Chronic Pain and Exercise: Where to Begin?

Many people in pain want to become active but don’t know where to begin. This is a brief introduction on exercise for those with chronic pain. Before we discuss the specifics of exercise for pain, I want to take the time to explain pain. Pain is a very complex topic and it is not realistic to think that this article can explain pain in a detailed manner.

We have to start thinking of pain as the body’s way of protecting itself and is not simply an indication of tissue damage. This is made clear in the definition of pain as described by the International Association for the Study of Pain:

Pain is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”

The purpose of this post is to discuss chronic pain and exercise. Chronic pain is defined as pain lasting more than 12 weeks. In many cases, the original injury has healed that led to the initial pain output from the brain. However, the brain is still outputting pain as a way to protect and warn us.

I urge you to watch these short videos on YouTube describing chronic pain:

1. ‘Understanding Pain: What to do about it in less than 5 minutes’:

https://www.youtube.com/watch?v=RWMKucuejIs

2. ‘Lorimer Moseley: Why Things Hurt’: https://www.youtube.com/watch?v=gwd-wLdIHjs

Professor Patrick Wall described three stages that take place when you are injured in his excellent book ‘Pain: The Science of Suffering’. The 3 stages are withdrawal, protection and resolution.

Withdrawal is what your nervous system will do in order to remove your injured body part from the initial source of injury. Think of the time you burnt your hand on the stove and you instinctively removed it without having to think. This is your nervous system working for you in order to reduce further tissue damage.

Following the initial withdrawal phase your body will protect. Protection is your nervous system’s way to try to ensure no further painful stress and possible damage occurs. When your hand got burned, you grabbed and held it. You may have even rubbed it and blew on it. That’s your nervous system working to protect your hand from further damage. It is all done instinctively and you don’t have to think about it.

This is an important stage for healing. However, in some cases your body continues to protect the injured area long after the tissue has healed. It would be like holding the hand that was burnt close to your body and rubbing it for months after the skin has healed. This can happen and we see it with injuries to the lumbar spine. People will protect and guard the motions of their spine long after the initial strain. They’ll avoid bending and turning at the waist just like the first day they hurt themselves even though the back has healed.

Resolution is your nervous systems way to restore normal mobility and function to the injured part. People with pain that persists long after the initial injury are stuck in the protective phase. They may feel ongoing stiffness, coldness and spasms. They will also struggle with coordinating their movements. Exercise and movement may help move out of the protective phase and into the resolution phase.

During or after exercise you may feel you might feel warmth and reduced stiffness of the painful area. This is due to the body releasing pain relieving endorphins and creating blood flow into the painful area. These endorphins and blood flow can help reduce sensitivity of the area and muscle stiffness. A physiotherapist can help you create an exercise program that works for you in order to move from the protective into the resolution phase.

Many patients I see in my practice have chronic pain. My role is to provide education about their pain as well as prescribe exercise. My role is to assist your nervous system to move from the protective phase into a resolution phase. Naturally, people are hesitant about exercising while in pain. There is a misconception that movement and exercise is harmful and could make the problem worse. However, a physiotherapist is an expert in movement and will know what would be a safe starting point for exercise. It is important to understand the concept of ‘hurt vs. harm’. When you begin an exercise program we would expect there to be some discomfort and pain. However, keep in mind these movements are safe and are not harmful to your body.

Pacing is important when returning to exercise. If you have been fearful to walk for many months we wouldn’t expect you to go for a one hour walk if the longest you have walked has been 10 minutes. This is where setting a schedule and pacing yourself is helpful. I have some clients that begin with 5 minutes of walking per day. Each week they may increase their walking time by 1-2 minutes. This might not seem like much, but it is helpful to gradually increase your distance in order to prevent pain that may last for days after exercise. This gradual reintroduction to exercise can lead to blood flow to sensitive nerves and ongoing tension on the nerves.

