Appendix B Exercise and Pain Management Why Do Exercises? How Can Exercise Help Real Pain? About 10 years ago, I injured my back while participating in an aerobic exercise class. I was diagnosed with a herniated disc and had to have surgery. After surgery, I was afraid to do the exercises my doctor had prescribed, since exercise caused my pain in the first place. A couple of weeks after surgery, the pain started getting worse and I figured I better try something. Once I started exercising, I was surprised that the exercising actually made the pain better. Now, 10 years later, if I stop my exercise program, the pain comes back. Also, I can tell my back and all of my body are much stronger and I don t feel I get injured as easily as I did before. Dr. Marcus Exercise is a vital part of pain management that provides two essential benefits: pain reduction and protection. Pain Reduction Pain causes an involuntary muscle spasm. If you twist your ankle, the muscles around the ankle become stiff, forming a natural cast around the injury that helps stabilize the injured joint while it heals. People with back pain sometimes notice this, saying, I bent over and the pain was so bad I couldn t stand up. When you have chronic pain, your muscles develop a pattern of muscle spasm that no longer is helpful for protecting a newly injured area. The muscle spasm itself is also painful. It is easy to see what happens to these structures when we do not exercise. If you have ever spent a couple of days in bed rest, due to illness or your pain, you probably noticed that your whole body felt stiff and achy once you started getting out of bed. Our muscles and joints expect to be used, and if we do not use them, our pain usually becomes worse. Pain management exercises begin with gentle stretching. This helps relieve the muscle spasm. When you start exercising, you should notice that after a few repetitions, the stretching exercises feel soothing. After the exercise session is over, however, D. Marcus, Chronic Pain: A Primary Care Guide to Practical Management, 389 Humana Press, a part of Springer Science + Business Media, LLC 2009
390 Appendix B Exercise and Pain Management the muscles will probably go into spasm again. That is why you need to do stretching exercises a couple of times each day. As you perform a consistent routine of stretching, your muscles get used to being stretched and are less likely to go into spasm. This will result in longer lasting pain relief. If you do stretching exercises too vigorously or overstretch the muscle, the muscles react by increasing muscle spasm. For this reason, you need to work with a therapist while beginning an exercise program, especially if you notice pain aggravation with exercise. The therapist will encourage you to stretch muscles just to the point that you first feel them stretching and not to the point that you have stretched as far as you possibly can. Pain Protection Muscles and connecting structures, such as tendons and ligaments, provide important protection for the rest of the body. In order to provide protection, they must be in shape and strong. We keep our muscles, tendons, and ligaments in good shape by exercise. After we have been injured once, there is a natural tendency to try to avoid future injuries. For example, when I hurt my back while exercising, I was scared to start exercising again. It is natural to think, I ll just sit quietly in the chair and that way I ll never be hurt again. Unfortunately, the more inactive we become, the more out of shape our protective muscles, ligaments, and tendons become. This puts us at high risk for injury, from even slight trauma. When these tissues are out of shape, minor incidents, such as twisting our ankles, carrying small bags of groceries, or bending, can result in major pain flares. Future injury from these minor events is reduced when the supporting and protective structures of our bodies are strong and flexible. How Do I Get Started? Forget the no pain, no gain motto. Pain exercise first concentrates on stretching and later works on muscle strengthening. Stretching exercises are very boring, but very important. Try to do them while watching a television program or listening to the radio, so you do not dread doing them and find excuses for not stretching. You will need to do stretches for the whole body and also stretches that target your pain areas. Body reconditioning exercises such as walking, swimming, and biking are also essential. Your doctor can help you decide which exercise is right for you. Begin this program gradually and slowly increase exercise duration and intensity after you have become comfortable at each exercise level. Do not increase the exercise intensity too quickly, otherwise you will cause muscle spasm and increased pain. Do not exercise too little, or you would not achieve exercise benefits.
Whole-Body Stretches 391 General Principles of Stretching Exercise Perform stretches twice daily, in the morning and before bed. Begin stretches after taking a warm shower or using a heating pad over your most painful area for 15 minutes. Perform deep-breathing exercises or relaxation techniques while warming the painful area before exercises. Perform exercises while listening to music or television to provide distraction. Perform each stretch slowly. Stretch until the first sensation of stretching is reached, then hold the stretch for 5 seconds. Relax and repeat three to ten times. When pain flares up, do your exercise program, but reduce the intensity and number of repetitions. If pain levels are higher after stretching, apply ice wrapped in a towel to the most painful area for 10 minutes. If pain levels are consistently high after stretching, reduce the extent of the stretch and review your exercise program with your physical therapist. Whole-Body Stretches Lie down on the floor on your back, with your legs stretched out on the floor. Perform each stretch slowly. Stretch until the first sensation of stretching is reached. Then hold the stretch for 5 seconds. Relax for 10 seconds and repeat three times. The following exercises should be performed while lying on your back on the floor Exercise description Exercise drawing Neck rotation Rotate your neck slowly to the left, trying to place your left ear flat on the floor. Hold for 5 seconds. Return to center and relax. Then rotate to the right and hold for 5 seconds. Return to center and relax. Shoulders and arms Hold each arm outward at the shoulder so that your body makes a giant cross. Keeping your arms on the floor, bend your elbows to make a 90 angle. This is your starting position. Keeping your arms on the floor between the shoulder and elbow, rotate your forearms up and over, so that your fists become level with your waist. Rotate back to the starting position.
