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movement for
PAINFUL
problems
One of the issues we face, which you probably know already, is that it is
not as simple as just taking exercise from the world of fitness and simply
porting them over into clinic. Exercise for painful problems is a different
beast from exercise for fitness and we may need a different knowledge
base and skill set to deal with it!
We should always keep in mind that the real point of any exercise or
activity program is to get people back to what they enjoy doing and not
simply just doing exercise.
The real key is understanding more about both pain & exercise and also
the person you are working with and their painful problem! There is not a
singular answer many times and clinical reasoning is the most powerful
tool we have but does take a bit of effort!
What’s the clinical challenge?
Exercise and its dosing are mostly based around changing one of these
physical factors and is pretty good at doing this consistently when we
are talking about gains in the gym. BUT this consistency is not repeated
in clinic where responses to exercise and pain can be pretty varied.
So we can say that getting stronger can enable people to function better
in a general sense but does it always help my patients pain get back to
doing what they LOVE? Often the answer is no.
But don’t forget that a program to increase moving can involve all of
these things. Something lighter to do daily keeping the body ‘oiled’, more
of what people love to do and then also more structured exercise as
well.
Finding a program of tolerable and sustainable moving has been of great
help to many people with long term pain issues. That favourite clinical
question like “what’s the best exercise for back pain?” unfortunately
does not have a definitive answer. Instead there are lots of options to try
which is really liberating but a bit scary at the same time.
There are lots of potential mechanisms that explain how exercise might
work for pain and this is be important for a couple of reasons.
So, let’s start with the different ways it can help. Each of the different
mechanisms might allow us to set exercise up in different ways to be
beneficial. If we think that social aspects of exercise might help someone
then finding ways to get people into a group scenario or exercise class
would be the way to go.
If we wanted to try to alter someone’s perceptions of their body’s
capability then exercise that is achievable, tolerable and is positively
reinforced might be a key.
What do we want?
Exercise and movement like all other components of rehab should have
a large helping of clinical reasoning. Part of this is to consider what
effect we are trying to get and how that fits to the patient we are working
with. This is a simple consideration guide to help think about what effect
we might want. This requires a bit of knowledge about the problem, the
person and what they want to achieve.
Graded exposure
Graded activity
Time contingent
This uses time rather than pain or symptoms as a guide for stopping
exercise. The aim is to reduce the associations between hurt and harm
for the exerciser and is used often used for those with longer term pain
conditions. In essence we can have pain during exercise that may not
damage our bodies or cause longer lasting pain.
This is a key topic as we know getting rid of pain is far from easy and
exercising and moving with some pain is going to be the reality for many
people. So, understanding our attitudes to pain can be key with things
like pain self-efficacy but also knowing how much is OK. This is not up to
us clinicians to decide really, so we have to find, within reason, what is
tolerable for the person doing it. We can do that through traditional pain
scores or through verbal communication to determine that
This is a KEY skill and often requires a bit of informed trial and error.
One of the ways I use to minimise risk of flare ups is the rule of 10 (it’s
not really a rule :). This takes into account current pain level and
irritability of that pain (often missed).
We can lose trust and confidence with people if our exercise prescription
flairs them up. By taking into account their pain levels and pain
behaviour we can better dose people and progress accordingly for a
favourable and hopefully a less bumpy journey to sustainable
movement.
I simply use a lower perceived effort score (RPE) with higher VAS and
irritability. This often gives me a tolerable starting point or baseline to
work off. This is an inexact science certainly but can be really clinically
useful.
Final word
The aim of this short guide was to highlight some of the issues that need
to be overcome in using movement and exercise in modern clinical
practice with relation to pain. This is so much more than simply taking
what we know about S &C or general exercise and porting it over to the
clinic. These exercise components can certainly be part of what of what
we need to know but need to be enhanced with a better knowledge of
applying it to painful problems too!