When beginning an exercise program it’s important to avoid the “no pain, no gain” approach. Your nervous system is already sensitive and protecting. If you push past your pain threshold you can further irritate the already sensitive nervous system defeating the purpose of exercise which is pain relief. If you cause yourself pain and feel worse for days after exercise you run the risk of feeling defeated and giving up.

The second mantra to avoid is “if it hurts, don’t do it”. This is common since many think that they’re damaging their body when they feel pain. This approach could lead to fear of movement and further atrophy of the body. You won’t reduce your nerve sensitivity and achieve resolution if you never push your body to some extent and reproduce some pain. The key is that the amount of pain you experience should be acceptable to you and not leave you sore for days after you exercise.

Finally, you should follow the “tease it, touch it, nudge it” mantra. Here you are expected to exercise to the point of slight discomfort but not push through the pain and ignore it. As you challenge your body and move slightly further than you’re used to you will notice a reduction in pain. You’ll also see a gradual increase in the number of sets and reps you can perform as well a distance you can walk. This will gradually lead to improvements in your function which should always be your focus rather than decreasing pain.

There are several forms of exercise you can perform that can lead to reduced pain and improved function. I am going to focus on aerobic exercise and strength training.

Movement is considered to be the greatest pain-killer that exists. Long distance running has been shown to be a proven form of analgesia.  Of course, we wouldn’t expect you to start with running for miles as a form of exercise. The point is that exercise is a proven pain reliever. In fact, think of your brain as having a drug cabinet full of pain relieving hormones. Exercise unlocks this drug cabinet and releases these hormones into your bloodstream.

It has been shown that short bouts of exercise can lead to pain relief. Aerobic exercise at a level of 50% VO2 max and for a duration of 10 minutes is required to elicit exercise analgesia (Hoffman et al 2004). In order to achieve 50% VO2 max you should aim to exercise and raise your heart rate to 100-110 beats per minute. This is a level that can lead to exercise analgesia. You could start with 5 minutes and each week add 1-2 minutes or more as you improve. Before long, you’ll be walking for 30 minutes.

Strength training has also been shown to reduce pain. Evidence suggests that lighter weight and higher reps should be used with patients with chronic pain (Brosseau et al 2008). There’s no need to start with a heavy weight that you can only lift 6-8 reps. Instead, find a light weight that you can lift 15-20 times for 2-3 sets. You may only be able to perform 1 set of 15-20 reps which is also fine. Remember, the goal is to gradually increase activity over time. There is no quick fix to chronic pain. Don’t focus on the pain as you exercise. It’s more important that you track the weight, sets and reps that you’re performing. 

Hopefully this is helpful information and motivates you to start to exercise as a way to mange your pain.  Contact one of our 4 physiotherpists at Advantage Physiotherapy Fredericton, New Brunswick to help design an exercise program that’s right for you.

Written by: Rob Willcott Physiotherapist

Advantage Physiotherapy 102 Main St. #15 Fredericton NB

http://www.advantage-physio.ca

twitter: @advantagephysio

References:

Brosseau L, Wells GA, Tugwell P, Egan M, Wilson KG, Dubouloz CJ, Casimiro L, Robinson VA, McGowan J, Busch A, Poitras S, Moldofsky H, Harth M, Finestone HM, Nielson W, Haines-Wangda A, Russell-Doreleyers M, Lambert K, Marshall AD, Veilleux L (2008). Ottawa Panel evidence-based clinical practice guidelines for strengthening exerices in the management of fibromyalgia: part 2. Phys Ther. Jul;88(7):873-86.

Hoffman MD, Shepanski MA, Ruble SB, Valic Z, Buckwalter JB, Clifford PS (2004). Intensity and duration threshold for aerobic exercise-induced analgesia to pressure pain. Arch Phys Med Rehabil. Jul;85(7):1183-7.

Wall, P. Pain: The Science of Suffering.May 7th 2002 by Columbia University Press.