392 Appendix B Exercise and Pain Management Raise both arms back over your head. (Like a police man has said, Stick em up! ) Breathe out and reach out with your arms in a half circle, first upward toward the ceiling, then downward to your sides. Breathe in and reach overhead again. If this is uncomfortable in your back, try bending your knees when you do this exercise. Lift both arms toward the ceiling. Hold. Lower both arms to your sides. If this is uncomfortable in your back, try bending your knees when you do this exercise. Back Lift your left arm up to the ceiling. Grab your left wrist with your right hand. Keeping your left arm straight (do not bend the left elbow), pull the left arm across your chest to the right. Turn chin to the left. Hold. Then raise right arm to the ceiling, grabbing right wrist with left hand and pulling the arm across the chest to the left. Turn chin to the right. Hold. Stretch your right arm over your head. At the same time, point your left toe and stretch your leg. The arm and leg should be reaching in opposite directions. Hold. Repeat with the left arm and right leg. Pelvis Squeeze and tighten buttock muscles. Hold. Tighten muscles in the stomach and buttocks, pressing the small of your back flat onto the floor. Hold. Bend your knees. Keep knees together and your shoulders on the floor. Slowly lower your knees to the floor at the right, causing a rotation of your pelvis. Turn your head to the left, away from your knees. Hold. Return knees and head to the center. Then lower your knees to the left and look to the right. Keep your head and shoulders on the floor to allow your pelvis to rotate.
Flare Management 393 Legs Spread feet about 2 feet apart. Turn both feet inward toward the middle. Hold. Turn both feet outward so your arches are turned toward the ceiling. Hold. Flare Management Even if you practice your exercises and pain management techniques consistently, you will probably experience times of increased pain or pain flares. If the increased pain has the same characteristics as your typical pain, flare management techniques are often helpful. If you develop a new pain, see your doctor. Flare management techniques are used when chronic pain increases to help minimize pain. Several techniques may be used together: Apply heat or ice (whichever you find more soothing) for 20 minutes to the painful area. Begin relaxation techniques: deep breathing, imagery, or biofeedback. Perform stretching exercises that stretch your painful area. Be sure to stretch slowly, and only to the point of first feeling a stretching sensation. Do oscillatory movements (small, rhythmic, side-to-side movements of the painful area). For example, for neck pain, turn the head through about 25% of its full range of motion. Starting with your head facing forward, first turn your head away from the painful side and back. Repeat at a rate of about one per second, for a total of 30 seconds. Rest for 30 seconds, and then repeat until no further relief is noted. Then switch to turning the head toward the painful side, and proceed as stated earlier. Your therapist can describe oscillatory movements for your painful area. Trigger-point compression: you may notice certain spots on your muscles that aggravate your pain when you press them. These are called trigger points. If you identify trigger points, apply pressure to them with your fingers and hold for 12 60 seconds. Release the pressure, and proceed with your usual stretching exercises.
