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Exercise in Chronic Pain
Why Exercise?
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Decrease pain
o 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 Mar;23(3):334-42
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Increase ability to participate in life
o systematic increases in both exercise levels and
expectancies of capability while reducing worry and concern
about exercising. Pain. 1986 Mar;24(3):365-72
Anti-inflammatory Benefits of
Exercise
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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 Jul;52(7):1098104.
Tomaszewski M et al: Arterioscler Thromb Vasc Biol. 2003
Sep 1;23(9):1640-4.
Which Conditions Benefit?
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Osteoarthritis
Low Back Pain
Rheumatoid Arthritis
Fibromyalgia
Etc.
Osteoarthritis
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“Wear and tear” arthritis is not benefited by
resting the joints completely
o 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 1;277(1):25-31.
o At 24 months, highly significant reductions in knee pain were
apparent for the pooled exercise groups compared with the nonexercise 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
Low Back Pain
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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 selfrated 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 7;322(23):1627-34
Low Back Pain
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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
15;22(24):2959-67
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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 Oct;18(10):971-81.
Low Back Pain
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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 1;24(23):2435-48
Rheumatoid Arthritis
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Home exercise in rheumatoid arthritis
functional class II: goal setting versus
pain attention. J Rheumatol. 1994
Apr;21(4):627-34.
Fibromyalgia
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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
Jun;23(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. 1996;25(2):77-86.
General Guidelines for Safe Exercise
in People with Chronic Pain
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Stretch before and after exercise
o Gentle stretches – no bouncing!
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Start Low, Go Slow
Emphasize Concentric Exercise, avoid
Eccentric Exercise
Emphasize Concentric Exercise,
avoid Eccentric Exercise
o Concentric – muscle contraction as muscle is
shortening
o Eccentric – muscle contraction as muscle is
lengthening, such as slowing yourself down
coming down a hill
Delayed Pain After Exercise
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Deconditioning
Improper body mechanics
Post-Exertional Fatigue
in CFS and Fibromyalgia
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Exacerbations of fatigue lasting a day or
more after exercise may indicate:
o Neurally Mediated Hypotension
o Adrenal Insufficiency
o Mitochondrial dysfunction
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If these conditions are treated, exercise
tolerance will improve
Motivation and Adherence
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Solitary vs. Group vs. “Buddy”
Keeping it interesting
o Conversation
o Books on tape
o Moving meditation
o Exercise equipment and television/VCR
Specific Forms of Exercise
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Water Exercise
Walking
Low-impact
o Elliptical Trainers
o Nordic Track
Guidelines for Walking
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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
Walking Guidelines Cont’d
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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