How Exercise Can Help You Manage Your Chronic Pain

The first step to any new exercise regime is to consult with your doctor prior to starting. Once you have the ok then you need to make sure that you are doing the appropriate amount, type and have the proper form and technique. With persons suffering from chronic pain (CP) you have to follow a specific exercise progression so as to not worsen your condition. You need to start slowly and one step at a time. Chronic pain requires a specially tailored exercise program with the goal of improving your strength, flexibility, mobility and functions of daily living without increasing pain levels. Chronic pain and exercise is a lot more complex then just going to the gym and doing a few different machines and walking on the treadmill for 20 minutes. It is specialized and tailored towards each individual’s needs and conditions. This manual is a sample of what a generalized exercise program for pain management would consist of. Most people with chronic pain fear exercise, but unused muscles feel more pain then toned flexible ones do. Starting to exercise is also a very scary endeavor for many people suffering from CP to embark on. You don’t want to cause more damage then good. Those with chronic pain may have a hard time believing that any exercise, which can sometimes worsen symptoms at first, will cause any pain relief. Exercising regularly can increase function and decrease pain in as little as 3-4 weeks and over the long term can actually help to moderate some of the symptoms. It is not a quick fix, but is something that you will have to continue with and incorporate into your daily life to truly acquire the benefits. If you start and stop you will not get to this beneficiary level. Here are some of the benefits associated with exercise:
  • Exercising regularly may require less pain medication for the same amount of pain relief
  • Resistance exercise can strengthen the muscles around sore joints that can provide a natural bracing effect that can take the load off the compromised area
  • Aerobic exercise can help with weight loss which can help to take the stress and load of the joints
  • Stronger muscles are less prone to micro trauma, which means less daily pain
  • Exercise done on a daily basis improves sleep and increases energy
  • Endorphins (the feel good hormones that can help take the edge off pain) are released naturally into the body
  • keeping joints moving can help you from feeling “stiff”
  • Increased blood flow, which aids in healing, and overall cardiovascular health.
When you suffer from CP the hardest part of exercise will be the beginning. You may have to work through some mild discomfort or initial pain that may deter you from gaining the many benefits that it has to offer. Your body will initially go through many changes both on a physical and a physiological level. Body parts that you have been afraid to move and have been protecting for some time now will suddenly get more oxygen and blood flow to them. There are many different components to an exercise program and we are going to look at each one in detail.
  1. Warm -up
  2. Flexibility training (Stretching)
  3. Posture and Body alignment
  4. Stabilization Training (Core Strengthening)
  5. Strength training (Resistance)
  6. Aerobic training (Cardiovascular)
  7. Balance and proprioception
  8. Rest and relaxation (Mind Body Awareness)
  1. The Warm-Up
With any exercise regime you always start with a warm-up, which is even more important when dealing with people with chronic pain. The purpose of a warm-up is to get the body ready for more strenuous exercise, loosen the joints and limbs to increase the internal core body temperature, increase flexibility of the muscles and elevate the heart rate, increase respiration rate and decrease viscosity of joint fluids. The main function of warming up is to prevent further injury. Some ways to achieve this are with very simple exercises.
  • General warm-up period: 5-10 minutes
  • Either marching in place for 5-10 minutes
  • Arm circles and leg lifts
  • Active Stretching
  • Walking on a treadmill, or cycling on a stationary bike at rate of perceived excursion of 5 out of 10 RPE.
  2.  Flexibility training (stretching) Frequency: Every other day to start then progressing to daily. Intensity: Begin with Gentle ROM (Range of Motion) work up to 30 second holds. Time: 10-15 minutes daily Type: Static and later PNF Stretching is very important for people suffering with CP. It will aid in the release of tight muscles and provide pain relief.Flexibility is a measurement of the range of motion (ROM). Static flexibility is the range of possible movements around a joint and its surrounding muscles during a passive movement, such as a partner assisted stretch where the other person provides the force. Dynamic flexibility refers the available ROM during active movements like raising your arms above your head or squatting.

