Pain and Physical Conditioning

Introduction

Chronic pain typically impairs or limits movement, and yet regular physical activity is a crucial part of healthy living. In this section we will discuss why Physical Therapy (PT) and physical conditioning are almost always included in comprehensive treatment programs for chronic pain.

Some form of regular physical activity should be a normal part of the daily life of anyone who is not bedridden by a serious illness. Our bodies were built to be moved and we pay a high price in terms of health and overall quality of life when we become physically inactive. Even persons who are injured, mildly ill or incapacitated in other ways continue to benefit from movement that accommodates their abilities.

Movement and activity

Our need for regular movement and physical activity is a fact of life. Whether we like it or not, the bodies that we inhabit evolved or were designed to be moved on a frequent and regular basis. If you happen to be in the fortunate minority of adults who get regular exercise, you are likely aware of most of the benefits that go along with being active:

you are more physically strong and flexible
you sleep better at night
you can safely and comfortably eat more of the foods you enjoy
it’s easier to control your weight and you feel better about your appearance
in general you have an increased sense of well being and just tend to enjoy your life more

Did you also know though that physically active people:

tend to have a stronger interest and participate more in sex
tend to have a slower resting heart rate and lower blood pressure
tend to have stronger and more effective immune function
are less likely to be clinically depressed
are generally more effective at managing pain

So how does all this happen? Truly, it’s all in the physiology. The physical load that exercise puts on the body triggers an amazingly complicated set of automated processes that together, interact to keep the body more in balance. This is especially true of aerobic activity, the kind of movement that makes us huff and puff and causes us to break a sweat.  Through this exercise-based fine tuning process, more oxygen gets to the tissues of the body and waste products are carried away more rapidly and efficiently. We burn more energy which means we are less likely to put it into storage in the form of body fat. The cells in the body that fight disease are strengthened and other immune processes work more effectively as well. Across the board, the body’s biochemistry is better balanced, which includes the chemistry of the nervous system. This is partly why exercise is so effective in preventing depression, or aiding in its management should we become depressed. Better brain biochemistry combines with all of the other perceived benefits of being active and fit to leave us much more resistant to the blues and the blahs.

There are also benefits in terms of managing pain. In our chapter above called “The Nature of Pain” we talked about rest and limited activity as being an important and appropriate response to acute pain, but not to chronic pain. To say “Let pain be your guide” for how active to be following an acute injury makes sense because injured tissues need time to heal. As pain becomes more chronic however, it typically becomes increasingly important to “move through pain”, that is, to find ways to be active on a consistent basis despite the fact that pain is present. All of the benefits listed above can potentially be available to chronic pain sufferers – as well as all of the predictable disadvantages of being inactive.

The place of physical therapy in managing pain

You can think of Physical Therapy (PT) as a clinical practice that promotes health and well being by focusing on:  patterns of physical movement; strength, balance and physical conditioning; and the specific health of muscles, bones and joints.

In PT, there are two general categories of intervention. First is movement and exercise, which are central to recovery and to maintaining good health. Gentle but sustained movement promotes healing after an injury while it improves your strength, your organ and tissue function and your enjoyment of life, as noted above. In many studies looking at the effectiveness of different kinds of treatment for chronic pain it has been found that a gradually increasing program of physical conditioning is the necessary element for a good outcome. Other treatment modalities such as relaxation training, cognitive therapy and some of the PT modalities described below certainly tend to contribute to effective pain management as well. But, regular gentle exercise is typically shown to be the treatment component that has to be present if real progress is going to be seen. Toward the end of this chapter we will describe a strategy that chronic pain sufferers can use for gradually increasing daily activity levels.

The second category of Physical Therapy interventions includes the PT ”modalities”.  There are three groups of these:

Thermal agents (heat or thermotherapy) are used to increase tissue temperature and blood flow to an area in order to reduce pain, decrease muscle spasm, and promote healing. Heat often causes muscles to relax, increasing your flexibility and range of motion.

Mechanical agents use force to apply pressure in or on the body. The goal is to decrease the pressure between bones or on tissues such as nerves and joints that often produces pain and inflammation when left untreated. Traction, compression, water, and ultrasound are all examples of mechanical agents.

Electromagnetic agents such as laser, ultraviolet, and diathermy (using electromagnetic energy to produce heat) are useful in the treatment of some painful conditions. These agents apply electromagnetic energy or an electric current to control pain and edema (swelling), promote tissue healing and increase muscle strength, or to deliver drugs through the skin.

In the context of chronic pain management, PT modalities are perhaps most helpful for treating and preventing re-injury and providing symptom relief during a pain flare-up.  They are used to disrupt the cycle of pain and spasm, improve circulation, promote healing, and reduce inflammation. Certain modalities can also be used to reduce muscle tension or tightness and increase joint motion. If you are currently working with a physical therapist, he or she will assess your stage of healing and choose the best modality to meet your treatment goals. Physical therapy modalities are usually used before or along with other interventions such as stretching, manual therapy, or exercise.

