Pain is a near-universal human experience. In some cases, it provides a valuable learning experience, without lasting effect, regarding what actions to avoid or adapt in order to prevent pain from re-occurring. In other cases, pain can significantly interfere with the ability to function in daily life on many levels. Pain can be short-term (acute) or long-term (chronic) in duration.
There are two basic types of pain. Nociceptive pain results from direct mechanical, thermal, or chemical trauma and if mechanical in nature, may manifest itself as musculoskeletal pain. Neuropathic pain results from damage to the peripheral or central nervous system tissue or from abnormal processing of pain in the central nervous system (Wilkie, Brown, Corless, Farber, Judge, Shannon, et al, 2001).
Pain is more than a simple annoyance; it can lead to serious physical and psychological consequences across almost every bodily system. Further, if acute pain continues without adequate relief, it can become neuropathic pain, in which the normal pain pathways become altered, making it much more difficult to treat (Wilkie et al, 2001).
It is widely hypothesized that people with disabilities experience more pain with greater severity than the non-disabled population; however, data supporting this hypothesis have not yet been systematically examined or summarized (Chetwynd, Botting, & Hogan, 1993; Ehde, Jensen, Engel, Turner, Hoffman, & Cardenas, 2003).
Pain is also a multidimensional experience, with each dimension influenced by an individual’s culture and upbringing. The four dimensions of pain are affective (emotional responses to pain), behavioral (actions taken when pain occurs), cognitive (attitudes and beliefs about pain), and physiological-sensory (the body’s internal response to pain) (Wilkie et al, 2001).
Emphasis is often placed on the physiological-sensory dimension with pharmacology (medications) being the first line of defense. While medications can provide pain relief, especially for musculoskeletal pain, it is often introduced when pain has already reached a high enough intensity to seek treatment (Hicks, Martin, Ditor, Latimer, Craven, Bugaresti, McCartney, 2003). It stands to reason that preventing pain, or at least managing it when the intensity is still modest, might be a more beneficial approach. Surgery can be an option to relieve pain in some disabilities, but is generally used after other, less-invasive options have been exhausted (Mailis & Furlan, 2003; Siddle, 2004).
Some people take herbal medications to help relieve pain, based on the assumption that herbal medicines are natural and therefore safe. The truth is that many herbal medications have been associated with numerous adverse effects. This is not surprising considering that medicinal herbs contain pharmacologically active ingredients. Herbal medications are largely unregulated in most countries, which can result in serious safety and quality issues. In addition, herbal medicines taken in conjunction with other medications may cause unexpected herb-drug interactions. A few herbal medications mentioned later in this report seem to hold promise based on initial randomized controlled studies. Further replication and study is needed. As a precaution, it is important to consult with your physician before starting any new treatment, herbal or otherwise (Weiner & Ernst, 2004).
To manage pain most effectively, all four dimensions of pain must be addressed. Each dimension can have a dramatic impact on how pain is experienced. As a result, a multi-modal, multi-disciplinary approach is required. Treatments may need to be introduced initially on a trial-and-error basis. Since pain can be caused by a number of different mechanisms, it may require some experimentation until a treatment or combination of treatments is found to be most effective for each individual (Ambrose, Lyden, & Clauw, 2003; Ehde et al, 2003; Flor, 2002; Jones, Clark, & Bennett, 2002; Middleton, 2003; Nielson & Jensen, 2004; Nyland, Quigley, Huang, Lloyd, Harrow, & Nelson, 2000; Siddle, 2004; Sprott, 2003; Thorsteinsson, 1997; Widerström-Noga, Felipe-Cuervo, & Yezuersji, 2001).
In addition to medications, there are effective non-pharmacological strategies to reduce pain. Education of both the person experiencing pain and their caregivers has been cited in numerous studies as a way to reduce pain by increasing understanding, identifying positive coping strategies, and improving attitudes and self-efficacy (Agre, Rodriquez, & Tafel, 1991; Ambrose et al, 2003; Cedraschi, Desmeules, Rapiti, Baumgartner, Cohen, Finckh, Allaz, Vischer, 2004; Curtis, Tyner, Zachary, Lentell, Brink, Didyk, Gean, Hall, Hooper, Klos, Lesina, Pacillas, 1999; Gilbert-MacLeod, Craig, Rocha, & Mathias, 2000; Häkkinen, 2004; Häkkinen, Sokka, & Hannonen, 2004; Hammond & Freeman, 2004; Iversen, Eaton, & Daltroy, 2004; Kavuncu & Evcik, 2004; Mannerkorpi, Ahlmen, & Ekdahl, 2002; Nyland et al, 2000; Olanow, Watts, & Koller, 2001; Richards & Scott, 2002; Sprott, 2003; Thorsteinsson, 1997; Weigl, Angst, Stucki, Lehmann, & Aeschlimann, 2004; Young, 1989). Education initiatives among people with disabilities have been associated with considerably lower disability scores and decreased pain scores, in many cases to the same degree as a non-steroidal anti-inflammatory drug (NSAID) (Moskowitz, Kelly, Lewallen, & Vangsness, 2004). Education about the condition itself and the variety of treatment options available allows the individual to be an active partner in decision-making that can improve self-efficacy (Häkkinen et al, 2004; Jones & Clark, 2002). Fitness professionals need to become educated about the impact of exercise on people with various disabilities in order to avoid harm and increase function without increasing pain (Houlihan, O’Donnell, Conway, & Stevenson, 2004).
Social support has also been identified as a common factor across disabilities to help reduce pain. An individual’s support system includes friends, family members, and caregivers, including professionals (Ambrose et al, 2003; Häkkinen, 2004; Häkkinen et al, 2004; Moskowitz et al, 2004; Olanow et al, 2001; Sharma, Cahue, Song, Hayes, Pai, & Dunlop, 2003; Strumse, Stanghelle, Utne, Utne, & Svendsby, 2003). Being around people who have a positive attitude, offer support, and are optimistic can reduce the amount of pain medication needed by an individual (Sprott, 2003).
Exercise is another potential non-pharmacological approach to pain management. In a few cases, certain types of exercise may increase pain. It is important to know which activities increase pain in people with a given disability so the activities can be avoided or modified in order to keep a person physically active so he or she can garner the benefits of exercise. In other cases, exercise may not reduce pain, but can be done without increasing pain. This provides assurance to people whose fear of pain prevents them from trying exercise at all. In yet other cases, especially for musculoskeletal pain, exercise can alleviate pain and be a primary factor in increasing function (Ditor, Latimer, Ginis, Arbour, McCartney, & Hicks, 2003; Grainger, & Cicuttini, 2004; Hicks et al, 2003; Kettunen & Kujala, 2004).
Exercise compliance is a key factor in long-term pain management in people with disabilities. As compliance declines, pain may increase (Ambrose et al, 2003; Cedraschi et al, 2004; Ditor et al, 2003; Gowans, & deHueck, 2004; Hicks et al, 2003; Mior, 2001; Redondo, Justo, Moraleda, Velayos, Puche, Zubero, Hernandez, Ortells, Pareja, 2004; Richards & Scott, 2002). Compliance may be increased in people with disabilities through the following tactics:
- Set flexible goals that can change as pain or disease state changes (Ambrose et al, 2003; Fransen, 2004).
