Manage Your Pain: Practical and Positive Ways of Adapting to Chronic Pain - Michael K. Nicholas, Allan Molloy, Lee Beeston, Lois Tonkin (2012)

Chapter 10. Stretching and Exercising

Health experts often tell us ‘Don’t take exercise seriously, just regularly’. This is all very well for those who are capable of exercising, you may be saying, but how could someone with ongoing pain like mine possibly be expected to exercise?

Many people who experience chronic pain tend to arrange their lives to avoid activity as much as possible in an attempt to lessen their pain. Is this sensible? At first sight it may seem so, because activity may be uncomfortable. A closer look, however, shows that taking less exercise is not the answer to the problem.

As you become less active you become less fit. This means that you can no longer exercise as much, and when you do exercise, it is more of a strain and often causes more pain. This can be the start of a vicious spiral of decreasing activity, as outlined in the diagram on page 112.

In the end the person with chronic pain may decide to give up many of their usual activities. They may give up their job, hobbies and sport. They may feel they can no longer walk with confidence, do the gardening, or even leave the house. As a result, they may become very isolated.

Exercises can be used to reverse this downward spiral. Of course, getting fitter doesn’t guarantee success, but it can be a big help. Over time, getting fitter can help you to achieve an optimum level of physical and psychological functioning.

The Downward Spiral

The downward spiral

Athletes exercise to enhance their performance so they can go higher, faster and longer. Unlike machines which wear out with use, the body has a unique ability to repair itself. But to do this, joints and muscles need to be used, they need exercise. Otherwise they will become stiff and sore.

Fifty years ago people recovering from injuries, strokes, heart attacks or surgery were advised to rest as much as possible. Many were advised to stay in bed for weeks. But over time it was realised that rest was bad for these people. As a result, people with these conditions today are generally encouraged to get moving as soon as possible and to take up suitable exercises. Exercising promotes recovery, avoids the bad effects of rest and helps people regain near to normal function of their body.

In the early stages of recovery from these conditions people seem to accept pain in the short term for the long-term benefits which they know they expect to achieve. Similarly, it is a good idea for people whose pain does not go away to maintain at least some regular exercise. This can avoid the effects of disuse—muscle tightness, weakness, poor fitness and abnormal coordination.

The upward spiral

Being fitter and more active can also help you to feel good and improve your confidence in yourself. The diagram on page 100 shows how exercising can lead to being more active and feeling more confident.

You have already read in the Introduction about the difference between acute and chronic pain. It is a commonly held view that pain is always a sign of damage. This is true in the acute stage of a problem, when the pain is a warning sign that something is wrong. In the chronic stage, however, changes occur to the way pain is transmitted along the nervous system. These changes can amplify the pain signal from the original site of the problem, via the spinal cord, to the brain. In addition, the message coming down from the brain to the spinal cord is not dampening down the pain signal.

Once pain becomes chronic, it will fluctuate in severity, but that is normal and it doesn’t necessarily mean further damage has occurred. It may simply be a sign of changes in the nervous system. Exercising is unlikely to take your chronic pain away, but it can help you to do more and to feel better than if you don’t keep active.

The Upward Spiral

Issues to address before starting an exercise program

Fear of pain

It is normal to be a little fearful of starting an exercise program. You may be concerned that if you exercise you could cause more damage, or you may just be fearful of the pain itself. By following the advice in this book, you will find that you are gaining skills and strategies to help you overcome these fears. Most importantly, as you increase your activity level despite your pain these fears will ease, especially when you see for yourself that nothing really bad happens.

Consider the case of Jane, who sprained her knee in a fall on some stairs and was fitted with a knee brace to support her knee. Because of her fear of the pain and the way she associated the pain with more damage, she avoided putting weight on her leg. This in turn meant that she started relying on a walking stick to walk and changed the way she walked. Eventually, the only way she could walk was to lean on the stick and swivel her body around to get the other foot forward. Before long she was suffering with back pain and a stiff and painful hip from holding her leg close to her body for protection.