Picture 2.2: Chest Stretch

Musculoskeletal flexibility can improve person’s joint movements and possibly decrease the risk of further injury. Increasing the ROM of a particular joint is a main objective in working with a person with chronic pain. The ROM of a particular joint is determined by a number of factors, such as connective tissue structure and a person’s activity level, age and sex. It is also specific to each joints anatomy and the movements required at that joint. If their ROM increases, then their functions of daily living may improve. Simple daily chores, like grooming and washing, can become easier due to improvements in ROM of the shoulder joints. Stretching is one way to improve a person’s ROM and it can be done daily almost anywhere and on your own.   Static Stretching should be done daily. It is a slow and constant force that is held at the end position for 30 seconds. The end position is where you feel the stress which may cause slight discomfort but not pain. It includes relaxation and concurrent elongation of the stretched muscle. It is very easy for the patients to learn and perform on their own with very little risk associated if shown how to properly execute.                                                                                                     Picture 2.1: Lower Lumbar Stretch     

                           Picture 2.3 A: “Cat”                                                                                                                                                    Picture 2.3 B: “Cat”

Core exercise “Cat exercise” 1. Get into table top position equal balance on knees and hands 2. Anterior pelvic tilt, 3. Exaggerated arch of the spine with abdominals engaged 4. 4.From the cat position you’re going to create a hollow in the abs 5. 5.Posterior pelvic tilt 6. 6.Repeat 10-15 times

                                                            Picture 2.4: Lying hamstring stretch                                                                             Picture 2.5: Supine Torso Stretch   Proprioceptive Neuromuscular Facilitation stretching or PNF, is a technique that can be very helpful in increasing ROM in patients with CP. It involves both passive and active movement (concentric and isometric) muscle actions. The basic philosophy behind PNF is that all human beings including those with disabilities or medical conditions have untapped existing potential. Continued activity is essential to maintain and improve the power, endurance, coordination, flexibility and strength of the neuromuscular mechanism.
  1.  The exercise therapist moves the client passively through the movement; once the client understands the pattern of movement he or she begins active movement. Once this is achieved the therapist begins to apply resistance. At no time will the patient be moved into positions that are contraindicated (causing more harm than benefit).
Three types of contractions are used: concentric, the contraction phase of an exercise where the muscle shortens, eccentric the lowering or elongating portion and isometric exercises where you hold a position or push or pull against static force for an allotted period of time. These techniques are used to increase strength and coordination. Contract and Relax is typically used for increasing ROM and facilitating relaxation. The trainer places the segment at the point of limitation within the movement pattern. Resistance is placed on all concentric contractions of either the restricted agonist or antagonist.

Types of PNF exercises: Contract-Relax

  1.  Begins with a passive pre-stretch that is held at the point of mild discomfort for 10 seconds.
  2. The patient then pushes or pulls against resistance (10-20%) for the full ROM of the exercise e.g. Hamstring curl, which causes a concentric muscle contraction
  3. The patient then relaxes and a passive stretch is held for 30 seconds.