- Cultivate positive coping skills in clients with disabilities (Ambrose et al, 2003; Richards & Scott, 2002).
- Utilize pacing (breaking down tasks into shorter manageable segments rather than one longer one) (Agre et al, 1991; Ambrose et al, 2003; Perry, Barnes, & Gronley, 1988; Spector, Gordon, Feuerstein, Sivakumar, Hurley, & Dalal, 1996).
- Provide encouragement and support (Ambrose et al, 2003)
- Maximize self-efficacy by involving client in decisions about the exercise program, linking exercise with specific benefits and providing specific instruction on how to perform or adapt recommended exercises (Häkkinen et al, 2004; Iversen et al, 2004; Jones & Clark, 2002).
- Provide close supervision to home-based exercise recommendations or supplement home-based exercise with group classes (Fransen, 2004; Kettunen & Kujala, 2004; McCarthy, Mills, Pullen, Roberts, Silman, & Oldham, 2004; Weigl et al, 2004).
If exercise is to be a strong component of community care for people with disabilities, it is necessary to have access to community-based exercise programs that are sensitive to their needs. Lack of individualization is one reason why many people with disabilities are unsuccessful in attending exercise classes at local health clubs (Jones & Clark, 2002). Specific training for community instructors regarding exercise intensity and progression may be needed. One study demonstrated that personal trainers with no previous experience with people with fibromyalgia were successful in adapting their exercise programs after a brief period of education and training (Gowans & deHueck, 2004; Richards & Scott, 2002).
Exercise benefits are abundant for all people, with and without disabilities, but not all relate to pain management or reduction. The exercise recommendations contained in this report are limited to their impact on pain management and should not be taken as a holistic recommendation. Increasing aerobic capacity, strength, mobility, and ability to perform activities of daily living are important benefits not highlighted in this review. Further, this is not a comprehensive review and represents one semester of study. New data becomes available every day and there are studies that may not have been identified that could provide additional information.
Spinal Cord Injury (SCI)
Neuropathic Pain
| Description | – Neuropathic pain (also called central pain) is most common and most difficult to treat. Can cause referred pain in other area of body such as shoulder, neck and trapezius muscles in tetraplegia (18,93). – Allodynia (pain with typically non-painful stimulus) is a common type of neuropathic pain (18). |
| Location of Pain | Below level of lesion, can be back, buttocks/hips, legs/feet, and/or upper extremities (18). |
| Aggravating Factors | N/A |
| Alleviating Factors and Treatment Options | Pharmacotherapy (medications), physical therapy, acupuncture, and aromatherapy have not been rated as very helpful (18). |
| Specific Exercise Guidelines to Manage Pain | Little has been studied or noted in regard to exercise and neuropathic pain. One small study showed no neuropathic pain relief with a bicycle ergometry exercise regimen in 4 people with SCI (80). |
Musculoskeletal Pain
| Description | Musculoskeletal pain (usually associated with wheelchair use) (18). |
| Location of Pain | – At or above level of lesion, can be back, buttocks/hips, legs/feet, and/or upper extremities (18,66). – Wheelchair use (transfers, propulsion, pressure relief) most commonly associated with shoulder, neck, elbow, wrist, and hand pain (6,11,18,25,50,66,98). |
| Aggravating Factors | – Wheelchair use (6,18,50,66). – Longer time with SCI (18,66). – Advancing age (15,18,66). – Decreased range of motion (15). – Overweight or obesity (66). – Injury at C6 or higher (15). – Incomplete SCI may cause more pain and spasticity than complete SCI (66). – Not starting shoulder exercises within 2 weeks on initial SCI (93). – Lower levels of recreation/physical activity (25,71). |
| Alleviating Factors and Treatment Options | – Pharmacotherapy (medications), physical therapy, acupuncture, and aromatherapy have not been rated as very helpful (18). – No single treatment has been shown to be effective for any pain problem in persons with SCI. A multidisciplinary / multimodal approach may be best (18,66,98). Pharmacological Non-steroidal ant-inflammatory drugs (66). Non-Pharmacological – Education (11,66). – Therapeutic modalities (66).Stretching (66). – Exercise/recreation may reduce pain in addition to improving social integration and reducing depressive symptoms (71). – Participation in wheelchair sports (mixed results, but study with sedentary wheelers as control showed positive results) (10,25) – Reduce body fat (66). – Change environment to place frequently viewed objects (TV, computer screen, phone) to appropriate height from wheelchair to minimize neck pain (50). – Consider a wheelchair with a higher (or adjustable) seat height and ability to tilt back or recline trunk to minimize neck pain (50). – Whenever possible, have friends, family and clinicians sit rather than stand while conversing with a wheelchair user (50). – Whenever possible, have wheelchair seat and transfer destination heights equal to minimize upper extremity effort required (66). |
| Specific Exercise Guidelines to Manage Pain | – Little has been studied or noted in regard to exercise and neuropathic pain. One small study showed no neuropathic pain relief with a bicycle ergometry exercise regimen in 4 people with SCI (80). General Guidelines – Optimized pain management may lead to greater exercise compliance (15). – Exercise program must be ongoing to provide long-term pain management. As adherence declines, musculoskeletal pain increases (15,39). – Frequency recommendations vary from once or twice daily strengthening/stretching shoulder exercises to 2- or 3-times weekly combined cardiovascular endurance and resistance training. Keep in mind that 2x weekly vs. 3x may increase compliance (11,15,39,66). Aerobic Exercise / Flexibility Training Although aerobic endurance and flexibility exercises are important to overall health, there was no data available in this literature search relating to pain relief benefits. Strength Training – Begin a shoulder strengthening/stretching exercise regimen within two weeks of initial SCI (93). – Stretch anterior shoulder musculature including pectoralis and bicep muscles; strengthen posterior shoulder musculature and maintain range of motion in shoulder, especially groups which control external rotations and adduction. Watch for and address any strength deficiencies or imbalances (11,66). – Stretch scapularic protractors; strengthen scapularic retractors (11,66). – Rowing exercises or backward wheeling, through sports or other activities, can strengthen scapularic retractors (25,66). – Wall pulley exercises, free weights, exercise bands, wheelchair friendly weight machine with or without wrist straps can all work well in devising a resistance training program for persons with SCI (11, 39). |
Non-specified Pain
| Description | N/A |
| Location of Pain | N/A |
| Aggravating Factors | – High pain intensity (18). – Pain in several locations (98). – Gunshot wound etiology (some but not all studies) (18,71). – Social isolation (71). |
| Alleviating Factors and Treatment Options | N/A |
| Specific Exercise Guidelines to Manage Pain | N/A |
Neuropathic Pain
| Description | – Phantom Limb Pain. Described as stabbing, throbbing, burning, cramping, shocking, or shooting pain (59,79). – Allodynia (pain with typically non-painful stimulus) – Residual Limb Pain (also called stump pain). |
| Location of Pain | Non-present limb; more intense in distal portion of phantom (23). |
| Aggravating Factors | – Older age at time of amputation (14,23,96,97). – Lower limb amputation (vs. upper limb) (14). – Bilateral amputation (vs. unilateral) (14). – Multiple studies show a correlation between the presence of stump pain and phantom limb pain (14,23,59,99). – Catastrophizing (18,23,97). – Stress and/or anxiety (23,59,79,89). – Etiology of electrical burn (vs. flame burn) in children (85). – Etiology of sudden blood clot in adults (14). – Surgical amputation (vs. congenital) in children (85). – Unemployment may increase intensity of PLP but no other type of pain associated with limb loss (96). – Presence of chronic pain before amputation (23). For RLP – Presence of scar tissue or neuroma on stump, bony spurs, infection, ischemia, necrosis, adhesions, muscle spasm, a poorly fashioned stump, or poorly fitting prosthesis (59). |