At work she was put on light duties, which she found very boring. She was sleeping in a different bed from her husband because she was fearful of the pain if he touched her through the night and the risk of causing more damage. She had been having massage and heat applied to her knee and had been told not to move the knee if it caused her pain. The message to remain fearful of the pain had been inadvertently reinforced by the person treating her. No wonder she was fearful!

It should be mentioned that when anyone begins exercise after a period of not exercising, it is normal to feel muscle pain. This additional pain is to be expected and will settle as you maintain your exercise program and gain more flexibility and strength.

It is also possible that when you start exercising you may find that your chronic pain is aggravated. This is what you would often have experienced after overdoing something. As will have happened in the past, this additional pain will also settle. Any flare-ups in your pain through overdoing things will not mean that you have caused yourself more injury. It could suggest that you have set your exercise levels a little too high and you should start at a slightly lower level. Have another look at Chapters 7 and 8 on pacing and goal setting for more discussion of this issue. It would also be a good idea at times like this to have a look at the chapters on dealing with flare-ups (Chapter 17) and challenging ways of thinking about pain (Chapter 11).

One approach you could try would be to practice your relaxation technique, do some gentle stretches, and decrease the number of repetitions (say, by 50 per cent) and the level of difficulty of your exercise program until the flare-up settles. But don’t stop completely. After a day or two you could gradually increase your exercises again to your pre-flare-up level.

As well as these steps, you should try to monitor the thoughts going through your mind at this time—things like ‘Oh no, something has gone wrong, some more damage has occurred’. If you find you are thinking thoughts like this, you should use the thought challenging described in Chapter 11 and try to turn your thoughts around to something like ‘I know my nervous system is oversensitive and this is why I am feeling more pain now than would be normal. I know it will settle. I’ve had it like this before. I should try to keep myself calm. Use my relaxation techniques, check any unhelpful thoughts’.

In Jane’s case, she had several periods when her pain flared up in the first couple of weeks of the exercise program. Over time, as she applied the principles of pacing to her exercise program, she could see that she could in fact do more overall if she timed herself to do shorter periods of activity, alternating with other activities when she was not on her feet. However, she didn’t wait for the pain to become so severe that she had to sit down. Rather, she had worked out her average tolerance for putting weight through her leg, and had set a timer to go off at that time.

During these times when the pain flared up, Jane became quite anxious about what was happening. She found it very helpful at these times to write down what she was thinking, and then see if she could turn her thoughts to a more helpful way of dealing with the flare-up.

Acceptance

Another hurdle to overcome is accepting that your pain is chronic and that you have to learn to manage your pain. As we have emphasised earlier, before you can be expected to come to terms with having chronic pain, it is essential that you have been thoroughly investigated by the appropriate doctors for any medical or surgical options available to you. This should ensure as much as possible that there is no reasonable medical or surgical solution available.

Once the appropriate specialists have concluded that they have nothing further to offer, then it is a matter of accepting their advice. Of course you may choose to pursue the problem, seeking more opinions. But it is our experience that this can result in keeping you in the downward spiral of frustration and disappointment.

The case of Jane provides a good illustration of this situation. Jane’s knee had been thoroughly investigated by knee specialists. There was certainly a minor problem showing in the knee, but nothing that any surgery or drugs or injections could help. This had been very distressing for Jane initially, because she wanted a cure. However, over time she came to accept that there was not going to be an easy, immediate cure. She also came to accept that she could benefit from seeking help in learning ways of coping with her pain and getting back into life again.

Goals

When you start exercising, keep in mind some realistic and achievable goals. Realistic goals for an exercise program are increased flexibility, strength, fitness and more endurance to do things without becoming so tired. Improving your physical coordination will help you to regain the skills necessary to perform many normal activities. Pain may be reduced, but it is more realistic to work towards functional goals rather than use pain relief as a goal. Functional goals are things that you do, like walking, driving, vacuuming and working. Seeking pain relief or cure from an exercise program would be unrealistic.