 

 

 

 

Searching for the Science of Manual Therapy

Written By: Rob Willcott Physiotherapist

“We don’t treat anatomy – we treat physiology.” – David Butler

When I first read this quote by David Butler I wasn’t exactly sure what it meant.  However, through my own research and experience I gained a greater appreciation for this quote.  At one time I used manual therapy (MT) based on a biomechanical model.  I would try and feel facets and other joints glide. I believed that I could locate the problematic joint thought to be the source/cause of pain. After many years of trying to convince myself that I could feel these subtle motions I came to the conclusion that you can’t.  Thankfully, the literature supported my conclusion.

First of all, the use of motion palpation to determine positional faults has poor reliability (Troyanovich et al., 1998; Seffinger et al., 2004).  Of course, I’m sometimes told that I haven’t taken enough courses or treated enough patients to feel these subtle movements.  But that’s not a valid argument either. Whitman et al. (2004) examined the influence of experience and specialty certification on outcomes for patients with low back pain receiving a standardized manipulation or stabilization exercise intervention program. They found that increased experience and specialty certification status did not result in an improvement in patients’ disability.

It’s also been shown that our MT techniques are not going to have any lasting positional change on tissue (Tullberg et al., 1998; Hseih et al., 1995).  The MT techniques we perform are for short term and lack the necessary magnitude to provide plastic changes on the targeted tissue (Threlkeld, 1992).

Finally, joint biased technique forces are dissipated over a large area (Herzog et al., 2001; Ross et al., 2004) and are not specific to one level as we like to fool ourselves into thinking.  Manipulations of the cervical spine influence the thoracic spine and vice versa.

Despite this wealth or research, I still had to ask myself why MT seems to help people in pain.  If I’m not being specific to a piece of joint or tissue why do people report a reduction in pain?  “We don’t treat anatomy – we treat physiology” kept ringing in my head.  As it turns out, MT does have an effect after all and it’s based on a neurophysiological model.  The neurophysiological model includes peripheral, spinal and/or supraspinal mechanisms (Bialosky et al., 2009).

When dealing with an injury the inflammatory response will result in the release of histamine, cytokine and prostaglandin.  These chemicals can irritate nerve endings resulting in increased nociceptive input to the dorsal horn of the spinal cord and increased temporal summation.  MT can lead to a significant reduction of blood and serum level cytokines (Teodorczyk-Injeyan et al., 2006) Also, soft tissue biased techniques have been shown to alter substance P levels in individuals with Fibromyalgia (Field et al., 2002).  This indicates that MT could be having an effect on these chemicals at the peripheral level potentially reducing nociceptive input to the spinal cord.

MT also leads to afferent input to the dorsal horn of the spinal cord. The concept of the dorsal horn as a first site to control the modality and intensity of sensory signals conveyed to higher CNS centers dates back to Wall and Melzack’s gate control theory of pain (Melzack and Wall, 1965). Nociception from high-threshold neurons synapse in the dorsal horn and can lead to increased temporal summation.  This increased temporal summation could overwhelm the normal brain response and lead to an experience of pain.  We can reduce or block this temporal summation via low-threshold neurons (i.e., non-nociceptive neurons) resulting in spatial summation at the dorsal horn.   By stimulating these low threshold neurons we activate glycenergic inhibitory interneurons which will spatially summate at the first synapse and prevent or at least reduce nociceptive traffic into the CNS (Foster et al., 2015).

When discussing supraspinal mechanisms and pain there is scientific evidence that structures such as the anterior cingular cortex (ACC), amygdala, periaqueductal gray (PAG), and rostral ventromedial medulla (RVM) are involved.  We can indirectly influence these structures by stimulating low threshold sensory neurons during MT.  These supraspinal structures can cause descending inhibition at the spinal cord level.  Schmid et al. (2008) conducted a systematic review of the literature in relation to the effects of MT. They concluded that MT can assist the regulation of the top/down, bottom/up pain regulatory pathways by facilitating the inhibitory pain modulating pathways. They also advised not to increase pain significantly with MT as it can lead to promotion of inhibition of inhibitory pain modulating pathways via the above-mentioned mechanisms.