| Alleviating Factors and Treatment Options | Neuropathic pain is difficult to treat. No single treatment has provided consistent relief in all cases. Trial and error may be necessary. A multidisciplinary / multimodal approach may be best (23,59,79,85). Pharmacological For phantom limb pain (PLP) – Preemptive analgesia before and during surgery (mixed results reported) (23,59,103). – Aggressive postoperative pain management such as epidural infusion, patient-controlled intravenous analgesia, intrathecal opioids or nerve blocks along the adjuvant analgesics such as – – NSAIDs and paracetamol (59,79). – Sympathetic or regional nerve blocks (59). – Local anesthetic injections in neuromas (79). – Low doses of anticonvulsant and antidepressant drugs (in lower doses than used to treat epilepsy or depression) (23,59,79). – NMDA-receptor antagonists (memantine or ketamine) are thought to be especially helpful with allodynia (mixed results – a recent randomized, double-blinded, placebo-controlled trial of memantine showed it ineffective; another recent study of memantine of the same design showed it effective in reducing PLP when used during amputation surgery. It may be of more value in preventing pain than treating it (23,53,59). – Opioids (23). – Oral methadone found effective in small case report study (n=4). Further study needed (4). For residual limb pain: – Botulinum toxin type B injections offered relief of residual limb pain for 10 to 14 weeks in small case report study (n=4) (48). – NSAIDs are especially helpful in treating stump pain (59). – Local anesthetic injections of neuromas (23,79). – Opioids (18,59). – Trigger point injections (59) Non-Pharmacologial – Adaptive coping skills (23,97). – Increasing activity levels. – Support system (23). – Time passage since amputation (14). – Transcutaneous electric nerve stimulation (TENS) (conflicting results) – may involve a bit of trial and error regarding current used and amount and position of electrodes (18,23,59,79). – Spinal cord stimulation (46). – Deep brain stimulation of the thalamic nucleus vertralis caudalis (46). – Motor cortex stimulation. Requires skill in placement of electrode – computer imaging can help with accuracy (46,81). – Psychological therapies to reduce stress, anxiety, and catastrophizing may help since they seem to go hand-in-hand with pain intensity. – Use of prosthetic limb in lower limb amputation can reduce pain, but excess use can aggravate – more study needed (96). – Early fitting of prosthesis may significantly reduce incidence of phantom limb pain (59). – Refitting and/or adjusting of prosthetic lower limb to ensure fit with changes that occur in stump after initial fitting. Surgical – Surgical or chemical sympathectomy may be useful in people who describe pain as burning, but can have undesirable complications such as increased pain, new pain, and abnormal sweating – more study needed (54,79). – Surgical interventions such as cordotomies and neuroablation can cause more harm than good and should be tried as last resort. Scar tissue or neuroma removal and stump refashioning are less drastic and may be more helpful surgical options (59). – Surgical removal of neuromas (79). |
| Specific Exercise Guidelines to Manage Pain | Little has been studied or noted in regard to exercise and neuropathic pain relief in limb loss. |
Limb Loss
Musculoskeletal Pain
| Description | Musculoskeletal Pain Back pain, especially with lower limb amputations.Arthritic pain mainly from prosthetic limb use (96). |
| Location of Pain | -Back, non-amputated leg or foot, buttocks/hips, neck/shoulders (18). – NOTE: Back pain in some studies and residual limb pain in others is reported as significantly more troublesome and interfering with activities than phantom limb pain (18,56). |
| Aggravating Factors | – Stress – Excessive use or too little use of lower limb prosthesis – mixed results; more research needed to determine what level of prosthesis use is most beneficial (96). – Advancing age. |
| Alleviating Factors and Treatment Options | See section on Osteoarthritis for information on arthritic pain. |
| Specific Exercise Guidelines to Manage Pain | Little has been studied or noted in regard to exercise and musculoskeletal pain relief in limb loss.See section on Osteoarthritis for exercise guidelines to manage arthritic pain. |
Non-specified Pain
| Description | N/A |
| Location of Pain | NOTE: Many persons with limb loss experience multiple types of pain in multiple locations (18). |
| Aggravating Factors | N/A |
| Alleviating Factors and Treatment Options | N/A |
| Specific Exercise Guidelines to Manage Pain | Although not directly related to pain relief, if physical therapy and initial prosthetic training takes place immediately after the amputation, there is improved independence in mobility and ADL skills (17). |
Cerebral Palsy (CP)
Musculoskeletal Pain
| Description | Musculoskeletal pain from: – Spasticity leading to bony deformations, contractures, and joint stress (18,77). – Scoliosis (77). – Congenital dislocations (18). – Wheelchair use.Hip subluxation (65). Other pain from: – Gastro-esophageal reflux (65). |
| Location of Pain | – Most common sites are low back, hip, leg, and knee. Other reported sites include foot / ankle pain, hand and wrist, elbow, neck, shoulder, arm and upper back pain (17,19,42,65,77). – Less common sites included head, abdomen and pelvis, buttocks (19). – Postoperative pain from any number of surgical procedures a person with CP may face (65). |
| Aggravating Factors | – Fatigue. – Stress. – Greater severity of impairment. – Presence of gastrostomy tube. – Gastrointestinal problems in children with CP. – Higher fat stores in children with CP. – Catastrophizing. – CP-related pain may be under-evaluated and under-treated (9,12,18,26,42). – Depression (65). – Overexertion (77). |
| Alleviating Factors and Treatment Options | Pharmacological: – Intrathecal baclofen and possibly botulinum toxin may reduce spasticity and pain in children and adults with CP (18,65,91). – Acetaminophen (42). – Ibuprofen (42). – Codeine (42). Non-pharmacological: – For musculoskeletal pain arising from wheelchair use, the following options may help: – Change environment to place frequently viewed objects (TV, computer screen, phone) to appropriate height from wheelchair to minimize neck pain (50). – Consider a wheelchair with a higher (or adjustable) seat height and ability to tilt back or recline trunk to minimize neck pain (50). – Whenever possible, have friends, family and clinicians sit rather than stand while conversing with a wheelchair user (50). – Whenever possible, have wheelchair seat and transfer destination heights equal to minimize upper extremity effort required (66). – Exercise balanced with resting (42). – Stretching (42). – Transcutaneous electrical nerve stimulation (TENS) (42). – More often used cognitive strategies like task persistence, diverting attention, coping self-statements, reinterpreting pain sensations, praying, and hoping (18). – Lesser-used physical strategies like postural guarding, increasing activity, and resting (18). – There are a reasonably wide variety of pain treatments that may provide short-term pain relief but has minimal effect on average pain ratings over a two-year span. Of note, despite self-reported helpfulness of many pain treatments, only a small proportion of people with CP used them (18,42). Surgical: – Selective dorsal root rhizotomy (to reduce spasticity and improve gait). It may also decrease the need for future orthopedic operations (65,13). – Soft tissue releases to relieve contractures (65). – Arthrodesis (77). – Total joint arthroplasty (5). – For any surgical option, keep in mind that postoperative pain will be created and need to be managed (13). |