Hold –Relax technique

  1.  Begins with a passive pre-stretch that is held at the point of mild discomfort for 10 seconds
  2. Partner applies force and the patient is instructed to hold and not let you move their leg during this manual resistance at 20% of their strength which causes an isometric muscle contraction hold for 6 seconds
  3. Followed by a complete relaxation of the muscle by the patient for 30 sec.
  4.  The leg is again passively taken through the same ROM which should have increased slightly from the first time.
  5. Repeat exercise 3 times..
3. Posture and Body Alignment Frequency: Daily Intensity: Begin with Gentle ROM (Range of Motion) work up to 30 second holds Time: You can work on your posture anywhere and at anytime Type: Neutral spine and core stabilization exercises Postural Awareness is very important and is one of the first areas to focus on. People with chronic pain have the habit of slouching, standing and sitting in ways that take the load off of the painful area. This habit is called Pain Postures. Persons suffering from CP have to spend a great deal of time correcting and improving on their posture. This is usually an issue even in healthy individuals. You can notice this especially in the upper body with the curvature of the back, slouched or elevated shoulders, or internally rotated shoulders and tight pectorals muscles. You can also notice the shortness of breath or shallow breathing that usually accompanies the poor postural alignment. Lower body weaknesses that can be seen, are likely caused by long periods of sitting where the hip flexors become tight the abdominal and back stabilizers are weak, and their head position is usually in a forward thrust position.             Poor standing posture                       Good Standing Posture                            Poor Seated Posture                            Good Seated Posture Ideal alignment is a balanced posture in which the body positioning is centered and relaxed for all the joints of the body. When the joints are in their proper position then they can relax and unnecessary tension can be released. Ideal alignment is the most mechanically efficient positioning for the body. Ideal alignment uses a plumb line down the length of the body to compare the relative positions of the: • Ears • Shoulders • Spine • Hips • Knees • Ankles • Feet If these structures are not lined up with the plumb line, there are likely to be muscular imbalances which need to be corrected. **Proper postural alignment is essential in helping to decrease pain and increase strength. This can be achieved by learning to engage the core muscles. Most people think that the core consists primarily of the abdomen. Core stabilization involves the deep muscles of the abdominals, the transverse abdominus, which acts like a corset around your abs, the multifidus which lies along your spine from your neck to your pelvis. Its main function is back stability and the pelvic floor which creates a flexible but stable frame for the lumbar spine.   4. Core Stabilization Training Frequency: Daily Use sets of 1-3 Reps 15-25 Intensity (20-30%) Tempo: 4/2/2(eccentric, isometric, concentric) Rest: 60-90 seconds Briefly, muscles act in two ways: they allow the body to move by contracting and prevent movement in specific directions in order to allow movement to take place in other directions. The muscles that act to move your body are called primary movers. The other muscles which prevent movements in other directions during a movement are called stabilizers. Core stabilization is very important for the strength and alignment of the whole body. A body is one long kinetic chain starting from the top of your head running down your spine through your pelvis, down your thigh into your calf down the ankle and into your toes. Now think of a break in the chain and the concept of only being as strong as the weakest link. Therefore we have to make sure that everything is strong and working well and if there is a weak spot we have to try to repair and patch up the weakened area so that we can function at optimal performance. The core is the area that we always have to go back and retrain and re-align it is where the kinetic chain comes together. This is our body’s foundation for posture, balance, and coordination. A stable and strong core can lead to many benefits, which include: A) Feeling stronger and healthier B) Daily activities can become easier C) Decrease in the amount of pain in the back D) Decrease your chance of further injury  

Chronic Pain

In this day and age, weight loss is something that many people struggle with. We see commercials and billboards advertising the hundreds of “guaranteed” weight loss approaches. We hear about the latest shakes and bars that claim to melt the extra weight away. It seems like every week there is a new diet that a friend of a friend used to lose huge amounts of weight. The reality is weight loss is not as great a mystery as the media would make it seem. It’s quite simple really. Just remember to lose weight you must burn more calories than you take in. For many of us that is easier said than done. With our hectic lifestyles and the demand from us daily, it can be hard to know how much you take in verses what you are burning. While it is always more convenient to stop at a drive through at lunch or grab something with your morning coffee, often times these “convenient” meals carry more calories, sodium and fat than one person would really need in one sitting. The word diet gets throws around a lot. The meaning of the word has gotten lost somewhere in the societal need to lose the maximum amount of weight in the most minimal amount of time. A diet is not meant to be a quick fix to losing weight. Often times the miracle diets that we hear of are short term, not sustainable, not realistic and can even be dangerous to our overall health. A real diet, is one that does not focus on weight loss per say, but on an overall healthy eating plan that we can maintain for a lifetime. A diet should be rich in whole foods that are good for you in more ways than one. Fresh fruit, fresh veggies, lean proteins and whole grains are all part of a healthy and sustainable diet. A diet should never leave you feeling deprived or very hungry. Most of all, a diet should never cause you feel or become ill. Portions are another way to control weight and overall health. The reality is that the portions that we are used to seeing in some restaurants are much too large and pack more calories than most of us will burn in a day. Being aware of what you eat is only half the battle. We also need to be aware of how we eat. Our stomach needs to deliver the message to our brain that we are full. This happens when signals are received by the brain from digestive hormones that are released in the digestive tract. By eating slower, we allow time for the message to be received to our brain. Sips of water, taking time to chew our food or even putting our cutlery down after every few bites can aid in controlling how quickly we eat our meals. When we eat slower, we notice that we are full faster, limiting the portion of food we consume. Weight loss is 75% what we eat, and 25% how active we are. If we are following a healthy diet, and are watching our portion sizes we will begin to see and feel our bodies change. Physical activity pushes our body to burn the extra calories that we consume. When we lead sedentary lives, we are limiting the amount of calories that we burn. A brisk walk can be a great way to burn those extra calories and a great excuse to get outdoors with friends and family. Fitting in some extra physical activity doesn’t have to be complicated. For example, taking the stairs instead of the elevator everyday or walking instead of driving are ways to sneak some extra activity into your busy day. If you work at a desk, try standing up every once in a while and taking a walk around the office. This may not seem like much, but any physical activity is progress. Diet and exercise are the keys to not only weight loss, but overall health. If your health is negatively affected by your weight, or if you are simply not happy in your own skin, eating right and getting active are the best ways to shed the extra weight and feel good in the process. It may not happen overnight, but with time, patience and commitment, the weight loss will come and it will be easily maintained.