How can you plan to achieve these goals? If your goal is to pick up the grandchildren, you have to look at what picking them up requires. First, you will need enough flexibility in the joints of your legs to get down to the child’s level. Then you will need enough strength in both your arms and legs to hold the child and raise your body weight, plus the child’s, to a standing position. You will also need good trunk or back stability and strength.

An exercise program specifically designed for you would include all those component parts. Over time the exercise goals should be increased. At the same time it will be necessary to gradually include some lifting practice as part of your exercise program. This will help you overcome your concerns, especially if your original injury was caused by lifting, and will also help you to increase your confidence to perform the task, despite the pain.

Your lifting program would also be upgraded to work towards achieving your lifting goal of the weight of your grandchild. For example, this could be done by gradually lifting heavier and heavier weights.

In Jane’s case, her goals were to stop using the walking stick and knee brace, return to her normal work duties and to have a family. Initially, Jane was examined by a physiotherapist and a detailed summary of her problems was prepared. She had some tight muscles, some other weak muscles, some stiff joints, some very bad postural problems and very poor balance and coordination. The advice about her exercise program was directed towards correcting the problems noted. At the same time, she started very gently to increase the time she could tolerate putting the weight through her bad leg.

At the same time, Jane started to go up and down stairs. Remember, her original injury was from a fall she had going down stairs. Naturally, she was apprehensive about doing this activity, at least to begin with. As she got going these fears diminished and her confidence grew.

Remember, confidence grows out of doing things. Waiting until you are confident before you do things may take a long time and you may still not get anywhere.

The Purposes of an Exercise Program

• To reverse the effects of inactivity on your body

• To help you to do more of your normal activities

• To reduce your physical limitations

• To help you feel better and more confident about yourself

Remember, expecting exercises to get rid of chronic pain is generally unrealistic. The usefulness of exercises should not be measured in terms of pain relief.

Getting under way

Planning your exercise program

Like most people, you can work out your own exercise program or simply go to a local gymnasium for advice and equipment. However, if you are not confident about doing this or you have been inactive for an extended time then discuss your plans and goals with your doctor. He or she may advise you to have a general physical check-up, especially for your heart, first.

You might also find it helpful to see a physiotherapist for guidance. This use of a physiotherapist should not be confused with having ‘hands on’ treatments such as manipulation or massage, which are not generally useful in the management of chronic pain. Rather, the physiotherapist would be expected to give you a good physical examination to identify exactly which areas of your body are tight, which areas are weak, and what postural problems you may have. These imbalances may have resulted from your pain and subsequent inactivity and could be corrected by appropriate exercise and advice.

You will find a number of stretches and exercises described in the following pages, but there are many stretches and exercises for each muscle group.

This chapter will cover the main aspects of a typical exercise program for someone in chronic pain, but you might find it helpful to obtain specific advice about your problem from an expert like a physiotherapist. If you do seek advice we recommend that you take this book along to show the physiotherapist the sort of thing you are seeking. You should only need to see the physiotherapist two or three times to work out a suitable exercise program and to get it started.

Once you are confident about performing your exercise program, going to a gymnasium regularly can be a good way to maintain your program—if you like that sort of place (many don’t feel comfortable in them). If you like swimming, or cycling, or just walking, then these also can be appropriate ways to upgrade your fitness. But you shouldn’t work on these sorts of activities until you have achieved adequate flexibility and strength through your exercise program.

A stationary bike or treadmill can be a good way to start. For your swimming program, you would need to develop adequate shoulder mobility and strength and leg strength to be able to perform the stroke correctly.

Remember, it doesn’t really matter where you exercise as long as you are exercising regularly.

Typical components of an exercise program

People who exercise regularly, from elite athletes down, use a basic format. They stretch, they do strengthening exercises, they improve their aerobic fitness which increases their endurance to avoid becoming fatigued, and they improve their skills to perform specific tasks by working on their coordination.

Stretching

Stretching has the effect of loosening tight structures. When a muscle is gently stretched the fibres that make up the muscle elongate and relax. This allows the joints to move further. The structures in our body most responsive to stretching are muscles, tendons, ligaments, joint capsules, the sheath around the nerves, skin and fascia. Because all these tissues are somehow involved with muscles, it is easiest to talk about stretching ‘muscles’.