| Specific Exercise Guidelines to Manage Pain | Little has been studied or noted in regard to exercise and musculoskeletal pain relief in CP. More study is needed to understand what type of exercise is safe and most beneficial (40,77). General Guidelines – When caregivers perceived more benefits of exercise, the adults with CP in their care were more likely to exercise. Educating caregivers on the benefits of exercise, how to customize a program to individual needs, and how to monitor activity to ensure enjoyment and safety (40). – Caregivers in nursing homes tend to be less positive about exercise than in non-nursing home environments (40). – Aerobic Exercise / Flexibility TrainingFrequency recommendations vary from 2- or 3-times weekly cardiovascular endurance combined with resistance training (2x weekly vs. 3x may increase compliance). – Although aerobic and flexibility exercises are important to overall health, there was no data available in this literature search relating to pain relief benefits. Strength Training: – Strength training has not been shown to increase spasticity or contractures, or decrease range of motion (ROM) in people with CP as previously believed. There is some evidence that strength training may even increase ROM, especially in the lower limbs (16). – Frequency recommendations vary from once or twice daily strengthening/stretching shoulder exercises to 2- or 3-times weekly combined cardiovascular endurance and resistance training (2x weekly vs. 3x may increase compliance). – For musculoskeletal pain arising from wheelchair use the following strength training strategies may help:Stretch anterior shoulder musculature including pectoralis and bicep muscles; strengthen posterior shoulder musculature and maintain range of motion in shoulder especially groups which control external rotations, and adduction. Watch for and address any strength deficiencies or imbalances (11,66). – Stretch scapularic protractors; strengthen scapularic retractors (11,66). – Rowing exercises or backward wheeling can strengthen scapularic retractors (25,66). – Wall pulley exercises, free weights, exercise bands, wheelchair friendly weight machine with or without wrist straps can all work well in devising a resistance training program for persons in a wheelchair (11,39). – Exercise program must be ongoing to provide long-term pain management. As adherence declines, musculoskeletal pain increases (15,39). |
Non-specified Pain
| Description | Pain experience with cognitive and communication deficits: Requires different method for non-traditional pain assessment. Changes in facial expression, head and body movements, and verbalizations / crying can provide clues to people who know them best. Behaviors typically associated with pain in non-disabled people may or may not indicate pain in intellectually disabled people. Further, lack of behavioral response does not indicate that there is no pain perception (9,12,18,65,102,103). |
| Location of Pain | N/A |
| Aggravating Factors | – Fatigue. – Stress. – Greater severity of impairment. – Presence of gastrostomy tube. – Gastrointestinal problems in children with CP. – Higher fat stores in children with CP. – Catastrophizing. – CP-related pain may be under-evaluated and under-treated (9,12,18,26,42). – Depression (65). – Overexertion (77). – People with intellectual disability appear to have a greater incidence of concurrent health problems that can link to increased pain (12,102) – Children with developmental delays (not necessarily from CP) don’t show as much reaction to painful stimuli, and seek less help and comfort than non-delayed children, which may lead to an underestimation of actual pain in these children (26). – Adults with profound intellectual disability may also be at risk of having their pain underestimated due to differences in how pain is perceived and expressed in this population (12). – Adults with mild intellectual disability may under-report pain because they use different words to describe it such as an ache or feeling sore rather than pain. Clinicians may need to spend more time probing and listening to best identify and treat pain (9). |
| Alleviating Factors and Treatment Options | N/A |
| Specific Exercise Guidelines to Manage Pain | There is very little data available on efficacy and effectiveness of any type of exercise for people with CP and cognitive deficits. Many studies that exist exclude those with cognitive problems. Further, no reliable pain measurement standards are available for people with intellectual disabilities. Self-report, the gold standard of pain measurement, cannot be used (12,16,18,102). |
Fibromyalgia (FM)
Musculoskeletal Pain
| Description | Little is currently known about the cause of FM so the cause of pain is still unknown. Some feel it is a central problem (neuropathic) and others feel it may be peripheral (musculoskeletal) and others a combination of the two (7,32,44,74,76). |
| Location of Pain | 18 tender points (muscle-tendon junctions) (44). |
| Aggravating Factors | – Fatigue, – Stress, – Catastrophizing (thinking overly negative thoughts), – Unrealistic expectations (2). |
| Alleviating Factors and Treatment Options | People diagnosed with FM are very heterogeneous and cannot be treated with universally accepted strategies. What works for one person may not work for another. An individualized multidisciplinary, multimodal approach is more effective, including (2,44,64,83): Pharmacological – Non-steroidal anti-inflammatory drugs (NSAIDs), analgesic drugs, antidepressants, and muscle relaxants improve symptoms such as pain, sleep fatigue, anxiety/depression in the short-term, but many abandon medications because symptoms do not continue to improve. More study needed for long-term effects (44,74,76,83). – Glucocorticoid injections except for those with concomitant carpal tunnel syndrome (83). Non-pharmacological – Education about FM and self-management techniques may not directly decrease pain but doesn’t appear to increase it and may increase quality of life, self-efficacy and satisfaction while minimizing unrealistic expectations (2,7,83). – Stress reduction techniques. – Individually adapted exercise (45,83). – Stretching (44,45). – Cognitive behavioral strategies like biofeedback, counseling, meditation, relaxation, and stress management can lead to an increased sense of control over pain, a belief that one is not necessarily disabled by FM, that pain is not necessarily a sign of damage, decreased guarding, increased use of exercise, increased seeking of support, activity pacing and use of coping self-statements (44,64). – Physical strategies such as graded exercise, increasing activity, and resting (55,76,83). – Social support (2,83). Other promising alternative treatment approaches that need further study to verify effectiveness and efficacy in treating pain in FM: – Balnotherapy (sulfur baths) (83). – Osteopathic manipulation (83). – NOTE: Spinal manipulation of the cervical vertebrae can lead to serious complications that make it less compelling (95). – Acupuncture (20). – Green algae supplements (Chlorella pyrenoidosa) (20). – S-adenosyl methionine supplements (20).Massage (20). |
| Specific Exercise Guidelines to Manage Pain | General Guidelines – Do a very thorough pre-assessment to determine fitness level (many are extremely deconditioned), any concomitant conditions, medications and any other pain generators such as previous injuries, arthritis, tendonitis, and myofascial trigger points (45). – Exercise carries both risks and benefits for people with FM. Have a thorough understanding of FM before attempting to develop an exercise program. Some medications commonly taken with FM may increase likelihood of orthostatic hypotension, dizziness, and balance problems. Know potential side effects. As a precaution, gradually change positions from movement to movement (2,43,44,45,83). – If fatigue rather than pain is primary complaint, consider that orthostatic hypotension and/or disrupted sleep (common in FM) may be the cause. Seek medical guidance to manage (45). – Prescribed exercise can be performed in the community by personal trainers previously unfamiliar with the management of people with FM (76). – Exercise is most effective in persons whose pain control is optimized (44,45). – All components of an exercise program (strength, aerobic, flexibility, and balance) can fit and appear safe and beneficial if individually tailored. Customization will increase likelihood of compliance and minimize risks (43,45,74,83). – Spend time teaching how to properly perform the exercises, being aware of bodily signals, and how to modify exercises to match threshold of pain and fatigue, and minimize eccentric contractions in daily activities (45,55). – Educate