___________________________________________________ Pain Assessment and Management, 2nd Edition
Exercise Physicians and practitioners commonly recommend exercise. Research has made significant gains in identifying the types of exercise that may be beneficial for various pain diagnoses. However, the specific duration and intensity of physical activity recommended by healthcare providers to decrease pain remains subject to debate. Table 8 provides exercise recommendations for diagnoses of nonspecific neck pain, fibromyalgia, and low back pain. From the client’s perspective, exercise can invoke a number of challenges and barriers. These include discomfort during activity, uncertain and fluctuating abilities, fatigue, perceived risks, support, access to supports for activity, and perceived outcomes (Vader et al., 2021). To assist a client in initiating an exercise program, the practitioner might emphasize the importance of consistency, help the client overcome fear, and provide ongoing motivation. Although exercising can be added to a client’s daily or weekly schedule, the practitioner will want to look at the client’s ability to manage their time and consider outside factors that might distract from the routine. Fears related to exercising may stem from a number of con- cerns, including the fear of exercising in the presence of others. These fears may reflect insecurities about how one is perceived by others or feelings of shame over being unable to exercise as much or as intensely as in the past. There is also a fear of increased pain with exercise. Often this pain is short term. However, it can be difficult to distinguish between the soreness typically resulting from disuse or lack of exercise and the pain from an actual pain flare-up. Motivational interventions should address clients’ internal locus of control. Do clients believe that they can change their own behavior or that the external environment is to blame? It is beneficial to explore with clients where they are in terms of readiness to change. The transtheoretical model of change (Prochaska & DiClemente, 1982) is a helpful place to start this inquiry. This model describes five stages of change: precontem- plation, contemplation, preparation, action, and maintenance. Each stage describes the client’s level of desire to change and a time frame. For example, a client in precontemplation is not even considering change, whereas a client in contemplation is considering a change within the next month. To improve a cli- ent’s motivation to change, the practitioner needs to learn what is valuable to the client. To this end, the client can complete a values checklist. There are several values checklists available online, including the Checklist for Personal Values by Roberts (2013). Implementation of the identified values can involve rephrasing a goal. For example, the goal of “exercising two times each week” can be rephrased as “play with my grandchildren without getting out of breath.”
Physical activity can be viewed as a continuum, with decon- ditioning from lack of exercise on one end and a flare-up from overuse on the other. The optimal balance is based on the individual and needs to be discovered through a carefully planned intervention involving collaboration between all healthcare practitioners. The practitioner can begin by con- sidering past exercise interests and modifying those activities, if appropriate. The concept of pacing can help break down an exercise activity and gradually increase the demand. For example, if the client used to like to hike but has not walked more than 5 minutes at a time during the past 3 months, then the exercise goal must start small. The client might begin with a 5-minute walk on a flat surface several times a week to build up endurance. The practitioner should consider factors such as weather and temperature, as well as the time of day that the client has maximal energy. The client’s daily routines, comfort with the environment, and ability to access social support for continued motivation should also be taken into account. Education about the possible effect of exercise on the body can help ease fears. Increased pain in the short term is a typical physical reaction when reengaging in exercise after a period of prolonged inactivity.
EDUCATION AND TRAINING Client Education on Pain
At present, there is little evidence to support the use of pain neuroscience education to improve treatment outcomes for those with chronic pain (Ram et al., 2023). Other researchers found that providing education as part of a multidisciplinary program is likely to improve self-management and self-efficacy for individuals with chronic pain of any etiology (Joypaul et al., 2019). Practitioners can provide the education either on an individual basis or in groups during one or more sessions. The content includes a description of the pain pathway and an explanation of how, in most instances, the brain interprets sig- nals from nerves as a warning of potential danger. However, the brain’s interpretation is not always correct. In some instances, a person’s brain overrides the warning signal, such as when an injury occurs while something more important is occurring and the person does not notice the tissue damage until later. Alternatively, a person can perceive pain in the absence of ongoing tissue damage. In this instance, the brain and ner- vous system are attempting to protect the body. When a body part has been injured or was painful in the past, the nerves change to become more sensitive and fire more frequently, and the brain becomes more aware of the body part, even in the absence of actual pain. The changes to the brain and nervous system with chronic pain are described as central sensitization. Pardos-Gascón et al. (2021) found that MBSR techniques were superior to usual care for all pain diagnoses including the variables associated with pain in central sensitization.
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