits. This is a significant behaviour change, and it may be difficult to put it into effect.

Aerobic exercise
The individual needs to choose the type of activity, which they can eventually participate in two or three times a week for 20 minutes or more. Again, the starting quota is 20% less than they can do before precipitating pain. They should stay at this level of activity, even if they feel that it is too little. Any later decision to increase the level of activity must be made before the start of the activity, as deciding to go further during activity is a common trap.

Gym-type activities
It is easiest to do this in a gym on one of the exercise-on-prescription schemes that are available. The individual exercises themselves are not as important as choosing exercises for different parts of the body that suit the patient’s particular difficulties. For example, a person with neck pain can do ‘sit-ups’ in reverse, lifting the lower body rather than the head and shoulders. It is best that the design of the programme is done by a qualified person on an individual basis.

The plan would be to choose ten different exercises, and to set the levels of each by repetition, resistance or time as appropriate. Take 20% off as usual to get the quotas and stick to them for a period of time. Graded increases over time, daily repetition and occasional substitution to avoid boredom are the way to proceed.

The biggest risk is probably having a non-specialist in pain setting the programme, as the levels then tend to be set according to what is expected that patients can manage. Patients must set the levels themselves, no matter how ‘easy’ they appear to be. A mistake here, with a severe exacerbation of pain, will inhibit further attempts at exercise.

Stretching
Patients often find this to be very useful, and it can usually be continued when increased pain (setbacks) make the usual regime difficult to stick to. A series of stretches can be taught for calf, quads, hamstrings, low back, neck and shoulder muscle groups. Technique is important, with a steady hold of 20 to 40 seconds for each stretch.

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Stage 4: Review

It is rare for patients to embark on this and not have problems. Review with an experienced therapist is useful after a month or so, and patients appreciate the facility of being able to get in touch for advice. Long-term compliance and self-management is the aim, and such a large behavioural change cannot be expected to happen over a short time.


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