client that even when exercise is started at a suitable level and progressed slowly, it may produce a small and transient increase in pain that will abate after the first few weeks of exercise (27,44,76). – Exercise prescription should combat deconditioning without triggering pain (45,83). – Start at low intensity and very gradually increase to moderate intensity (months rather than weeks). It may not result in traditional changes associated with fitness, but should minimize the progression of deconditioning while managing pain (27,45). Exercise program must be ongoing to provide long-term pain management. As adherence declines, musculoskeletal pain increases (2,7,27,60,74,76). Ways to increase compliance may be: – Designing an exercise program with flexible goals (2). – Identifying potential high-risk situations before they occur (2). – For people with a low threshold for pain, exercising in the late afternoon rather than the morning may lessen the perception of pain based on diurnal rhythm patterns (3). – Developing coping skills (2,76). – Education on specific techniques to help adjust a program when a relapse or flare occurs (2,55,76). – Pacing (breaking down tasks into manageable segments).Multiple short sessions vs. one long session (2). – Cognitive reappraisal (changing reaction pattern to flares or set-backs) (2). – Social support from professionals is as crucial in promoting positive health behaviors as family and friends (2). – Maximize self-efficacy (belief in one’s capabilities) to encourage continued exercise compliance (45). – An exercise videotape depicting modifications needed for people with FM and other pain-related conditions is available at www.myalgia.com. Proceeds fund FM research (44). Aerobic Exercise – Emphasize non-impact loading exercise such as walking, water aerobics in a heated pool, and stationary bicycles to reduce pain (27,45,55). – In general, intensity should be based on perceived exertion and pain limitations (2,44). – People with significant musculoskeletal pain or those who are more fearful that exercise will increase their pain may benefit most from a water-based program (27). – Warm (therapeutic) pools (93 F) may reduce pain but can be difficult to find in the community. This makes compliance more difficult, but even pools with a water temperature 85 F will be better tolerated than a standard community pool (27,44). – Some suggest avoiding overhead movements in aerobic activity, even during water activities (44). Others suggest that overhead movements can be tolerated in aerobic exercise if introduced gradually (27). – Stationary bicycles may aggravate gluteal tender points and produce symptoms resembling sciatica (2,45). – In order to engage in a walking program, client must be able to rise from chair and hold the trunk stable. If unable, begin a strength-training program or perform aerobic conditioning while sitting in a chair (45). – Walking should be done at an intensity that makes it possible to talk but not sing (44). – A lower-intensity aerobic exercise program of longer duration may be more effective in FM treatment, resulting in less pain, greater compliance, and more enjoyment than a high-intensity program (2,27,90) Strength Training – Some experts feel strength training might be the best first step in preparing a deconditioned person with FM to engage in a more comprehensive program that includes other dimensions (43,45). – Strategies include:Actively or passively warm up muscles (44). – Focus on functional strength and muscle toning rather than ‘body building’ (45) – Use bands, soft weights, machines such as Nautilus or Universal that don’t require a tight grip, and sustained contractions (43,45). – Allow a 4-count pause between each repetition to allow return to resting state or work the opposing limb during the pause period (43,45). – Minimize eccentric contractions such as walking downhill and using overhead movements (44,45). – Minimize plyometrics. One small study (n=11) showed increased leg pain and reduced neck pain in a strength training regimen that included ‘explosive’ strength training at the end of the 21-week regimen (32).Increase ratio of contractions near the body midline vs. farther from midline (43). – Maximize the concentric phase (8 count) and minimize the eccentric phase (4 count) (27,43,45). – Start with small sets of 3 to 5 repetitions and add sets as tolerated (43, 45). – Be aware that there appears to be a delayed onset of muscle relaxation in people with FM. Consider a twice-weekly program consisting of one day upper-body followed by a day of no strength training, a day of lower body training followed by a day of no strength training (44). Flexibility Training – Actively or passively warm up muscles before stretching them (44). – Actively or passively warm up muscles, stretch to point of resistance, but not pain, then hold stretch (27,44,45). – One method to help client identify stop point is to stretch with eyes closed. Use cues that discourage overstretching such as ‘hang your head toward your chest’ rather than ‘stretch your chin toward your chest’ (43,44). – Do not bounce and do not stretch to point of increased pain (45). – Minimize stretching in FM tender point locations (43). – Care must be taken to avoid overstretching, especially for those with joint hypermobility (27,44). Exercise recommendations that may help during a flare: – Stress need for passive warm-up and warm-down using a hot bath or hot tub (45). – Consult with physician regarding medical pain management (45). – Use NSAIDs before exercise (45). – Decrease intensity of exercise before altering frequency or duration (2,45). – If pain continues, discontinue exercise until pain flare has subsided by 75% (45). |
Parkinson’s Disease (PD)
Neuropathic Pain
| Description | Neuropathic pain thought to arise from abnormal firing in afferent nerve fibers within dystonic muscles. May include paresthesia, burning dysthesia, coldness, numbness, and deep aching (68). |
| Location of Pain | Many pain problems occur only in the ‘off’ state. Legs and feet are more often involved than arms with face and neck being least commonly affected. Pain is often more severe on side of body on which PD symptoms are worst (68). |
| Aggravating Factors | N/A |
| Alleviating Factors and Treatment Options | N/A |
| Specific Exercise Guidelines to Manage Pain | Little has been studied or noted in regard to exercise and neuropathic pain relief in PD. |
Musculoskeletal Pain
| Description | Musculoskeletal pain from arthritis or bursitis, especially in the shoulder. About one-third of people with PD attribute their pain to other musculoskeletal disorders aside from PD (72). |
| Location of Pain | N/A |
| Aggravating Factors | N/A |
| Alleviating Factors and Treatment Options | It’s important to distinguish the source of the pain, if possible, in order to treat it effectively (72). |
| Specific Exercise Guidelines to Manage Pain | – Little has been studied or noted in regard to exercise and musculoskeletal pain relief in PD. – See section on osteoarthritis for pain management suggestions since people with PD may also have arthritis (72). |
Non-specified Pain
| Description | Non-specified Most commonly described as dull, tingling, aching, cramp sensation, stiffness, and muscle tension (72). |
| Location of Pain | Lower part of back/trunk and lower extremities (72). |
| Aggravating Factors | – Fatigue (68). – Sleep disturbances (72). – Lower levels of education (72). |
| Alleviating Factors and Treatment Options | Pharmacological Pain often responds to adjustment of antiparkinsonian medications, especially dopamine agonists (68). Non-Pharmacological – Education given in selective amounts depending on stage of disease. Initially don’t want to provide too much information as to cause alarm or anxiety but enough to give sense of control (68). – Social support – initially support groups with one-on-one peer support or groups with newly diagnosed people with PD can be more helpful (68). – Employment, even if modifications are needed such as changes in job requirements, fewer hours or workplace environment changes (68). – Physiotherapy (72). – Massage (72). |