The diagram above shows the muscles with mainly postural functions which tend to tighten then shorten. In our bodies, some muscle groups have a tendency to tighten. These include our calves, hamstrings (behind the knee), hip flexors (across the front of the hips), the outside band of the upper leg, back muscles, muscles across the front of the chest to the upper arms, muscles at the front of the upper arm across the elbow and wrist, upper shoulder muscles, and the muscles at the front of the neck. It is these muscle groups which are targeted in a stretching program.

On the following pages, 11 key stretch exercises are described. In general, we recommend that you do all of them rather than pick and choose between them. To begin with, you may not be able to do each stretch for as long as required. That’s all right; just do what you can manage, then build it up over time.

Your physiotherapist or gym instructor can give you further advice on stretch exercises or suggest other stretch exercises. If you are not sure of the explanation for certain stretches or exercises, keep asking until you get the answer, or don’t do them. Before you start the stretches described here make sure you have read the whole chapter first.

Remember, this is your exercise program. Ultimately, it is up to you to do it. It is under your control, you have responsibility for it and you claim the credit for the gains you will ultimately make.

Shoulder-neck stretch

Place the right hand on top of the left shoulder and tilt the head towards the right shoulder. Shrug the left shoulder upwards for 5 seconds, whilst pushing down on the shoulder with the right hand. Relax the muscle, then push the shoulder down for a further 10 seconds, maintaining the head position. Repeat for opposite side.

Posterior shoulder stretch

Bend elbow to 90 degrees and use opposite hand to bring it across chest. Hold elbow against chest, but rotate hand away from body while maintaining the elbow position (that is, 90 degrees). Hold the position for a minimum of 15 seconds, and repeat. The best results will be achieved if this stretch is done three or more times across the day.

NOTE: If at any time you are uncertain about your exercises, discuss it with your physiotherapist or doctor.

Triceps stretch

Raise your right arm and place your right hand behind your neck. Reaching over your head with the left hand, pull the right elbow back towards the centre of your back. If you have difficulty reaching over your head with the left hand, bring your left arm in front of your body and push the elbow backwards. Hold the position for a minimum of 15 seconds, and repeat. Then repeat with the other arm. The best results will be achieved if this stretch is done three or more times across the day.

NOTE: If at any time you are uncertain about your exercises, discuss it with your physiotherapist or doctor.

Spinal rotation

Sitting in chair, place one hand on the chair behind the opposite shoulder. Twist your body to look over that shoulder using the hand on the chair to pull your body around. Hold for 5 seconds. Repeat to other side.

NOTE: If at any time you are uncertain about your exercises, discuss it with your physiotherapist or doctor.

Pectoral and anterior chest wall stretch

Place hand against wall, fingers pointing backwards, thumb upwards, palm flat on wall. Straighten elbow and turn body away from wall gradually, until a pull is felt. Maintain for 10 seconds. Repeat for opposite side.

VARIATIONS: Follow the instructions above, with fingers pointing upwards and thumb forwards; or fingers pointing forwards and thumb down.

Calf stretch

Lean forward on to a stable surface (for example, back of a chair or the wall). Place one foot forward and straighten the other leg behind. Feet should be facing forwards. Keeping the heel of the back foot on the ground and the knee on the front leg bent, lean forward onto the front knee. Hold the position for a minimum of 15 seconds, and repeat. The best results will be achieved if this stretch is done three or more times across the day.

NOTE: If at any time you are uncertain about your exercises, discuss it with your physiotherapist or doctor.

Quadriceps stretch

Stand on one leg, bend the other knee and grasp the foot with the opposite hand. You may need to use something stable for balance. Keeping the knees together, pull your foot towards your buttocks. It is important that you do not bend forward at the hips. Hold the position for a minimum of 15 seconds, and repeat. The best results will be achieved if this stretch is done three or more times across the day.

NOTE: If at any time you are uncertain about your exercises, discuss it with your physiotherapist or doctor.

