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Use of exercise in the management of non-malignant chronic pain

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Fran Hall, MSc Pain Management, RN.

Clinical Nurse Specialist, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust

Non-malignant chronic pain, no matter where it is and whatever the cause, can be extremely debilitating. It has been defined as 'pain that has lasted for three months or longer, is ongoing on a daily basis, is due to non-life- threatening causes, has not responded to currently available treatment methods, and may continue for the remainder of the patient's life' (McCaffery and Beebe, 1994). It seems to take over the patient's life and involves his or her family, friends, workmates and health-care workers. More often than not, a patient ends up in a chronic pain clinic as a 'last resort' because other health-care professionals can 'do nothing further for them'.
Non-malignant chronic pain, no matter where it is and whatever the cause, can be extremely debilitating. It has been defined as 'pain that has lasted for three months or longer, is ongoing on a daily basis, is due to non-life- threatening causes, has not responded to currently available treatment methods, and may continue for the remainder of the patient's life' (McCaffery and Beebe, 1994). It seems to take over the patient's life and involves his or her family, friends, workmates and health-care workers. More often than not, a patient ends up in a chronic pain clinic as a 'last resort' because other health-care professionals can 'do nothing further for them'.


It is at this point that the patient has often developed fixed beliefs concerning the illness. Family and friends may not react with as much sympathy as before. The condition or pain can then become worse, leading to further disability and dependence on others, thus encouraging illness behaviour to become abnormal illness behaviour (Pilowsky, 1995).


It is recognised that many patients who present at pain clinics are well established in the pain and illness behaviour role (Williams, 1989). Initially, a relatively simple problem/pain can snowball into a condition that is very difficult to treat by health-care professionals. Family and friends may 'reward' illness behaviour by telling the patient to rest, by giving him or her a lot of attention, or by allowing the patient not to have to perform certain duties, and so on. When interest seems to wane, the patient has to show an increase in symptoms to keep the attention or even financial gain, and so the condition perpetuates itself. Patients can also become very frightened of the pain, believing it to be causing them serious damage, which in turn leads to further immobility and more pain.


It has long been recognised that exercise can have a beneficial effect in treating pain. A classic paper by Fordyce et al in 1973 showed that the benefits of exercise could have a direct effect on the quality of life for the chronic pain patient by means of operant conditioning or pain behaviours that may be increased or decreased.


This paper explores the reasons why exercise, in terms of increased physical function, is important in a pain-management programme and how cognitive behavioural strategies can influence the implementation of this exercise in such a programme.


Benefits of exercise programmes
In an everyday situation it is obvious to health-care workers that a certain amount of controlled exercise such as gently mobilising a badly sprained ankle can effectively reduce discomfort and hasten recovery even though it may hurt initially.


Normal movement is associated with normal function. Owing to the effects of pain some patients may have ceased to use or move a joint or joints, thus leading to immobility and increased pain following any movement. They lack confidence in their ability to move the affected joints and so their invalidity increases. If exercise can be used to gradually regain some normal movement the patient will feel both psychologically and physically much improved.


Active exercises, movements made voluntarily and by the patient alone, are used to improve strength, endurance and flexibility, improve everyday activity, break down adhesions and prevent contractures (Pert, 1997). All these measures can reduce the level of pain. This type of exercise, as well as acupuncture and the use of transcutaneous electrical nerve stimulation (TENS), has also been shown to precipitate a release of natural endorphins, which has an effect on the descending pathways and leads to a reduction in the level of perceived pain (Bowsher, 1996).


Many studies show that exercise, when incorporated into a chronic pain programme, can be very beneficial (Fordyce, 1973; Jensen et al, 1991; Burns et al, 1998). One of the reasons for this, especially in the case of low back pain, is that the spinal muscles inevitably become weaker as inactivity continues, making patients feel more pain when they make sudden or twisting movements.


Patients who confine themselves to bed will suffer 1-3% muscle strength loss a day. This increases to 10-15% a week and, after six months, they can expect to have lost up to 70% of trunk musculature (Young and Cole, 1997). With the use of steady exercise these muscles will strengthen and the patient will then start to feel the benefit and feel better able to continue the treatment (Wynn Parry, 1994). It can also be said that one of the most important things to do is to make sure that patients know that they will not be damaging themselves by continuing this kind of treatment and that in fact immobility may be far more dangerous for them in the long term (Clinical Standards Advisory Group, 1994).