| Specific Exercise Guidelines to Manage Pain | Although not specifically shown to reduce pain, the following general guidelines appear not to aggravate pain while increasing mobility and mood: – Include aerobic, strengthening and stretching activities (68). – Aerobic exercise intensity should be 60%-70% of maximum heart rate (68). – Non-weight bearing aerobic exercises may be especially beneficial although few studies exist to confirm this (68). – Consider warm water aerobics. It may reduce rigidity and provide additional sensory cues to help control movements (75). – Strengthening exercise should use lightweight with the goal to improve flexibility and strength but not to add bulk. Emphasize extensor muscles to counteract the flexor postures common with PD (68). – Stretching should be performed when muscles are warm (68). – To minimize impact of fatigue, it may be helpful to learn energy conservation techniques from physical therapist (68). – Identify any comorbidities or limitations such as reduced range of motion to minimize risk of injury (68). – Treadmill training with body weight support may be more effective in improving short-term mobility of people with PD than physical therapy. More study is needed (61). – Consider music therapy to help bradykinesia and rigidity by providing external rhythmic cues that may stimulate different sensory pathways and enhance mood (69,75). |
Rheumatoid Arthritis (RA)
Musculoskeletal Pain
| Description | Musculoskeletal pain originating in joints. |
| Location of Pain | Ankles, knees, feet, hands, and elbows (62). |
| Aggravating Factors | Joint swellingPerceptions about RA may be more important than the actual disease status in how a person experiences pain in RA (29). |
| Alleviating Factors and Treatment Options | Pharmacological – Disease-modifying anti-rheumatic drugs (DMARDs) reduce inflammation, reduce symptoms, delay or prevent structural damage and improve functional performance of the patients (33). – Anti-tumor necrosis factor medications may slow progression of RA. Non-pharmacological – Social support from friends, family, and professionals (31,33). – Education on benefits / side effects of medications, joint protection strategies, use of orthoses, coping methods, self-relaxation techniques, and exercise benefits (31,35,47). – Exercise (includes range of motion exercise, physical therapy, aerobic conditioning, and strength training) (41). – An exercise prescription is much more likely to occur when a doctor initiates the exercise discussion (41). – Joint protection strategies like rest and splinting, using compressive gloves, assistive devices and adaptive equipment may lead to long-term reduction in pain (35,47). – Low-level laser therapy (LLLT) may reduce pain in hand joints. Further study needed to determine optimal dosage, wavelength, and type of LLLT (24). – Transcutaneous electrical nerve stimulation (TENS) may reduce pain. Further study needed (24,47). Surgical – Joint fusion (arthrodesis), especially for foot joints (62). – Joint replacement (arthroplasty) (24,62) – Synovectomy. Other promising alternative treatment approaches that need further study to verify effectiveness and efficacy in treating pain in RA: – Borage supplements (20). – Phytodolor , a proprietary German medicine, has shown favorable results in pain relief in 10 randomized controlled trials (20,95). – Topical application of Thunder god vine extract (20). – Muscle relaxation training (20). |
| Specific Exercise Guidelines to Manage Pain | General Guidelines – Check with physician about specific movements to avoid.Avoid exercises that include risk of injury or high-impact load, or result in increased joint pain or fatigue (24,49). – Compliance is a critical factor in maintaining benefits. Educate clients on exercise benefits, specific recommendations and precautions necessary (31,33,41). – Compliance may improve when there is mutual decision-making, if an association between exercise and benefit is made, and if specific instructions are provided on how to perform the exercises (33,41). – Physical performance and disease activity may fluctuate even on a daily basis and most of the signs during or after exercise are not harmful (i.e., joint pain during or 1 or 2 hours after the exercise, delayed muscle soreness). Long-term compliance improves if clients are aware of their bodies’ responses to exercise and if they learn to modify various training programs according to their fitness and changes in disease activity (31,33,41). – People with arthritis that exercised in their youth perceive greater benefits from exercise (36). – Adequately understanding and addressing a person’s beliefs and concerns about exercise will increase exercise compliance (24). – Likewise, the trainer needs to regularly revisit and adjust the exercise regimen to address changes in disease activity, pain status, function, and motivation (24). – Adapt exercises as needed to accommodate painful sites.Heat can be used before exercise to relieve muscle spasms and improve elasticity (47). – Home-based, individual, or group-based programs appear equally effective, but long-term compliance to home-based exercise may require close supervision (24,49). – Supplementing a home-based program with an exercise class or other leisure activities such as swimming, walking, or cycling can increase compliance by offering variety (24). Aerobic Exercise – Aerobic conditioning and strength training can increase aerobic capacity with no detrimental effect on pain (49). – Aerobic intensity of 60-70% of heart rate maximum, 3 times per week, 30- to 60-minute sessions (24). Strength Training – The majority of studies report no change in disease activity (measured by erythrocyte sedimentation rate, joint count, and pain) with strength training, although a few showed decreases (31). – Progressively strengthen muscles across all major muscle groups of the upper and lower extremities and trunk, not just the affected sites (31,49). Intensity and frequency for strength training is 50% to 80% maximum voluntary contraction, 2 to 3 times per week. Start at the lowest range and build gradually to avoid pain and fatigue (47,24). – When a joint is acutely inflamed, isometric exercises 40% maximal voluntary contraction may provide adequate muscle tone without increasing disease activity (47). – When joints are not inflamed, isotonic or isokinetic exercises may be used (47). – Joint swelling and pain can lead to immobilization and decreased activity. Whenever possible, begin strength training before immobilization occurs to minimize the large loss of strength that occurs in immobilized muscles (31). Flexibility Training – Stretching of tight muscles and maintenance of existing range of motion (ROM) should be a primary focus for people with RA (49). – Tai chi is beneficial for lower-extremity ROM but doesn’t provide much aerobic or weight-bearing benefit (36). – Every joint should be moved in the ROM at least once per day in order to prevent painful contractures. |
Osteoarthritis (OA)
Musculoskeletal Pain
| Description | Musculoskeletal Pain. |
| Location of Pain | Knees most common; hips; back; and hands, especially fingers. |
| Aggravating Factors | – Obesity (58,78,94). – Fear that exercise will aggravate their pain (58). – Age (78). – Greater proprioceptive inaccuracy (for knee OA) (78). – Higher pain intensity (78). – Concomitant disorders, especially pulmonary diseases, other mobility problems (94). – Joint malalignment or laxity (24,78). – Muscle imbalances (22,24). |