Hamstrings stretch

Rest one heel on a support of a suitable height to allow you to keep the knee straight. Keep your back straight (that is, bend at the hips) as you lean forward towards your toes. Hold position for a minimum of 15 seconds, and repeat. The best result will be achieved if this stretch is done three or more times across the day.

NOTE: If at any time you are uncertain about your exercises, discuss it with your physiotherapist or doctor.

Hip extensor stretch

Lie on your back with one leg out straight. Bend the other knee up and use your hands to pull the leg towards your chest. Hold the position for a minimum of 15 seconds, and repeat. The best results will be achieved if this stretch is done three or more times across the day.

NOTE: If at any time you are uncertain about your exercises, discuss it with your physiotherapist or doctor.

Gluteals stretch

Lie on your back with both knees bent. Rest one ankle across the top of the opposite knee. Grasp the bent knee and pull it towards your chest, which at the same time will raise the other leg. Hold the position for a minimum of 15 seconds, and repeat. The best results will be achieved if this stretch is done three or more times across the day.

NOTE: If at any time you are uncertain about your exercises, discuss it with your physiotherapist or doctor.

Latissimus dorsi stretch

Start on your hands and knees, with your arms straight and your shoulders and hips at the same height. Gently rock your buttocks backwards until they rest on your heels. Slide your arms forwards until they are outstretched in front of you. Hold this position for a minimum of 15 seconds, and repeat. The best results will be achieved if this stretch is done three or more times across the day.

NOTE: If at any time you are uncertain about your exercises, discuss it with your physiotherapist or doctor.

Back arch press-up

Lie flat on your stomach on the mat, placing your hands under your shoulders. Without lifting your hips off the mat, push up with your arms. Your back and abdominal muscles should be relaxed throughout this exercise. Hold for 5 seconds then slowly lower your body, and repeat.

NOTE: If at any time you are uncertain about your exercises, discuss it with your physiotherapist or doctor.

Sciatic nerve stretch

Sit with one leg along the bed or table, the other foot on the floor. Keep the knee along the bed or table straight, and stretch down with both hands to reach towards your foot. Pull your toes up towards you.

NOTE: If at any time you are uncertain about your exercises, discuss it with your physiotherapist or doctor.

How long and how often?

You may have noticed that it is necessary to stretch regularly. If you have practised stretches for a few weeks or so and then had a period without stretching, you can feel quite stiff when you begin stretching again. This is because the tissues have a natural tendency to adapt to the positions in which they are used. Stretching beyond this point gives a sensation of tightness. Therefore, it is important to stretch regularly. This may mean 2–3 times per day, particularly if pain is limiting your natural ability to freely perform your full range of movements.

Holding each stretch for 15 seconds is a good time. Longer stretches may be more beneficial in some situations, but if you are suffering pain and you are trying to get your confidence to move your body a little more, then 15 seconds is okay. Of course, 15 seconds may be too much initially. In this case, stretch for as long as you can, but record how long you were able to stretch. The aim would be to gradually increase the time you are able to stretch.

After your first stretch, release the stretch, rest for a few seconds, then repeat the stretch. Follow this routine as you stretch all the muscle groups throughout the body. This should take about 20 minutes, once you are confident and familiar with your stretches. This 20-minute session should be repeated 2–3 times per day.

Warm-up stretches

Sometimes you may choose to use your stretches to warm up before doing your strengthening or aerobic exercise. Stretches are best performed when your muscles are warm. A warm shower can be a good way to warm up your muscles. Alternatively, you may like to warm up with a gentle walk before beginning your stretches.

Similarly, after exercising, it is helpful to stretch again to help relieve the after exercise muscle ache that sometimes occurs.

Stretching and relaxation

Because stretching is a slow, gentle and smooth activity, it is good to incorporate relaxation techniques with your stretching. As you are feeling the muscles let go in your stretch, you could try to breathe out slowly, just like you do in the relaxation exercise.