A neurophysiogical explanation of MT is scientifically plausible and should be used to explain the mechanisms of MT.  This means shifting our thinking away from a strictly biomechanical model to explain the effectiveness of MT.  Next time you use MT think of spatial summation and descending inhibition rather than the direction of your joint glides. After all, we don’t treat anatomy- we treat physiology.

 

Rob Willcott Physiotherapist

Advantage Physiotherapy

102 Main St. #15 Fredericton, NB

http://www.advantage-physio.ca

Twitter: @advantagephysio

 

References:

Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Man Ther. 2009 Oct;14(5):531-8.

Field T, Diego M, Cullen C, Hernandez-Reif M, Sunshine W, Douglas S. Fibromyalgia pain and substance P decrease and sleep improves after massage therapy. J.Clin.Rheumatol. 2002;8:72–76.

Foster, E., et al. (2015). Targeted Ablation, Silencing, and Activation Establish Glycinergic Dorsal Horn Neurons as Key Components of a Spinal Gate for Pain and Itch. Neuron, 85: 1289-1304

Herzog W, Kats M, Symons B. The effective forces transmitted by high-speed, low-amplitude thoracic manipulation. Spine. 2001;26:2105–2110.

Hsieh JC, Belfrage M, Stone-Elander S, Hansson P, Ingvar M. Central representation of chronic ongoing neuropathic pain studied by positron emission tomography. Pain. 1995;63:225–236.

Melzack, R., and Wall, P.D. (1965). Pain mechanisms: a new theory. Science 150, 971–979.

Ross JK, Bereznick DE, McGill SM. Determining cavitation location during lumbar and thoracic spinal manipulation: is spinal manipulation accurate and specific? Spine. 2004;29:1452–1457.

Schmid A, Brunner F, Wright A, Bachmann LM. Paradigm shift in manual therapy? Evidence for a central nervous system component in the response to passive cervical joint mobilization. Man Ther. 2008 Oct;13(5):387-96.

Seffinger MA, Najm WI, Mishra SI, Adams A, Dickerson VM, Murphy LS, Reinsch S. Reliability of spinal palpation for diagnosis of back and neck pain: a systematic review of the literature. Spine.2004;29:E413–E425.

Teodorczyk-Injeyan JA, Injeyan HS, Ruegg R. Spinal manipulative therapy reduces inflammatory cytokines but not substance P production in normal subjects. J.Manipulative Physiol Ther.2006;29:14–21.

Threlkeld AJ. The effects of manual therapy on connective tissue. Phys Ther. 1992 Dec; 72(12): 893-902.

Troyanovich SJ, Harrison DD, Harrison DE. Motion palpation: it’s time to accept the evidence.J.Manipulative Physiol Ther. 1998;21:568–571.

Tullberg T, Blomberg S, Branth B, Johnsson R. Manipulation does not alter the position of the sacroiliac joint. A roentgen stereophotogrammetric analysis. Spine. 1998;23:1124–1128.

Whitman JM, Fritz JM, Childs JD., The influence of experience and specialty certifications on clinical outcomes for patients with low back pain treated within a standardized physical therapy management program., J Orthop Sports Phys Ther. 2004 Nov;34 (11):662-72; discussion 672-5.

 

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4-Week Physiotherapy Program for People with Pain due to Knee Osteoarthritis

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Osteoarthritis of the Knee?  Advantage Physiotherapy is offering a 4-week program for people with knee osteoarthritis. Our program is based on the latest research supporting physiotherapy for knee osteoarthritis.

Arthritis is one of Canada’s most common chronic conditions and is a leading cause of pain, physical disability and use of health care services (Arthritis in Canada Report).  Osteoarthritis (OA) is the most common type of arthritis, affecting an estimated 10% of Canadian adults.  Osteoarthritis results from the deterioration of the cartilage in one or more joints.    This deterioration leads to joint damage, pain, and stiffness.  Unfortunately, there is no cure for OA. Treatments exist to decrease pain and improve mobility, and include medication (e.g. analgesics, anti-inflammatory drugs), exercise, physiotherapy and weight loss.   In severe cases, the entire joint – particularly the hip or knee – may be replaced through surgery.   Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat osteoarthritis.  Unfortunately, these medications can be harmful to your stomach and you should talk to your doctor for more information.