394 Appendix B Exercise and Pain Management Exercise and Activity Logs Daily recording logs can serve as motivational tools and self-checks for patients to ensure that they are staying on task with their exercise program and plans for increasing activity level. Patients should be instructed to maintain daily logs and bring completed logs for review to follow-up appointments. A quick perusal of completed logs provides a quick glimpse into patient compliance, areas of difficulty, and treatment efficacy. Stretching Exercise Program Stretching exercises should be done twice daily for 15 20 minutes in each exercise session. Stretching should be completed at least 4 days per week. Record the time spent stretching, as well as your pain levels before and after exercise. Name: ; First day of log: / / Morning stretches Evening stretches Time (minutes) Pain before Pain after Time (minutes) Pain before Pain after Sunday Monday Tuesday Wednesday Thursday Friday Saturday Do stretches in front of the television or with music playing. Record actual time spent for performing stretches in each session. Rate and log pain from 0 (no pain) to 10 (most severe pain imaginable). Estimating Target Heart Rate, Using Heart Rate Reserve Method Formula for calculation: Target heart rate = [(maximal heart rate resting heart rate) 50%] + resting heart rate Maximal heart rate = 220 age Target heart rate = [(220 age resting heart rate) 50%] + resting heart rate Example: 50-year-old patient with a resting heart rate of 90 beats per minute Target heart rate = [(220 50 90) 50%] + 90 Target heart rate = 130 beats per minute
Exercise and Activity Logs 395 Aerobic Exercise Log Name: ; First day of log: / / Walking program: Target goals are shown with dots. Place X in the boxes each day after you complete your walking program. Also, count the number of times your heart beats in 60 seconds and record this as your heart rate each day that you exercise. Ideally, walk outside with a partner who walks at the same pace. If walking on a treadmill, listen to a television or music while walking. Week 1: 1 mile ½ mile ¼ mile ⅛ mile Week 2: 1 mile ½ mile ¼ mile ⅛ mile Week 3: 1 mile ½ mile ¼ mile ⅛ mile
396 Appendix B Exercise and Pain Management Biking program: Target goals are shown with dots. Place X in the boxes each day after you complete your biking program. Also, count the number of times your heart beats in 60 seconds and record this as your heart rate each day that you exercise. Week 1: 20 minutes 15 minutes 10 minutes 5 minutes Week 2: 20 minutes 15 minutes 10 minutes 5 minutes Week 3: 20 minutes 15 minutes 10 minutes 5 minutes
Exercise and Activity Logs 397 Sample Aerobic Exercise Log Name: ; First day of log: / / Walking program: Target goals are shown with dots. Place X in the boxes each day after you complete your walking program. Also, count the number of times your heart beats in 60 seconds and record this as your heart rate each day that you exercise. Ideally, walk outside with a partner who walks at the same pace. If walking on a treadmill, listen to a television or music while walking. Week 1: 1 mile ½ mile ¼ mile ⅛ mile Week 2: 1 mile ½ mile ¼ mile ⅛ mile Week 3: 1 mile ½ mile ¼ mile ⅛ mile
398 Appendix B Exercise and Pain Management Biking program: Target goals are shown with dots. Place X in the boxes each day after you complete your biking program. Also, count the number of times your heart beats in 60 seconds and record this as your heart rate each day that you exercise. Week 1: 20 minutes 15 minutes 10 minutes 5 minutes Week 2: 20 minutes 15 minutes 10 minutes 5 minutes Week 3: 20 minutes 15 minutes 10 minutes 5 minutes
Exercise and Activity Logs 399 Identifying and Resuming Normal Activities Activity Assessment Name: ; First day of log: / / 1. Select desired target activity. 2. List barriers to achieving target activity. 3. Identify intermediate activity that can currently be accomplished. 4. Develop short-term strategy for accomplishing intermediate activity. 5. Develop long-term strategy for accomplishing desired target.
400 Appendix B Exercise and Pain Management Example of Completed Activity Assessment Activity Assessment Name: ; First day of log: / / 1. Select desired target activity. ÿ Shopping at an outlet mall with my daughter 2. List barriers to achieving target activity. ÿ Unable to ride in the car for 2 hours to get to the stores ÿ Unable to stay in one position, either standing or sitting, without changing position for more than 20 minutes ÿ Unable to walk more than 45 minutes without needing to sit and rest ÿ Unable to carry heavy packages ÿ Afraid that daughter will become angry and disappointed if we leave before she has done shopping 3. Identify intermediate activity that can currently be accomplished. ÿ Shopping at one store in the local mall 4. Develop short-term strategy for accomplishing intermediate activity. ÿ Discuss strategy with daughter, including need to take breaks during shopping. ÿ Use a lumbar support for the car ride. ÿ Arrange to do some brief stretches that can be done while standing after arriving at the mall. Follow this with 15 minutes of walking in the mall before you start shopping. ÿ Select only one store to visit and agree beforehand that you would not go to any other stores that day, even if there is a great sale. ÿ Take a watch and agree to shop for only 1 hour before stopping. ÿ Plan to get lunch after shopping to celebrate being together. ÿ After arriving home, use relaxation techniques and do your stretching exercises, even if you feel tired. 5. Develop long-term strategy for accomplishing desired target. ÿ Successfully complete several brief trips to the local mall. ÿ Gradually increase shopping time, remembering to take breaks to sit, stretch, and use pain management skills. ÿ Identify rest stops on route to the outlet malls. Use rest stops to walk and do stretching exercises. ÿ Identify 2 4 stores you will visit at the outlet mall. ÿ Take breaks in between visiting each store. ÿ Allow daughter to carry bundles to the car between stores to minimize carrying. ÿ Do not be discouraged if your first attempt is not completely successful.