Chronic Pain

When the words “mental illness” are heard, often times it leaves people feeling uneasy, unsure, and guarded. This is because we as a society tend to fear things that we do not understand. Mental illness is very much a misunderstood term. A negative stigma clouds over those who suffer from mental illnesses. This needs to change. What we see and hear in the media has a huge impact on how we as a society perceive mental health. We are lead to believe that someone with a mental illness is uncontrollable, violent, and unable to function and adapt in society. This cannot be further from the truth. In fact, there likely are people around you, friends, work colleagues, even some of your own family members who are suffering with symptoms of mental illness but have perfected the art of masking it from others out of the fear that they will no longer be seen the same way. The number of people who suffer with mental illness is larger than you may think. In fact, 10% of the population in Canada has reported symptoms of a mental health disorder in 2012. These are only the reported 10%. There are countless of people who have not reported to a health care provider and are suffering in silence because of the stigma that mental illness carries along with it. They are worried that they will not be seen in the same light. The fear is that the stigma attached to mental illness will overshadow who they are their achievements, credibility and leave them forever labeled as someone with a mental illness. The truth is that a negative stigma such as the one we associate with mental illness can cause not only fear, but damage. Because society is not educated on mental illness, we are also limited to how much we know about mental health and maintaining long term mental health. Mental illness involves our most complex and vital organ; the brain. Just as with any other illness such as heart disease or kidney disease, the illness is due to the organ not functioning the way that it should be. When we are talking about mental illness, we are referring to the brain not working the way it should be. Mental illness is an umbrella term used to describe a variety of problems causing the brain to not function the way it should be. This can be in the form of depression, anxiety, schizophrenia, bipolar disorder and many other mental illnesses. A mental illness can be caused by a number of factors. Medications, other illnesses, addictions, genetics and environmental factors can all cause someone to develop a mental illness. Mental illness doesn’t discriminate. It has no preference. People who have suffered a traumatic experience such as war, violence, abuse and neglect are prone to developing a mental illness. Often times addictions such as a drug addiction, alcohol addiction or engaging in other forms of addictive behavior lead to, or are the result of a mental illness. Genetics can also play a heavy role in mental illness. A family history of mental illness can predispose you to developing a mental illness. With so many factors affecting mental health, and such large numbers of individuals who are battling a mental illness, it is hard to understand how our society can close its eyes to what is happening. If we cannot openly discuss and educate ourselves on mental illness, then we cannot understand mental health. We are too heavily influenced by what media is depicting that we are ignoring the health of the most vital organ in our bodies. The negative attitude society displays in the face of a mental illness is causing damage almost beyond repair. People are suffering needlessly, not being diagnosed and as a result, not getting treatment. People are afraid to ask even the closest of family members for help. This can cause difficulties in the home and in forming and maintaining relationships with others. It has affected people negatively in the workplace, some even losing their jobs because asking for help and empathy was not an option. The sad reality is, some have been suffering in the darkness and have been masking the symptoms to all outsiders looking in for so long that self harm was the result. The darkness from within the illness is all that can be seen and they are drowning in a society that refuses to hear their cries for help. With limited places to turn to and a stigma so negative that it can rob you of who you are, it is the duty of society to embrace mental health and end the stigma once and for all. The same way we wouldn’t turn our back to someone suffering from an illness of the heart, we cannot close our eyes to someone suffering from an illness of the mind.  