Fortunately, a Physiotherapist can help.  Physiotherapists are university trained health professionals that treat a variety of musculoskeletal injuries/conditions.  Physiotherapists have an advanced understanding of how the body moves, what keeps it from moving well and how to restore mobility.  Physiotherapist’s treat osteoarthritis of the knee through a variety of methods including specific exercises to strengthen the knee and leg, mobilizations of the knee and surrounding joints and therapeutic modalities.

There has been recent scientific evidence to support the use of physiotherapy for people with osteoarthritis of the knee.  The study consisted of 83 men and women with knee pain and osteoarthritis that were randomly allocated into two groups.  Patients in group 1 received manual therapy/mobilizations of the knee and specific exercises all provided by a Physiotherapist.  Group 2 received placebo ultrasound of the knee.  All patients in each group attended 2 times per week for a total of 4 weeks.

After 1 month, 2 months and 1 year, the physiotherapy group had significant improvements in their knee pain and walking tolerance as compared to the placebo group.  Also, 20 % of the patients in the placebo group had to undergo a total knee replacement (8 of them) as compared to 5 % of the patients in the physiotherapy group (2 of them).

Therefore, only 4 weeks of manual Physiotherapy and a supervised exercise program by a Physiotherapist may delay or prevent the need for a knee replacement.

At Advantage Physiotherapy we offer a 4 week program for patients with knee osteoarthritis.  On the first visit we will perform a 1 hour assessment consisting of questionnaires, examination of your knee and a few measures of function to set a baseline and determine the appropriate treatment program for you.  Over the next 4 weeks you will attend twice per week.  Each visit will consist of an exercise program in our gym, manual therapy treatment and pain relieving modalities if required.  We will then review your home exercise program and make modifications/progressions as needed.  At the end of the four-week program we will provide you with an exercise program tailored for you that you will continue on your own to maintain strength, range of motion and function.  You can stop in at any time in the future for modification or advice on your exercises.

Study Reference:

Deyle, GD et al.  Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee.  A randomized, controlled trial.  Annals of Internal Medicine.  2000; Feb 132(3): 173-81

Understanding Pain: What to do about it in less than five minutes?

Pain is a very complex issue that affects billions of people. As a physiotherapist, I spend a large part of my day explaining pain with patients. It is crucial that patients have an understanding of pain. This understanding of pain forms the foundation of their rehab process. We no longer accept the tissue damage equals pain philosophy of Descartes. The accepted theoretical framework used to explain pain is the Neuromatrix Theory from Melzack (a fellow Canuck eh!).

It can be very difficult to explain pain in a way that eveyone can understand and apply to their own experience. However, I came across this excellent video and I often recommend patients view it. I think the authors of the video have done an excellent job explaining pain in a short and simple video.

Enjoy!

What to expect on your first visit to Advantage Physiotherapy

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The assessment is performed on your first visit by one of our Physiotherapists.  One hour is booked for the initial assessment.  This is to allow adequate time to from a diagnosis and understand the best approach to treat your pain and injury.

It is important to come in a few minutes early to fill out some paperwork.  This will also include questionnaires pertaining to the area of your body that you are being seen for.  This questionnaire is a measure of your injury and can be used to measure your progress.

The next step is to take a history of your pain and injury.  This is to help the Physiotherapist make a diagnosis.  There are also special questions that are part of the history to help rule out serious health problems such as infection and other serious problems that may be better dealt with by your family physician.

After the history is taken, the physical exam is performed.  This takes up the bulk of the one hour assessment.  The Physiotherapist will then watch your ability to move the injured area to gain an appreciation of your amount of movement.  Strength testing of the muscles in the area is also performed.

Next, special tests are performed that help to identify a specific structure that may be injured.  Often times the Physiotherapist performs a combination of tests to help make an accurate diagnosis.

