Exercise for Pain Management: Brain Aerobics?

Dr. Julia AlleyneUniversity of Toronto

Toronto Rehab University Health Network

julia.alleyne@utoronto.ca

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Disclosures

• No financial investment

• No conflicts of interest

Objectives

• To describe the current understanding of the brain’s role in pain perception and pain modulation

• To identify which exercise methods are effective for pain management control and the prescribing parameters for best outcomes

PAIN: Describe Pain in One Word

PAIN: Describe Pain in One Word

PAIN:

An unpleasant sensory and emotional experience associated

with actual or potential tissue damage

ORdescribed in terms of such

damage

What’s Missing ?

What’s Missing ?

• Function

• Disability

• Impact on role

• Impact on Self Perception

• Fears, Anxieties and Sleep disorders

Approach to the Patient with Chronic Pain

Anatomical Physiological Emotional

Applying Exercise Principles to Pain

How does Pain effect the body?

• Tight Muscles

• Hypersensitivity

• Inactivity

• Cognitive Fog

Does exercise work on Pain?

• Strength

• Flexibility

• Aerobics

• Balance

What are the types of chronic pain conditions ?

• Headache

• Osteoarthritis

• Fibromyalgia

• Low Back Pain

• Neuropathic Pain

• Post Surgical Prolonged Pain

• MSK related Oncology Pain

What is Pain ?

Past Theories of PainSpecificity of Pain

“The Intensity of Pain is directly related to the amount of tissue Injury” Rene Descartes, 1600

“The meaning associated with the injury was related to the experience of pain Henry Beecher, 1945

Peripheral• Bradykinen• Substance P• Prostanoids • Serotonin• Cytokines

Central • Prostanoids • EAA – NMDA • Substance P• NO / CCK• NGF / CGRP• 5HT / NK• GABA / CGRP

Nociceptors• A-delta • C • Silent - skin

– viscera – Joints– muscle

Dynorphin A

Pain Pathways and Chemical Modulation

Gate Control Theory

Melzak & Wall, 1960’s

Gate Control Theory

The spinal cord is processing Sensory signals of pressure, temperature and vibration.

• Heat/Cold

• Acupuncture

• Massage

• Neuro reception

Exercise ?

Gate Control

Factors that Open the Gate Factors that Close the Gate

Gate Control

Factors that Open the Gate

Feel – Stress and Tension

Think – Focus and Boredom

Do - Weak and Stiff

Factors that Close the Gate

Feel- Relaxation and Contentment

Think – Distraction and Learning

Do- Activity and Fitness

Heel Raises

The Brain in Pain• Production of Endorphins may inhibit pain

• Exercise, Stress, Excitement

• Cognitive & Emotional Factors a) Increase Pain

Focus, Analysis, Worry and Negative Fearsb) Decrease Pain

Positive Outlook, Purpose, Control, Tasks

The Brain in Pain

New Theories

- Neuro Chemical Receptors

- Neuro Sensitivity and Increased Reaction

- Neuro Processing Blocks

The Brain in Pain

Central Sensitization

Pain itself can change how pain works, resulting in more pain with less provocation

New Theories of Chronic Pain Education

1. Pain does not always reflect Pathology2. Normal Investigations don’t mean “it’s in

your Head”3. Physiology is the key to Function4. Pain Perception is based in genetics and

personality development.5. The Mind-Body Connection is Key.

Loesser’s Onion Theory

Assessing the Severity of Pain

• The patient report is valid!

• Verbal: 5 or 10 point scale

• VAS, Brief Pain Inventory

• Pain and activity diaries

Clinical Questions to detect Chronic Pain

• Psychosocial Risk Factors that predict risk or probability of Chronic Pain

• Predictive of Poor Outcome in Rehabilitation

• Indicate the need for early multi-disciplinary treatment including Cognitive BehaviouralCounselling

Assess the Impact on the Patient’s Life

• Activities of daily living

• Sleep

• ‘Downtime’ vs. ‘uptime’