Chronic Pain

Mental Health is as important as any other aspects of Health, if not be the most important one among them. If one be in perfect physical condition but the mental or emotional state be disturbed, then the whole health of that individual will be compromised. But Mental Health is linked to so many aspects of one's personal , familial, societal, professional and global matters that in order to reach the perfect state of mental health, a comprehensive collaboration of all stakeholders is needed. Collaboration is the cornerstone of Mental Health as good Mental Health cannot happen in isolation. Collaboration between the Patient, family physicians, social workers, Mental Health workers, psychologists and psychiatrist are among a few to name in the large network of collaborations needed for supporting Mental Health. You can use this online platform along with ZENDOSE on twitter free of charge for linking your different support elements in a collaborative Mental Health network.

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Opioid Medical Complications Long Term Opioid Therapy may be needed of appropriate for your pain management. However in higher doses and in long term, you may develop some medical complications. The following are there complications that you may experience as a result of long-term opioid therapy. Please talk to your doctor if you feel any of the following problems: 1- Neuroendocrine abnormalities and erectile dysfunction You may experience difficulty with erection, lower libido and lower stamina due to lower testosterone level. Please talk to your family doctor or your treating physician if you experience any of these symptoms. 2- Sleep Apnea: Long Term Opioid Therapy can aggravate Central Sleep Apnea meaning it can impair ability to breath at night through sedating the breathing centre of brain. It can also aggravate obstructive sleep apnea. If you snore, wake up tired, get muscle twitches or spasms at night you should speak to your family doctor or treating doctor. Mixing opioids with benzodiazepines or other sedative medications can increase the risk of sleep apnea. Please do not mix opioids with any sedating medication or alcohol. Please inform your doctor of any changes in your medications. 3- Opioid Induced Hyperalgesia (OIH): It maybe difficult to believe that taking pain medications like opioids can have a paradoxical effect and increase the pain. OIH is a paradoxical hyperalgesia (increased in pain sensation) resulting from Long Term Opioid Therapy. It is characterized by pain sensitivity (hyperalgesia: increased pain sensation, and allodynia: perception of pain from a non painful touch message) in the absence of overt opioid withdrawal. It is distinct from tolerance in that pain extends beyond the area of initial complaint. It is also known as opioid neurotoxicity. Please inform your Family Doctor or Treating Doctor if you encounter any of these complications while on Long Term Opioid Therapy. Sleep Apnea can be a life threatening complication and the two other medical complications can impair your quality of life. It is important to inform your doctor if feel any sign of these complications so your doctor can adjust the dose or change your medications.

Chronic PainRemedies


Postpartum depression, like many other mental illnesses, carries with it a stigma. With this stigma there is shame, guilt, fear, anxiety, and anger. As with all mental illnesses, if left untreated the effects can last for a longer period of time, worsen, and become a permanent part of your daily life.

Over the last few years there has been more talk about postpartum depression. The media has brought it in to the light to try and ease the stigma. However until we can change the way society perceives mental health, there will always be those who suffer in silence. I know this. I am one of them.

Approximately 50% to 75% of all new mothers will suffer from something called “Baby Blues”. This is a temporary and often mild feeling of fatigue, feeling overwhelmed, crying either out of sadness or frustration and changes to your sleeping and eating patterns. Given the fact that a newborn has the highest demands, requires immediate attention and has no concept of day or night it is easy to see how the vast majority of new mothers reported feeling the Baby Blues. Most new mothers recover once they get into the swing of life with a new baby. Having a child is a big change and specifically for first time mothers, there are some significant lifestyle changes that will need to be made that can take some getting used to.

Approximately 15% of mothers have reported struggling with Postpartum Depression. It is worth noting that these are only reported cases. Many mothers either don’t recognize the symptoms, or are ashamed to report what they are feeling. I admittedly, am an unreported case. I know firsthand what it is like to carry with you this secret, all the while acting seemingly normal to those around you.