Strengthening exercises

Strengthening has the effect of making muscles stronger as muscle fibres get bigger. Muscle is the only tissue that responds to strengthening exercises. Strengthening muscles depends on gradually increasing the load on the muscle. This can be done by increasing the number of repetitions and/or sets of the exercise, increasing the length of time the exercise is held, or increasing the weight or resistance the muscle has to work against. Strengthening is differentfrom stretching, which depends on the regular elongation of the tissues.

Muscles with a Tendency to Weaken

As was noted before, certain muscle groups have a tendency to shorten and tighten. Equally, some other muscles have a greater tendency to weaken, often simply in response to becoming inactive and not being used—not in response to the underlying pain problem alone. See the diagram above for the muscle groups with a tendency to weaken.

These muscle groups are the ones that help pull the body straight after the tight ones have pulled it into a hunched over, curled up position. They tend to be the muscles at the front of the shins, along the inside of the knee, the buttocks, the abdominals, the muscles between the shoulder blades, the muscles which pull the head back.

You may have noticed a pattern here. Muscles work in pairs across every joint. The aim of exercises is to have full flexibility and strength of both muscle groups across each joint. For example, when you bend your elbow, muscles at the front of the elbow shorten and tighten, while muscles at the back of the elbow have to lengthen. When you straighten the elbow, the reverse happens. Therefore, both muscle groups need both flexibility and strength. Imbalance between these muscle groups will cause a dysfunction to the quality of movement at the elbow, and may cause more damage at the joint.

The whole body works according to this principle. In the trunk and spine, the pair of muscles supporting the trunk is the back extensors and the abdominals.

Planning your strengthening routine

In order to plan the exercise program, it is important to work out which muscles or muscle groups you plan to strengthen. A professional assessment by a physiotherapist will help you to determine this.

An outline of a basic strengthening exercise program for the whole body is presented here to get you started. This program applies regardless of the site of your pain. Remember, the reason for these exercises is to help you do more rather than relieve your pain.

Strengthening Exercise Chart

Before starting to upgrade your strengthening program, it is important to establish a baseline—that is, a safe and comfortable level at which to begin your program. See Chapter 7 for a discussion on learning to pace up your activities. Remember to break up large tasks into small bits, take frequent short breaks and to gradually increase the amount you do.

Use the Strengthening Exercise Chart provided on page 132 as an example. You can copy your own chart onto a piece of paper.

To set your exercise baseline, you should record the number or repetitions you perform of each exercise on the first and second day of your program. Remember to start at a level that you can manage comfortably, no matter how little. Don’t push yourself.

Once you have two recordings for each exercise, you do the following calculations. Add the number of repetitions together. For example 6 + 4 = 10 and then work out the average of those two figures. In this case, 10 divided by 2 = 5.

Then work out 80 per cent of that figure (or take 20 per cent off the average figure). Eighty per cent of 5 is 4. This then becomes your starting point for your exercise program. This is your real baseline. The figure doesn’t have to be exact, a rough estimate will do, as long as it is less than your average.

The reason for starting this way is to be quite sure that you are starting your exercise program at a level that is safe and achievable for you. From then on it is a matter of setting a gradually increasing goal each day or two (you have to decide which would suit you better). So you might increase by one or more repetitions each day or every second or third day—whatever you feel you can manage. Remember to pace.

The way you upgrade your exercise program depends on the effects you wish to achieve. Upgrading in different ways will achieve different results. If you want to increase strength and bulk in the muscles, then a method called the ‘one rep max’ is appropriate. This means that you lift the maximum weight that you can lift only once. A modification of this method may be to find the weight you can lift once, reduce it by 25 per cent and then lift that weight 4 or 5 times.

Probably the most useful method of upgrading for people who are trying to increase their activities despite their pain is to follow the principle of building up to doing three sets of 6–10 repetitions. The effect of exercising this way is to increase endurance and stamina to keep on doing things without becoming as tired.

Abdominal hollowing

Lie on your back with both legs bent and feet flat on mat/floor. Maintain the natural curve of your lower back. Breathe in … and out … then stop breathing for a moment and slowly and gently draw your lower abdomen in. Hold this contraction for a few seconds while breathing normally again. Then relax.