• Relationships

• Coping strategies

• Collateral information

Risk Factors for Poor Prognosis

- Intensity of Initial Pain

- Nature of Collision

- Women more than Men

- Not Prior Personality Features

- Physical Deconditioning

- Hypervigilance of Body Awareness

Green Flags

• Involved in Fitness and sport

• Good Family Life

• Satisfied in Career

• Insight and Intelligence

• Low Anxiety Factor

• Response versus Resistance

Formative ConceptLocalized Pain Central Sensitization Pain

Acute < 3 months

Localized Symptoms

Therapeutic Exercise

Injury Specific Goals

Identifying Yellow flags for risk of developing Chronic Pain Syndrome

Chronic > 3 months

Generalized Symptoms

Multi- focus etiologyIneffective RehabDelayed Healing Factors

Yellow FlagsSleep DisturbanceMood Changes

Pain Spiral

Pain Centred Life

Withdrawal from social activities

StigmaSurgery

Injury

Tissue Damage Depression

Rest/Passive Surgery

Harm vs. Hurt Limits Activities

Weak, tight muscles

Deconditioning

Pain Spiral – Breaking Free

Function Centred Life

Pain Centred Life

Improved social Functioning

Improved Self Esteem

Improved Motivation

Improved Conditioning

Increased Activity

Adequate Analgesia + Education

Pain Centered Exercise Prescription

• Target Large Muscles with Functional Activities

Increase Strength

• Target Tight Postural with Frequent Micro-stretches

Increase Flexibility

• Sub-optimal threshold with goal of 12-15 minutes

Increase Aerobic Endurance

Case Study

Frau Jaeger is a 41 year old office worker who began to experience generalized aching and stiffness in her back, legs and shoulders over the last year. She does not recall a trigger event. She is irritable and frustrated and wants to be investigated and diagnosed.

History Probe

- Sleep patterns are disrupted- Difficulty falling asleep- Frequent waking during the night

- Pain is described as frequent aching which intensifies with prolonged positioning or fatigue

- Tingling experiences intermittently circumferentially in hands and legs

Patient Symptom Inventory

- Fatigue

- Generalized weakness, hard to climb a hill

- Lumbar pain with occasional associated neck pain

- Morning stiffness in her hips, shoulders and back x 10 min

- Mood Swings described as irritability with some sadness

F. I.T.T.

Is exercise or activity a usual part of your week ?

“I like to walk when I’m not sore but that isn’t very often”

When was the last time that you were able to walk ?

“ About 2 weeks ago, I walked with a friend for an hour and really hurt for the next week”

When you walked, did you have to stop and start ? Did you recall if you were sweating?

“ I usually stop every 5 minutes and sit down, I don’t think I sweat when I walk”

F. I.T.T.

“I like to walk when I’m not sore but that isn’t very often”

About 2 weeks ago, I walked with a friend for an hour and really hurt for the next week”

“ I usually stop every 5 minutes and sit down, I don’t think I sweat when I walk”

F – Sedentary to Occasional

I – Low

T – Walking

T – 5 minutes

Disruptive Sleep & ExercisePartial Truth : Exercise will help your Sleep

Full Truth:

Sleep disturbance is reduced by 27% in Active Healthy Adults• 12 Population based studies that report better sleep patterns with physically active

adults• 2 Studies indicate a lower risk of Sleep Apnea with regular physical activity

Sleep Disturbance and Depression• Strength Training Exercise reduces sleep disturbance symptoms by 30%• Strength training > General Exercise• High Intensity > Low Intensity

P.J. O’Connor et al, American Journal of Lifestyle Medicine4(5)Mental Health Benefits of Strength Training in Adults ,September 2010Volume, 4(Issue5)Page, p.377To-396

http://reso

Sleep Disturbance

R- Routine

E- Exercise

S- Stimulants

T- Turmoil

Medications

Shifting Time Zones

Frau Jaeger

Risk Factors for Chronic Pain

- History of Motor Vehicle Collision , 9 months ago- Treated with medication, no rehab.

- Sedentary Lifestyle

- Underweight

- Family History of Rheumatoid Arthritis

- Susceptible to Anxiety and Stress

Psychological Screen

- Anxiety related headaches and increased muscle soreness

- Feels stressed and overwhelmed- Cries more easily - No vegetative depression signs- Complains of poor memory and

concentration- Mental Status is normal

Muscle Tension Reduction

Physical– Posture– ADL– Tight Muscle Groups– Stretching Techniques– Injury Prevention– Rest– Ice