Exercise can therefore play a major role in pain management, but before beginning this type of programme the patient's own level of physical activity should also be carefully assessed. This can be very difficult to measure as most patients can be individually assessed only within the relatively short period of time in which they are attending a pain clinic. Harding et al (1994) devised a series of tests to measure the physical functioning of patients attending a chronic pain programme. These included a walk test, a speed walk, stair-climbing, a stand-up test, balance test, sit-ups, arm endurance, grip test and, lastly, peak-flow measurement. Trained testers carried out the tests, with each being checked for reliability and validity.


Early intervention in the acute stage of all musculoskeletal problems in the form of controlled exercise has been shown to be advantageous (Linton et al, 1993). In this study, early active treatment resulted in less risk of developing chronic pain and less inability to work. Conversely, a study by Faas et al (1993) found that exercise had no effect on patients suffering from acute back pain. This perhaps could be an indication that exercise alone may be limited at any stage of pain management, and that incorporating it into a chronic pain programme with the use of cognitive behavioural strategies may be the answer, as in the so-called 'school of bravery' approach.


This type of approach is used to change illness behaviour to wellness behaviour. It aims to reduce fear and pain by ignoring illness behaviours and building confidence by rewarding resumption of normal activity (Pilowsky, 1994). The patient should be treated as an individual who is well instead of someone who is ill, thus teaching patients to tackle and cope with their own problems, and eventually to re-establish their self-respect and well-being.


There is more evidence to support this view. Nicholas et al (1992) demonstrated significant improvement in patients through the use of cognitive behavioural strategies within a pain-management programme compared with a control group, which received the same treatment but without the use of these strategies.


In order to gain these benefits of properly supervised exercise therapy, patients may have to undergo a complete reversal of their own beliefs about their condition. This is where the use of cognitive behavioural strategies can influence the implementation of exercise treatments by both initiating and continuing this adaptation in the patient's illness to wellness behaviour (Williams, 1989). This consistent change in their illness behaviour can be the key to their successful treatment. Turk and Rudy (1991) state that non-compliance and non-adherence can lead to high rates of relapse in a chronic-pain management programme.


The use of cognitive behavioural strategies in a chronic back pain management programme is clearly set out by Harding and Williams (1995). In this paper they describe the main aims of the programme and include the means by which this can be achieved (Table 1).


The authors describe how aspects of changing behaviour are reinforced and pain or illness behaviours are not. The cognitive behavioural strategies involved help patients to recognise their own thoughts and beliefs about their condition that serve only to make their pain and illness behaviour worse, and then teaching them how to change these beliefs. To help this process a clinical psychologist may be called on to counsel both the patient and to teach the carers how to manage the patient effectively.


Patients who have had chronic pain for a length of time are often prone to 'catastrophising' (Harding, 1998), which means that they tend to be very pessimistic and become unable to cope with even the smallest problem. Through the use of cognitive behavioural strategies these patients are taught how to recognise these thoughts as unhelpful, to challenge such thoughts and to eventually cope with the situation, usually through exercise and planning. Patients suffering from chronic low back pain were less likely to take any form of exercise by way of daily activities, such as housework or physiotherapy, if they had strong negative thoughts regarding their pain.


Patients are also taught to accept all the credit for the improvement in their condition by means of self-reinforcement (Harding, 1998), to enable them to gradually increase both their self-confidence and confidence in the effectiveness of the pain-management programme.


Conclusion
Chronic pain in patients who have sometimes had pain for years remains a huge problem. Fortunately, the advent of the multidisciplinary approach to pain management (Bonica, 1985) and a heightened awareness of the need for pain-management clinics and programmes is now helping to solve some of the problems for some people.


It seems clear that a chronic pain programme that includes exercise therapy, by way of introducing realistic goals of achievement and by teaching patients how to pace themselves towards these goals, can be very beneficial but that a high rate of concordance is also necessary to sustain improvements (Williams and Keefe, 1991; Turk and Rudy, 1991).


The cognitions or beliefs of the patient are a significant aspect of the hoped-for improvements in both coping strategies and in quality of life (Jensen et al, 1991). It is important for patients to understand that the aim of the chronic pain programme is to help them adapt to chronic pain and not necessarily to cure the pain.


Therefore, the use of cognitive behavioural strategies to influence the implementation of 'paced' exercise within a chronic pain management programme may have long-lasting effects on the individual. Callaghan (1994) found that lasting benefits could be achieved both as a result of four- and eight-week back rehabilitation programmes, provided the appropriate outpatient follow up was reliable in each case. The key must surely be the success in getting the message across and this need not be part of an ongoing pain-management programme.