| Alleviating Factors and Treatment Options | Pharmacological – There is no set combination of medications that will consistently relieve pain for all people with OA (63). – Paracetamol (some say acetaminophen) as first-line defense followed by NSAIDs or COX-2 inhibitors if paracetamol fails to provide adequate pain relief (28,63,94). – Two well-designed studies of oral glucosamine sulfate confirmed a 20% to 25% reduction in pain in patients with mild to moderate knee OA (28). – Topical application of glucosamine sulfate and chondroitin sulfate may be effective in reducing pain from knee OA (28). – Opioids, such as codeine, in combination with paracetamol can provide better pain relief but are not tolerated well, requiring discontinuation of opioids by up to a third of people prescribed this regimen (28,63). – Synthetic opioids, like tramadol, are better tolerated but are contraindicated in seizure disorders (28,63). – Intra-articular injections of synthetic long-chain hyaluronan preparations for knee OA decrease pain over 6 months but are very expensive and not covered by insurance, limiting their widespread application (28,63). – Intra-articular injections of glucocorticoids usually provide a modest short-lived decrease in pain. However, in some patients there are dramatic and sustained results, but there is no way of predicting which people will respond (28,63). – Intra-articular injections of steroids are not particularly effective for reducing pain in OA (28). – Topical capsaicin has a modest pain-relieving effect for knee OA either alone if systemic analgesics are not tolerated, or in combination with simple analgesics (28,63,95). – Use of topical agents in hip OA have not been studied. Intra-articular injections of glucocorticoids have not been well studied for hip OA and intra-articular hyaluronic acid is not approved for hip OA (28). Non-pharmacological – A review of 7 randomized controlled trials has shown that transcutaneous electrical nerve stimulation (TENS) may offer effective pain relief for people with OA of the knee (24). – In a double-blind randomized control trial, infrared low-power Gallium-Arsenide (Ga-As) laser therapies in conjunction with exercise offered significantly more pain relief than placebo (30). – Physical strategies such as exercise, physiotherapy, physical therapy, hydrotherapy, swimming, thermal therapy, and massage (58,63,78,94). – Assistive devices such as canes, walkers, orthotics, wedged insoles, taping and unloader braces may reduce pain by addressing abnormal biomechanics, joint malalignment, and muscle imbalances (63). – Self-efficacy – belief in one’s capacity to meet given demands (78). – Social support (63,78). – Weight reduction if overweight or obese (28,63). – Education of disease process, exercise instruction, prognosis and rationale, and implications of managing their condition. In many cases, education is as effective in managing pain as NSAIDs (28,63,94). Surgical Total joint arthroplasty relieves pain and improves function over at least a decade. Revision arthroplasty is more complicated, so it may be best to postpone arthroplasty in younger people with OA (28,94). Other promising alternative treatment approaches that need further study to verify effectiveness and efficacy in treating pain in OA: – Pulsed electro-magnetic fields to manage pain in knee OA (24). – Devil’s claw (H. procumbens) has shown favorable results in pain relief in 8 randomized controlled trials (RCTs) for OA and other musculoskeletal conditions (20,95). – Avocado-soybean unsaponifiables shows favorable results in 4 RCTs (20, 95). |
| Specific Exercise Guidelines to Manage Pain | General Guidelines – There are many possible reasons for OA pain. The ability to accurately identify the cause of OA pain significantly increases the ability to manage pain (63). – OA at different sites requires different approaches. Range of motion exercises may increase pain in OA of the hip, and knee extension exercises can increase pain in OA of the knee. Modify the program as symptoms or disease activity change (28, 63). – Knee pain in OA has been most frequently studied. Hip pain to a lesser extent (49,73). – At least in the short term, exercise improves pain, muscular strength, and function in older people with mild OA of the knee or hip (49). – In the long-term, people with knee and hip OA can experience a substantial reduction in pain through a comprehensive inpatient rehabilitation program followed by an individualized home-based program. Other reviews indicate that there is not enough evidence to draw this same conclusion for hip OA (24,58,73). – While this benefit is true, it is based on averages. There will be individuals whose pain may worsen with exercise (58). – Avoid exercise associated with greater risk of injury or high-impact loads (49). – The goal of exercise program for a person with OA is to reduce pain and disability by strengthening muscle, improving joint stability, increasing the range of movement, and improving aerobic fitness (28). – Exercise programs have varied widely in studies leaving insufficient data to offer specific recommendation on optimal dosage or optimal program content (49,73). – Like all populations, both disabled and non-disabled, long-term compliance to exercise is critical to long-term health benefits and reduction in pain. As compliance declines, pain may increase (49,58,94). – A contributing factor in lack of compliance may be the difficulty in maintaining standard exercise and dietary weight loss programs in previously sedentary, overweight adults with mobility challenges (58). – People with arthritis that exercised in their youth perceive greater benefits from exercise and may be more compliant (94). – Adherence problems may be greater in home-based programs vs. facility-based programs although other studies indicate they are similarly effective. The benefit of the home-based programs appears to be highly associated with the frequency of home monitoring (24,49,94). – A randomized controlled clinical trial showed ineffective pain improvement from a 6-month home-based exercise program (5 exercises over 30 minutes, 4x per week) primarily due to noncompliance (73). – Supplementing a home exercise program with a group class appears to increase compliance and reduce pain more effectively in the long-term than home-based exercise alone (57). – If knee replacement occurs, participation in no-impact or low-impact sports is fine, but participation in high-impact sports should be prohibited. (49) – The combination of diet and exercise produced greater pain relief after an 18-month intervention than either diet or exercise alone (58). Aerobic Exercise Both high- and low-intensity stationary cycling have been shown to improve pain with OA of the knee (49). Strength Training – Both isokinetic and progressive resistance exercise improve pain, although progressive resistance exercise showed a little better improvement. It also has the benefit of being less expensive, more easily performed, and more efficient than isokinetic exercise (22). – Progressive muscle strengthening is shown in multiple studies to reduce pain in OA. Home-based strengthening programs also shown to be effective in reducing pain in compliant people with OA (49,67). – A 6-month home-exercise strength-training program resulted in a reduction of pain in OA of the knee with the most relief achieved from those who were most compliant (67). Flexibility Training – In a small randomized, controlled trial (n=17), yoga was shown to reduce hand pain in OA and decrease tenderness of finger joints (20). – Stretch tight muscles and maintain existing range of motion (49). |
Post-polio Syndrome (PPS)
Musculoskeletal Pain
| Description | Musculoskeletal Pain – Joint pain (also called arthritic pain) (18,52,88). – Muscle pain.Myofascial pain (86, 88). – Upper extremity and trunk pain usually described as aching and may indicate muscle overuse (100). – Lower-extremity pain usually described as cramping (100). |
| Location of Pain | Mainly low back and lower extremities (knees, hips, thighs). Can also occur in elbows, trunk, neck, shoulders, and respiratory muscles (8,18,100). |
| Aggravating Factors | – There is no known test specific for PPS, so diagnosis is made by exclusion. Co-existing medical conditions can make diagnosis and treatment difficult (86). – Spinal stenosis, which has similar symptoms, can be confused with PPS (52). – Many people with PPS also have fibromyalgia or borderline fibromyalgia (86,87). – Physical exertion (37,92,100). – Chronic overuse of less- affected muscles (1,70,87,92). – Muscle imbalances (70). – Muscle disuse leading to further atrophy (1,51,100). – Aging (1,87). – Exposure to cold weather (37,100). – Fatigue (92,100). – Greater residual effects from or greater severity of acute polio (1,8,86). – Weight gain (1,70,86,92). – Belief promoted in acute polio era that use of assistive aids such as canes, crutches, slings, braces. or wheelchairs are a sign of weakness or ‘giving in’ (70,86,101). – Depression (86). |