Psychological– Stressors– Anxiety– Pain Cycle– Sleep Quality– Deep Breathing

Stress Management

Personality Preferences

Priorities & Planning

Decision Making

Circle of Support

Assertiveness

Attitudes

Motivation

Exercise and AnxietySystematic Review:• Healthy Adults/ Chronic Pain/ Anxiety

Disorders

• Strengthening in sequence like Circuit Training

• Mind-body cognitive exercise with therapeutic effect

• More Research needed to define anxiety disorders with type of exercise

M. Herring et al, The Effects of Exercise Training on Anxiety November 2014Volume, 8; 388-403 American Journal of Lifestyle Medicine

Physical Exam

- Strength - Static- normal- Endurance- sit to stand or ¼ squat- Stability- single stand or heel raise

- Neurological- Normal dermatomes, myotomes, reflexes

- Special Tests- Pain Behaviours- Joint Specific

Physical Exam

- Observation:- Facial pain expression, slowness in movement

- Active R.O.M. - Full with painful stretch at the end of range

- Passive R.O.M. normal

- Positive Trigger points 11/14

Planning Priorities

Education

Correct the Sleep Disturbance

Reduce the Muscle Tension

Stress Management and Relaxation

Increase Daily Physical Activity/ Exercise

Targeted Strengthening

Increase Endurance

Education

Fears and Myths and Language

Physiology

Good Pain/ Bad Pain

Triggers and Reactions

Guidelines and Acronyms

Daily Physical Activity

Energy Conservation

Energy Spenditure

Choosing when to use automation

Good Day Activity

Bad Day Activity

Using rest wisely

Treatment Plan – Exercise and Chronic Pain

• Osteoarthritis – Moderate Strengthening of lower extremity is very effective and can be done as aerobic walking or resisted movements (8 RCT’s)

• Low Back Pain – Moderate strengthening yielded functional change and 40% reduced pain levels equal to aerobic training. (5 RCT’s)

• Fibromyalgia- Strength training demonstrated more benefit than flexibility. Aerobic benefit was equal to strength but patient compliance was low. (4RCT’s )

Targeted Strengthening

Address Large muscles first

Flexors tend to tighten

Extensors tend to weaken

Postural muscles are a priority

Trunk Stabilization

Assessment must be detailed to customize program

Consider Right, Left, Upper, Lower

Aerobic Exercise

• Retrain the Brain

• Increase chemical changes

• Overall coordination

• Neuromuscular Benefits

• Mindfulness Movement

• Mind-Body Movement

Urbanpoling.com

Endurance Guidelines

The One Minute Manager

Increase 10% every 3 sessions

Increase one parameter at a time– Repetitions, Length of Hold, Weight, Time

Reduce 25% for every week off

Off one month, restart at Baseline

Warm-up, cardio, strengthen, stretch, cool down

Exercise Prescription

General Dose ResponseFrequency Daily Activity

Every other Day ExerciseAccumulated Daily ActivityInterrupt Sedentary Activity

Goal: Every other DayIntensity Moderate “ I feel some challenge and I

get muscle fatigue with increased repetitions”

Type StrengtheningMind-BodyAerobics

Large MuscleFunction basedGraduated Progression (10%)

Time

Summary

1. Exercise is evidence-informed treatment for Acute and Chronic Pain conditions – targeting pain pathways, mood changes & sleep disorder

2. Combine with Education, Activities of Daily Living and Pain Medication

3. Start with Strengthening – Large muscles, Low Repetition, Long Holds

4. Add mind-body awareness movement – Function based, Posture based

5. Add Endurance/ Aerobics

Case 2: My Aching Bones

58 year old male with complaints of bilateral knee pain and left hip pain.

- morning stiffness lasting an hour

- reduced walking tolerance to 15 minutes painfree

- using acetominophen on a regular basis

- Wants to continue with jogging and tennis

Physical Exam

- Medial Joint line tenderness

- Mild effusions

- 5 degree flexion contractures

- Valgus mal-alignment

- Decreased proprioception

Osteoarthritis

American College of Rheumatology

Guidelines for Care:

1) Control Pain

2) Improve of Quality of Life

3) Avoidance of Drug Toxicity

Arthritis & Rheumatism, Vol 43, No. 9, Sept. 2000, pp 1905-1915

Non-Pharmacological Treatment of Knee Osteoarthritis

Patient Education

Self management Programs

Weight Loss

Exercise: ROM, Strength, Aerobics

Gait Assistance

Joint Protection

Assistive Devices

Hot water exercise therapy

Pharmacological TreatmentDecrease Pain = Increase Function

Oral:

- Acetominophen

- NSAID’s

- Topicals

- Tramacet

- Injectables