Do as many as you can and record the number on your strengthening exercise sheet.

The tendency will be to hold your breath, however it is important to maintain the hollowing while breathing normally.

NOTE: If at any time you are uncertain about your exercises, discuss it with your physiotherapist or doctor.

Abdominal hollowing with double leg lift

Lie on your back with your knees bent and feet flat on floor/bed. While doing your abdominal hollowing, lift one leg off the ground, and then the other leg. Then lower one leg at a time back to the starting position. Then relax your abdomen.

The tendency will be to hold your breath, however, it is important to maintain the hollowing while breathing normally throughout this exercise.

NOTE: If at any time you are uncertain about your exercises, discuss it with your physiotherapist or doctor.

Lunge

Stand with feet apart in stepping position. Take weight forward on the front leg and bend at the knee and hip to lower your body toward the floor. Allow the back knee to bend and the heel of the back foot to lift off the floor.

NOTE: If at any time you are uncertain about your exercises, discuss it with your physiotherapist or doctor.

Vastus medialis obliquus retraining

Stand in a walk-stance position (as if you have just taken a step) with the front knee bent to 30 degrees and pull up the muscle on the inside of that knee. Arch the foot, then allow the foot arch to drop slightly. Repeat a number of times.

Alternatively, step down from a step and then back up, keeping the knee over the second toe.

NOTE: If at any time you are uncertain about your exercises, discuss it with your physiotherapist or doctor.

Hip extension with knee extension

Kneel on the mat on hands and knees with the pelvis and lower back in a neutral position. Straighten your left leg out behind you so that the knee is straight, and hold for 5 seconds. Slowly return to the kneeling position. Repeat with the right leg. It is important to maintain your pelvis and low back in a neutral position by using your abdominal muscles.

NOTE: If at any time you are uncertain about your exercises, discuss it with your physiotherapist or doctor.

Hip extension with knee bent

Kneel on the mat on hands and knees with the pelvis and lower back in a neutral position. Keep your left leg bent and take the sole of your foot toward the ceiling. Hold for 5 seconds. Slowly return to the kneeling position.

Repeat with the right leg. It is important to maintain your pelvis and low back in a neutral position by using your abdominal muscles.

NOTE: If at any time you are uncertain about your exercises, discuss it with your physiotherapist or doctor.

Hip abductor strengthening

Lie on your side. Lock your knee straight, raise your leg and slowly bring it backwards. Hold for 3 seconds then slowly return. Keep your pelvis stable and maintain a true side-lying excessive hip hitching.

NOTE: If at any time you are uncertain about your exercises, discuss it with your physiotherapist or doctor.

Shoulder retraction with arm raise

Lie on your stomach with a rolled towel under your forehead, arms above your head, elbows slightly bent. Draw shoulderblade down and back in the direction of the opposite hip. Hold in that position and at the same time lift your arm 2–3 cm off the bed/floor. Lower your arm and relax, then repeat with the other shoulder. It is important to reduce the amount of activity in the muscle that is located between your neck and the tip of your shoulder. That is, keep it as relaxed as possible.

NOTE: If at any time you are uncertain about your exercises, discuss it with your physiotherapist or doctor.

Neck retraction

Link hands behind the back of the head, well above the neck. Glide the head back without tilting it, giving yourself a ‘double chin’ and keeping the eyes level. Hold for a few seconds and then relax. Repeat 4–5 times.

NOTE: If at any time you are uncertain about your exercises, discuss it with your physiotherapist or doctor.

Take the example of Robert, who had had a back injury, a back operation and two falls over a period of five years. When he started his exercise program, he was unable to lie on his back because of the pain. He began with one ‘repetition’ of the abdominal hollowing exercise because that was as long as he could tolerate lying on his back. By working on his exercises each day he gradually increased the number of repetitions he could manage. After two weeks, he was feeling much more confident about being able to tolerate lying on his back.

So, it doesn’t matter how many repetitions you start with. Building up your confidence to know that you can do more despite the pain is what is important.

