When a person who has had persisting pain for a period of time commences any form of exercise as part of a rehabilitation program, it is likely that they will experience periods of increased pain or acute flare ups. This is because they are likely to have some level of central sensitisation that will tend to lower their threshold for pain signals to be sent to, and interpreted by the brain as a pain experience. Additionally their descending modulatory systems (such as the GABA, serotonin and a-adrenergic systems), that would normally suppress information of a less threatening nature are likely to be severely inhibited, therefore allowing the brain to be bombarded with pain signals that ordinarily wouldn’t make it through. However, even when a healthy person starts a movement program that they haven’t previously done, they are likely to experience some level of discomfort or even temporary pain as their body adjusts to the new movement and loading patterns being asked of it.
When starting someone on a movement program who has chronic pain, it is important to explain this concept to them. In the process of educating them and forewarning them of the possibility of increased pain in the initial phases, we are helping to set their expectations and therefore reduce their levels of distress in the event that they do have a flare up. It helps to normalise the situation and “normal” reduces fear.
Movement is an essential part of any program help people with chronic pain move to a better functional state. Combined with other active modalities such as stretching, modulation of activities, thought management (such as cognitive behavioural therapy) and returning to work, we are likely to see much better outcomes than those we would expect when patients continue with passive modalities such as manual therapy or medication 1.
Here are a few steps to help set up expectations for a movement program:
- Start with solid pain education including pathophysiological changes that occur in peripheral nerve tissues, the spinal cord and brain in persisting pain states. This helps to underpin your management which is going to involve normal movement to hopefully reverse some of these changes. It helps with the uptake of the exercise and other components.
- Include in your education the concept of flare ups and expectations that they might occur
- Further diffuse the fear associated with the potential for flare ups by arming the patient with a series of pain breaks. These are techniques and tools that they can use to temporarily reduce pain levels. Pain breaks may reduce pain scores enough to make the person feel more positive, move better and reduce some of the accompanying muscular tension that tends to go hand in hand with higher levels of pain. In some cases the pain break allows the nervous system to take a moment of rest and can break or reduce the pain cycle. Pain breaks might include:
- Very hot shower over the affected area for a period of time (make sure to warn the person not to burn themselves)
- TENs machine for 20-30 minutes
- Series of exercises or stretches
- Medication that has been prescribed for breakthrough pain
- Cognitive Behavioural Therapy worksheets
- Mindfulness meditation
- Manual therapy
As some of the above pain breaks could be considered passive interventions, it is important that you explain the context that they will be used in – that is that they are short term interventions used to break the pain cycle – not something that is aiming to be curative or used in the long term. They help to improve function in the short term so that progress can continue through to the longer term.
- Lynn Snow-Turek, Margaret Norris & Gabriel Tan, “Active and passive coping strategies in chronic pain patients” Pain, 64 (1996): 455-462.