PATIENT’S GUIDE TO CHRONIC DISEASE SELF MANAGEMENT WITH EXERCISE AND DIET
The following articles are a structured guide to self-management of chronic pain through diet and exercises. The guide has been broken down into a series of five chapters, with each chapter focusing on a different technique geared towards managing your pain. We hope that through this guide, you will gain the knowledge that you need to control your chronic pain, and reclaim your overall health along the way.
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.
- Warm -up
- Flexibility training (Stretching)
- Posture and Body alignment
- Stabilization Training (Core Strengthening)
- Strength training (Resistance)
- Aerobic training (Cardiovascular)
- Balance and proprioception
- Rest and relaxation (Mind Body Awareness)
- 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.
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.
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
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.
- 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:
- Begins with a passive pre-stretch that is held at the point of mild discomfort for 10 seconds.
- 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
- The patient then relaxes and a passive stretch is held for 30 seconds.
Hold –Relax technique
- Begins with a passive pre-stretch that is held at the point of mild discomfort for 10 seconds
- 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
- Followed by a complete relaxation of the muscle by the patient for 30 sec.
- The leg is again passively taken through the same ROM which should have increased slightly from the first time.
- Repeat exercise 3 times..
3. Posture and Body Alignment
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.\
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:
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
Use sets of 1-3
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