The positive effects of movement and activity on pain

It is very important for you to be able to move in a comfortable and safe way, every day, especially as you heal from an injury or learn to manage a chronic pain problem. Remember that chronic pain can be thought of as pain that persists despite the fact that healing has occurred. This typically means that the pain is not a signal that your body is experiencing ongoing damage, which in turn means that you are safe to move as long as you are careful and thoughtful while you are gradually becoming more active. So, the first question that has to be answered for anyone with chronic pain is whether or not movement is safe, even if it’s painful. If you haven’t already done so, check this out with your doctor. You need to be sure that an exercise program is safe as long as you are careful.

Once you’ve had this conversation with your primary care provider, your next step might be to meet with a physical therapist. Make sure it’s a practitioner who really understands chronic pain and has worked with lot of pain patients. You might even ask them to read through some of the material presented on this website to see if their opinions and approaches to pain treatment match what we’ve presented here.

The emphasis of your physical therapy needs to be on overall conditioning:  flexibility, muscle strengthening, and cardiovascular fitness. Work with your PT to develop a program that meets your unique needs. The overall increase in your activity level needs to be slow and gentle.

Probably the most important aspect of the whole program is to find activities that you will have fun with. People who go swing dancing every weekend don’t necessarily think of it as ‘exercise’ but it is, and at the end of the night there’s no doubt they’ve had a great workout. In the same way, most hardcore gym rats will tell you that they don’t think of themselves as being particularly disciplined – they just truly love the work out.

So what if you don’t love going to the gym?

Find an activity that you do like doing. Try new things as well. Having different activities to choose from helps you get in some kind of physical activity every day, no matter what the weather or the demands on your time might be. You can also combine your activity with social time. For many of us, walks are enjoyable with company as a way to spend time with someone you like to stay in touch with. Combining exercise with taking care of important friendships is a win-win situation. You get out for a walk and your body gets taken care of, along with your heart and mind.

Summary:  A strategy for getting more active

So putting these ideas together, we would like to suggest a strategy for gradually and safely getting more active, based on the idea that regular gentle exercise will prove to be one of the most important tools in your kit for managing your pain problem successfully.

Here are the steps:

1. Find a provider you trust who has had experience working with pain patients. Based on their careful evaluation of your pain problem, you need their reassurance that your body is well healed and that gentle movement is safe for you. Even though getting moving again may hurt more at the start, you need to feel secure in the knowledge that you are not at risk for damaging yourself as long as you start out slow and focus on making gradual but sustained progress.

2.  Consider carefully what your movement related goals are. What would you like to be doing that you aren’t doing now, and that is realistic given your history, your age and your current physical condition? Make a list if that’s helpful. Most folks who have been inactive for a while find that walking is a great place to start. It provides excellent general conditioning which can serve as a base for pursuing other activities or more specific conditioning.

3.  Using a regular walking program as an example, you begin by establishing a baseline.  On day one, go for a walk and pay attention to either the distance you walk or the amount of time you spend walking. Just starting out, it’s best to have a short lap or circuit of some kind so that you never get too far from your starting point. Maybe walk to the mail box and back and count that as one lap, or maybe once around the cul-de-sac. Several very short laps will give you a much more accurate idea as to what you’re capable of. The most important aspect of this first day is to only walk for as much as you feel like. Let pain or fatigue or boredom be your guide, and stop just when you feel like stopping. Then simply count the number of laps you were able to complete, or the number of minutes you spent walking.

4.  Continue in this way for two more days. Then, at the end of your third day figure out the average amount of walking you did over the first three days and reduce that number by about 10%. This will be your baseline. For example, if you were able to walk an average of four laps, your baseline will be a little less than that, maybe 3 ¾ or so. Then, think of where you would like to be in 8 weeks. Don’t be overly ambitious. It is far more important to see gradual improvement that you can sustain than it is to see fast improvement.  Increasing by about 10% per week is a pretty good rule of thumb for most of us. This may well be a good question to discuss with your primary care provider as well since they know you and may be in a good position to help you determine appropriate guidelines.

5.  Now, make a very simple graph. Start with week one and make an X on the vertical line for the number of laps (or minutes) equal to your baseline. Now go out to week 8 and make an X that shows the number of laps (or minutes) you would like to be walking by then (again, be realistic!). Now draw a straight line that connects the X’s. You’ll see that for each week there is now a target to shoot for, where your straight line falls that week.  This means that your goal will be to hit the quota for that week, regardless of how you’re feeling. This is important: If you’re having a bad day, hurting more or feeling especially tired, try to hit the target anyway. And, if you’re having a good day and can easily exceed the goal for that day, don’t. Pacing is just as important as pushing through discomfort and overdoing today will likely mean under-doing over the next day or two.

Keep in mind that this kind of strategy using baselines and quotas can be applied to any activity that can be counted in terms of laps, repetitions, weights, times, distances and so on. The critical features are to establish the baseline letting pain or fatigue be your guide; drop back a bit for your starting point; establish your target for two or three months down the line; connect the starting point with the ending point, and then use that line to set your quota for the day, regardless of how you feel.

Remember that time and again studies have shown movement and activity to be the most important parts of a program for recovery from injury and effective pain management.  Getting moving again should truly be your highest priority. Good luck!

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