In recent years, new categories have been added to the postpartum umbrella diagnosis, including postpartum anxiety, postpartum post traumatic stress disorder, postpartum obsessive compulsive disorder and postpartum psychosis. Someone who is struggling with postpartum depression can also be dealing with one or more of these diagnoses at the same time.

Postpartum anxiety affects approximately 10% of postpartum women and can be recognized by constant worry and the overwhelming sense of doom. You will often have racing thoughts that you are not able to control, most of which will be negative. You may assume the worse is going to happen without having any real reason to feel that way. You may find it is difficult to focus, sleep and eat. Often, the postpartum woman may be afraid of being left alone with the baby.

Postpartum post traumatic stress disorder affected 1%-6% of women and will often occur after birth following an unplanned or emergency cesarean, a baby who is sick or in the NICU, a difficult labor, a lack of support during labor, or other medical emergencies during delivery. Those who suffer postpartum post traumatic stress disorder will often have nightmares about the scenario or will avoid anyone and anything that reminds them of it. Often, the women will become overprotective of the baby.

Postpartum obsessive compulsive disorder affects 3%-5% of postpartum women. This can be recognized by repeating the same task over and over again in an attempt to cope with anxiety or depression which can include making lists, compulsive cleaning, checking and rechecking actions that you or others have already performed or repeatedly having mental images of yourself or the baby that can be disturbing. Often, the woman will be afraid of being left alone with the baby.

Postpartum psychosis is the most severe form of postpartum depression. It affects approximately 1 in every 1000 pregnancies. The onset is very sudden and usually occurs 2-3 weeks after birth. The symptoms are bizarre and uncharacteristic behavior, suicidal thoughts, delusions and hallucinations, thoughts of hurting the baby, and uncharacteristic hyperactivity.

Postpartum psychosis is considered to be a medical emergency. The person should be seen and treated immediately.

Symptoms of postpartum depression will usually appear shortly after birth. Sometime, mothers begin seeing the signs 3-6 months after birth. When a woman gives birth, her hormones take a sharp dive. This is the cause for the sudden changes in mood, the chronic feeling of fatigue and depression. That, in combination with a lack of sleep, being overwhelmed and feeling anxious about your parenting skills creates the perfect storm for feeling inadequate and depressed.

Mothers who suffer from postpartum depression are often confused about what is happening to them. They are uninformed about postpartum depression. In my case, I remember thinking to myself, “I should be happy. I must be a terrible person.” It is hard to imagine yourself finally holding your child after countless hours spent dreaming about this moment and feeling nothing but self-pity and remorse. But it is real and if left untreated it could escalate to something more severe.

Postpartum depression is not to be confused with Baby Blues. The feeling of depression and anxiety can last for months and even up to one year. Some mother report suffering from severe postpartum depression even 2 years after birth. This can happen if the problem is never addressed or treated. There is however, the possibility that childbirth only amplifies underlying symptoms that have been ignored for some time before, such as anxiety or post traumatic stress disorder.

I myself am no stranger to mental health, which is why I can see it from multiple perspectives. To the new mother who doesn’t feel normal, I have been there. To the woman who is toying with the idea of walking away from it all, I have been there. To the woman quietly sobbing in a dark nursery watching the sun rise and feeling the cold air brush against your ankles, I have been there. You are not alone in this. Reach out for help and understand that it is not you that is the problem. You are not broken. There is a solution. There is no shame in asking for help.

Chronic Pain

If you feel lonely and you believe that you have to face the world alone,then you have a lot to reconsider. Loneliness is the worst enemy of human's mind. For more than a million years we are adapted to live among others and to connect to others. It's imprinted in our DNA to live with others. That has become a part of our way of being. That is why it hurts so much to be or feel alone. But the good news is, YOU ARE NOT ALONE. You can join this or any other community, group of people or any person in your life path to share the weight of your moments with them. The first step is to allow yourself not to be alone. Accepting your value to others and their value to you. Allowing yourself to connect with others. Then you will see that: YOU ARE NOT ALONE!

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