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Exercise in Chronic Pain

Exercise in Chronic Pain. Why Exercise?. Decrease pain

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Exercise in Chronic Pain

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  1. Exercise in Chronic Pain

  2. 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 Mar;23(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 Mar;24(3):365-72

  3. 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 Jul;52(7):1098-104. • Tomaszewski M et al: Arterioscler Thromb Vasc Biol. 2003 Sep 1;23(9):1640-4.

  4. Which Conditions Benefit? • Osteoarthritis • Low Back Pain • Rheumatoid Arthritis • Fibromyalgia • Etc.

  5. 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 1;277(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

  6. 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 ofactivity 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

  7. 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 15;22(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 Oct;18(10):971-81.

  8. 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 1;24(23):2435-48

  9. Rheumatoid Arthritis • Home exercise in rheumatoid arthritis functional class II: goal setting versus pain attention. J Rheumatol. 1994 Apr;21(4):627-34.

  10. 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 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.

  11. 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

  12. 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

  13. Delayed Pain After Exercise • Deconditioning • Improper body mechanics

  14. 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

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

  16. Specific Forms of Exercise • Water Exercise • Walking • Low-impact • Elliptical Trainers • Nordic Track

  17. 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

  18. Walking Guidelines Cont’d • 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

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