Once a diagnosis has been made, the Physiotherapist will explain in detail your injury and cause of your pain.  This is performed with the help of anatomoy models and diagrams.  You will be encouraged to ask as many questions you like.  It is your body and it is very important that you have a good understanding of your diagnosis.  The more you understand the better chance you will appreciate the importance of Physiotherapy and the exercises you may be asked to perform.

Finally, a treatment is performed on the first day.  It is not uncommon to be sore after the assessment due to moving the injured area.  Don’t be alarmed! This is normal and will improve.  The treatment you receive on the first day can reduce this discomfort.  You will also be provided with some educational material about your injury/condition as well as home exercises and self treatments you can perform.

 

Vestibular Rehabilitation

vestibular

Vestibular Rehabilitation is a specific form of treatment for patients suffering from vertigo and dizziness.  The most common cause of vertigo is known as Benign Paroxysmal Positional Vertigo or BPPV.  BPPV accounts for 20-30% of all patients seen for vertigo (1).  It occurs in adults of all ages, although it is more common among older individuals.

Patients with BPPV complain of vertigo and possibly nausea when bending forward, looking up, rolling over in bed and lying down.  Once the symptoms of vertigo have stopped some patients report balance problems that may last for hours or days after the initial episode of vertigo.

BPPV is a biomechanical problem in which one or more of the semicircular canals of the inner ear is inappropriatley excited by loose pieces of calcium carbonate crytsals.  BPPV begins for no known reason in the majority of patients but it may also follow head trauma or an inner ear infection.

BPPV is frequently a self-limiting disorder and will commonly resolve spontaneously.  Since it is a biomechanical problem, antivertiginous drugs are often not helpful since these drugs cannot reposition loose crytals.  However, after remission, recurrences can occur (estimated at approximately 40% of patients) and the condition may trouble patients for years.  One study followed 50 patients with BPPV for a mean of 32 months and noted that the recurrence rate by 1 and 3 years was 18% and 30% respectively (2).

Physiotherapists treat a BPPV by using cannalith repositioning treatment (CRT).  This involves moving the head of the patient in a very specific direction in a sequence aimed to reposition the loose crystals.  The most commonly used technique is known as Epley maneuvre.  This technique is highly effective.  In one study the efficacy of CRT was reported as a remission rate of 88.2% with one treatment (3).  In another study the effectivenes of CRT in a group of patients with chronic BPPV was assessed compared to an untreated control group.  In this study, Wolf et al (1999) (4) found 93.5% of the patients treated with CRT responded positively versus 50% of the control group.

Physiotherapist Rob Willcott BSc Kin, BSc PT, CEP, MCPA is trained in Vestibular Rehabilitation and the CRT techniques described above.  If interested in being treated please contact the clinic for an appointment.  We ask that you have someone come with you for treatment since you may be dizzy following treatment and require a drive home.  This is normal initially and will improve after a couple of treatments.  When you are experiencing vertigo is the best time to be treated.  This is the moment when the crytals are loose and can be repositioned for good.

Once your vertigo has been resolved you will be provided with home exercises to continue on your own.  Often times there are deficits in balance if you have had this issue for a long time.  We will design a specific exercise program for you to improve your vestibular system.

References:

1.  Bloom J. Katsarkas A. Paroxysmal positional vertigo in the elderly. J Otolaryngol. 1989; 18: 96-98.

2.  Swartz R et al. Treatment of vertigo. Am. Fam. Phys. 2005, Mar. 71(6).

3.  Tusa RJ, Herdman SJ. Assessment and treatment of anterior canal benign paroxysmal positional vertigo using the canalith repositioning maneuvre. Am Acad Neurolgy Abstr Neurology. 1997; 48: A384.

4.  Wolf M, Hertanu T, Novikov J, Kronengerg J. Epley’s maneuvre for benign paroxysmal positional vertigo: A prospective study. Clin Otolaryngol. 1999; 24: 43-46.