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,
© Humana Press, a part of Springer Science + Business Media, LLC 2009
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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
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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
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.
Exercise drawing
392
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.
Appendix B Exercise and Pain Management
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:
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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
Time (minutes) Pain before
Evening stretches
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
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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:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Friday
Saturday
Friday
Saturday
1 mile
½ mile
¼ mile
⅛ mile
Heart rate
Heart rate: record your heart rate at the end of your exercise session
Week 2:
Sunday
Monday
Tuesday
Wednesday
Thursday
1 mile
½ mile
¼ mile
⅛ mile
Heart rate
Heart rate: record your heart rate at the end of your exercise session
Week 3:
Sunday
Monday
Tuesday
Wednesday
Thursday
1 mile
½ mile
¼ mile
⅛ mile
Heart rate
Heart rate: record your heart rate at the end of your exercise session
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:
Sunday
Monday
Tuesday
Wednesday Thursday
Friday
Saturday
Friday
Saturday
20 minutes
15 minutes
10 minutes
5 minutes
Heart rate
Heart rate: record your heart rate at the end of your exercise session
Week 2:
Sunday
Monday
Tuesday
Wednesday Thursday
20 minutes
15 minutes
10 minutes
5 minutes
Heart rate
Heart rate: record your heart rate at the end of your exercise session
Week 3:
Sunday
Monday
Tuesday
Wednesday
Thursday Friday
20 minutes
15 minutes
10 minutes
5 minutes
Heart rate
Heart rate: record your heart rate at the end of your exercise session
Saturday
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:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
1 mile
½ mile
¼ mile
⅛ mile
●
●
●
●
Heart rate
Heart rate: record your heart rate at the end of your exercise session
Week 2:
Sunday
Monday
Tuesday
Wednesday
Thursday Friday
Saturday
1 mile
½ mile
●
¼ mile
●
●
●
⅛ mile
Heart rate
Heart rate: record your heart rate at the end of your exercise session
Week 3:
Sunday
1 mile
½ mile
Monday
●
Tuesday
Wednesday
Thursday
Friday
●
●
●
●
¼ mile
⅛ mile
Heart rate
Heart rate: record your heart rate at the end of your exercise session
Saturday
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:
Sunday
Monday
Tuesday
Wednesday Thursday
Friday
Saturday
20 minutes
15 minutes
10 minutes
5 minutes
●
●
●
●
Heart rate
Heart rate: record your heart rate at the end of your exercise session
Week 2:
Sunday
Monday
Tuesday
Wednesday Thursday
Friday
Saturday
20 minutes
15 minutes
●
10 minutes
●
●
●
5 minutes
Heart rate
Heart rate: record your heart rate at the end of your exercise session
Week 3:
Sunday
20 minutes
15 minutes
Monday
●
Tuesday
Wednesday Thursday
●
●
●
10 minutes
5 minutes
Heart rate
Heart rate: record your heart rate at the end of your exercise session
Friday
●
Saturday
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.
_______________________________________________________________
_______________________________________________________________
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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.