| Alleviating Factors and Treatment Options | Pharmacological – Analgesics such as acetaminophen or NSAIDs (86,88100). – Antidepressants for myofascial pain (86). Non-pharmacological – Identify and treat co-existing pain causing conditions such as fibromyalgia (87). – Warmer climate ( 77 F) (84). – Physiotherapy (84). – Swimming activities (84). – Social and local community support (84). – Education on techniques to reduce or avoid pain and protect joints during activities of daily living may help (1,86,101). – Assistive devices and technical aids to conserve energy and help alleviate muscle imbalances to minimize overuse. The typical approach allows short-distance walking without assistive devices for those who fight their use. NOTE: Crutches and canes can be contraindicated if shoulder musculature is very weak or would be bearing too much extra weight (86). – Rest – orthoses can be used to rest muscles (1,37,70,88,100). – Heat/warmth (37,86,100). – Electrical stimulation such as transcutaneous electrical neural stimulation (TENS) or trigger point injections (86,88). – Stretching exercises (86,92). – Modified muscle strengthening surrounding painful joints as tolerated without fatigue and pain (86). – Weight loss (86). – A randomized controlled trial (RCT) of static magnetic fields (300-500 Gauss) found significant and prompt pain relief of musculoskeletal pain in PPS. More study needed to replicate results (88). Surgical: – Spinal fusion (for progressive paralytic scoliosis) (86). – Correction of obstructive contractures (70). |
| Specific Exercise Guidelines to Manage Pain | To date there is insufficient data available to offer specific recommendations on intensity, duration, frequency, and type of exercise that will benefit people with PPS. The few studies that exist are very heterogeneous in design and intervention, and mainly focus on strength gains and increases in aerobic capacity rather than pain relief. Additionally, people with PPS are also heterogeneous, making it difficult to determine the right exercise regimen to gain the most benefits with the least overwork (21,82). General Guidelines – Plan exercise at time of day when pain is lowest (37). – Find a balance between exercise intensity and avoiding fatigue (86). – Exercise regimen must be realistic with a limited selection of muscles that will improve function without increasing fatigue and pain. If exercise intensity is too great or the number of [remaining] motor units too few, damage can occur (1,86). – Be aware that standard measures of manual muscle strength significantly overestimate actual strength of damaged muscles (measured quantitatively) in people with PPS (1,70,101). – Use a pacing strategy (breaking down tasks into manageable segments – multiple short sessions vs. one long one) to minimize fatigue (1,70,82). – Allow longer rests between repetitions, sets, and exercises in strength training (82). – Recovery may take longer in people with PPS (70). – Use orthoses, walking aids and wheelchairs as a means of decreasing demands placed on muscles while preserving function (70). – Gait analysis can be a helpful tool in assessing where muscle weakness exists and how an individual compensates in order to develop a multi-disciplinary plan to achieve better muscle balance and avoid further overuse/abuse of some muscles and under-use/disuse of others (51,70). – Monitor person with PPS very closely for signs of fatigue and pain. Exercise should never be performed to point of pain or fatigue (82,101). Aerobic Exercise / Flexibility Training Although aerobic and flexibility exercises are important to overall health, there was no data available in this literature search relating to pain relief benefits. Strength Training – Strength training, if possible, may help alleviate or at least not aggravate joint pain (82.92). – Emphasize concentric contractions in strength training to minimize muscle damage (82). – To avoid muscle trauma, a 3-repetition maximum test (3RM) may be safer than a 1RM in determining intensity for strength training (82). |
Neuropathic Pain
| Description | – Neuropathic pain (most commonly caused by carpal tunnel syndrome) (92). – Radicular pain. |
| Location of Pain | N/A |
| Aggravating Factors | N/A |
| Alleviating Factors and Treatment Options | Neuropathic pain is very difficult to treat and may be caused by carpal tunnel syndrome rather than PPS itself (92). |
| Specific Exercise Guidelines to Manage Pain | N/A |
Glossary
Adhesions – the abnormal union of surfaces normally separate by the formation of new fibrous tissue resulting from, among many things, amputation surgery.
Allodynia – a condition in which ordinarily non-painful stimuli causes pain.
Arthrodesis – surgical immobilization of a joint (also called joint fusion).
Arthroplasty – surgical repair or replacement of a joint.
Bradykinesia – involuntary slowed or sluggish movement.
Catastrophizing – thinking overly negative thoughts.
Congenital – existing at or before birth.
Contracture – a condition of permanent resistance to passive stretch of a muscle.
Cordotomy – surgical division of a tract of the spinal cord for relief of severe pain that has been unresponsive to other treatments.
Dystonic (adj.) / dystonia (n.) – altered muscle tone.
Epidural – injection of drugs into the peridural space of the spinal cord.
Etiology – the cause or causes of a disease or abnormal condition.
Flare – symptoms become suddenly worse or more painful.
Gait analysis – analysis of the manner in which a person walks.
Gastroesophageal reflux – the return of stomach contents back up into the esophagus, frequently causing heartburn that can lead to scarring and constriction of the esophagus.
Gastrostomy tube – a surgically placed tube to allow feeding directly to the stomach in people unable to swallow or feed well.
Intra-articular – situated within, occurring within, or administered through a joint.
Intrathecal – injection of drugs under the arachnoid membrane of the brain or spinal cord.
Ischemia – a lack of oxygen in localized tissue due to obstruction of the inflow of arterial blood.
Joint fusion – surgical immobilization of a joint (also called arthrodesis).
Musculoskeletal pain – pain in the musculature and/or skeleton (includes joints).
Myofascial pain – pain in the broad muscles overlying the shoulder blade and spine typically caused by muscle strain. Trigger point on shoulder can produce a shooting pain that travels down shoulder to the arm and back.
Necrosis – death of a portion of tissue through any number of reasons such as loss of blood supply.
Nerve block – interruption of the passage of impulses through a nerve by pressure or drugs.
Neuroablation – surgical removal of a nerve.
Neuroma – a mass of nerve tissue in an amputation stump resulting from abnormal regrowth of the stumps of severed nerves.
Neuropathic pain – pain that results from a disturbance of a nerve, causing an abnormal response. Pain is typically described as burning, tingling, or shooting.
Orthosis (orthoses-pl.) – a brace or splint that prevents or assists movement.
Paresthesia – a sensation of pricking, tingling, or creeping on the skin that has no known cause.
Phantom limb pain – pain in a non-present limb or digit.
Preemptive analgesia – the attempt to prevent chronic pain before acute pain occurs, such as before and during surgery.
Proprioceptive inaccuracy – proprioceptors provide feedback on limb position and movement. Proprioceptive inaccuracy occurs when positions or joint angles cannot be accurately replicated. In others words, the position you are aiming for isn’t exactly where you end up due to disruption of the feedback the proprioceptors provide.
Residual limb pain – pain in the portion of the limb remaining after amputation; also called stump pain.
Radicular pain – pain that radiates into the lower extremity directly along the course of a spinal nerve root; usually brought on by compression, inflammation, and/or injury to that nerve root.
Rhizotomy – surgical interruption of spinal or cranial nerve root.
Scoliosis – curvature of the spine to the side.
Spasticity – an increased tightness or tone of muscle.
Spinal fusion – surgical fusion of two or more vertebrae for remedial immobilization of the spine.
Stump pain – pain in the portion of the limb remaining after amputation; also called residual limb pain.
Sympathectomy – surgical interruption of sympathetic nerve pathways.
Synovectomy – a procedure in which the diseased lining of the joint, the synovium, is removed to help relieve pain and swelling.
Transcutaneous electrical nerve stimulation – a method of producing pain relief through electrodes placed on the skin.
Trigger point – a specific spot that produces pain when stimulated by touch or pressure.