However, despite the success of such programmes it needs to be recognised that there are still vast numbers of patients who are unable to receive treatment because the services are not available in their area.


Further reading
Gifford
, L. (1998) Topical Issues in Pain. Whiplash: science and management. Falmouth: NOI Press.

Bonica, J.J. (1985) History of pain concepts and pain therapy. Seminars in Anaesthesia 4: 3, 189-207.

Bowsher, D. (1996) Modulation of nociceptive input. In: Wells, P.E., Frampton, V., Bowsher, D. Pain Management by Physiotherapy (2nd edn). Oxford: Butterworth Heinemann.

Burns, J.W., Johnson, B.J., Mahoney, N. et al. (1998) Cognitive and physical capacity process variables predict long-term outcome after treatment of chronic pain. Journal of Consulting and Clinical Psychology 66: 2, 434-439.

Callaghan, M.J. (1994) Evaluation of a back rehabilitation group for chronic low back pain in an out-patient setting. Physiotherapy 80: 10, 677-681.

Clinical Standards Advisory Group. (1994) Clinical Standards Advisory Group Epidemiology Review: The epidemiology and cost of back pain. London: The Stationery Office.

Fass, A., Chavannes, A.W., van Erjk, J.T., Gubbels, J.W. (1993) A randomised, placebo-controlled trial of exercise therapy in patients with acute low back pain. Spine 18: 11, 1388-1395.

Fordyce, W.E., Fowler, R.S. Jr, Lehmann, J.F. et al. (1973) Operant conditioning in the treatment of chronic pain. Archives of Physical Medicine Rehabilitation 54: 9, 339-408.

Harding, V.R., Williams, C. de C.A., Richardson, P.H. et al. (1994) The development of a battery of measures for assessing physical functioning of chronic pain patients. Pain 58: 367-375.

Harding, V., Williams, C. de C.A. (1995) Extending physiotherapy skills using a psychological approach: cognitive-behavioural management of chronic pain. Physiotherapy 81: 11, 681-688.

Harding, V. (1998) Cognitive-behavioural approach to fear and avoidance. In: Gifford, L. Topical Issues in Pain. Whiplash: science and management. Falmouth: NOI Press.

Jensen, M.P., Turner, J.A., Romano, J.M., Karoly, P. (1991) Coping with chronic pain: a critical review of the literature. Pain 47: 249-283.

Linton, S.J., Hellsing, A-L, Andersson, D. (1993) A controlled study of the effects of an early intervention on acute musculoskeletal pain problems. Pain 54: 353-359.

McCaffery, M., Beebe, A. (1994) Pain: Clinical manual for nursing practice. London: Mosby.

Nicholas, M.K., Wilson, P.H., Goyen, J. (1992) Comparison of cognitive-behavioural group treatment and an alternative non-psychological treatment for chronic low back pain. Pain 48: 339-347.

Pert, V. (1997) Exercise for health. Physiotherapy 83: 9, 453-460.

Pilowsky, I. (1994) Pain and illness behaviour: assessment and management (Chapter 72). In: Melzack, R., Wall, P.D. Textbook of Pain (3rd edn). Edinburgh: Churchill Livingstone.

Pilowsky, I. (1995) Low back pain and illness behaviour (inappropriate, maladaptive or abnormal). Spine 20: 13, 1522-1524.

Turk, D.C., Rudy, T.E. (1991) Neglected topics in the treatment of chronic pain patients - relapse, noncompliance, and adherence enhancement. Pain 44: 5-28.

Williams, D.A., Keefe, F.J. (1991) Pain beliefs and the use of cognitive-behavioural coping strategies. Pain 46: 185-190.

Williams, J.I. (1989) Illness to wellness behaviour. Physiotherapy 75: 1, 2-7.

Wynn Parry, C.B. (1994) The failed back (Chapter 57). In: Melzack, R., Wall, P.D. Textbook of Pain (3rd edn). Edinburgh: Churchill Livingstone.

Young, G.L., Cole, A.J. (1997) Physical therapy options for lumbar spine pain (Chapter 8). In: Cole, A.J., Herring, S.A. The Low Back Pain Hand Book: A practical guide for the primary care clinician. Philadelphia, Pa: Hanley and Belfus.
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