Posture

Posture refers to the alignment of the body. In a way, we all know what is meant by maintaining a ‘good’ posture. Most of us like to lie about at home, often slouching on a sofa or armchair. Yet we have all been told at one time or another that that sort of sitting is ‘bad’ for us. However, when you don’t have pain it may not matter very much if you have a poor posture, or sit in a poor posture for a while. But if you do have pain, poor posture can make things harder for you.

Don’t get too carried away about posture, however. There really is no perfect posture, and no one ever keeps a good posture all the time. A general awareness of a good posture and an attempt to maintain it as much as possible is usually enough for most people.

A ‘good’ posture is the correct alignment of the body so that all the muscles can perform their required functions in the best possible way. Posture is not fixed and rigid. Every time we move or remain in a sustained position, we are assuming some posture. Ideally, that posture should be such that the muscles working between the spine and the limbs can do the best job possible. If the bony attachments are not in correct position because of poor posture, muscles will have to work at a mechanical disadvantage and cause undue strain.

Physiologically Efficient Posture

It can be easy to get into bad habits with our posture, especially if we are trying to favour one side or one part of our body because of pain. A common example is trying to walk with a small stone in your shoe. As a result, you may change the way you walk to accommodate the stone. If you continue in this altered posture you may eventually notice pain in the knee and hip. The diagram at left shows what the ideal standing posture would look like. While stretching and strengthening the muscles of the spine is important, it is also important that our spine muscles can hold the spine in a stable position. The lower part of the spine requires good stability in order to allow the hips, and in turn the legs to function properly. Likewise, the upper part of the body around the shoulder-blades needs good stability to allow the shoulders and the arms to function properly and to relieve undue strain on the neck.

Take the example of Sally, who had been involved in an accident that had caused an injury to her neck. As a result of the length of time she had spent protecting and guarding her neck, she had developed changes to her posture.

Sally started using the stretch and strengthening exercises outlined in this chapter to improve her posture. In addition, rather than protecting and guarding her neck she tried to use it as normally as possible. She also started to use the other pain management coping strategies described in the following chapters. Gradually, Sally started feeling better about herself and was able to do things more confidently.

You can see this program is not a quick, or easy fix for your problems, but by persevering in the application of the strategies, you can regain much of your lifestyle. Of course you will have difficult times when you may feel it is not worth the effort. That is when you need to go over the pages in the book you have flagged as being important for you, and give yourself a little refresher course.

Lifting

One of the ‘postures’ that we assume throughout the day is the posture involved with lifting. Rather than practice a ‘best’ posture for lifting, it is more helpful to consider some general rules. First, wherever possible, avoid lifting by using mechanical aides as they can result in your developing or maintaining unhelpful postures. Second, if you must lift, reduce the weight. This may mean carrying two small bags of groceries from the car to the house rather than one heavy bag.

Raise the load so that you do not have to reach to the floor—for example, get your two year old to climb on the chair and lift her from that level. Hold the load close to your body. Get into a ‘semi-squat’ position with a small amount of bend in the knee, hip and trunk, not with the back fully bent forward (see the diagram on this page for an example of ‘good’ lifting).

Avoid twisting or bending sideways while lifting, and avoid lifting after periods of bending forward for a long time, such as after digging in the garden. Lift smoothly and slowly.

Safe Lifting and Carrying Positions

Preparing your body to be able to lift is of great importance. Strengthening the bones, ligaments and muscles by appropriate exercise is an essential part. Increasing the load you lift and the number of repetitions you lift by using the pacing principle of gradual increase will help prepare your body to perform the tasks safely.

One of the commonest triggers for back pain appears to happen when people are lifting. Naturally, people whose injury occurred while lifting are often very anxious about repeating this activity. The case of Robert (mentioned on page 139) provides a typical example.

Robert found it helpful to start lifting an empty box from the seat of a chair, and then gradually lowering the level until he was able to lift from the floor. At the same time, he started putting light weights into the box. Since one of his goals was to return to work, he started setting his lifting goals to try to reach a weight which was required for work.

He was not able to reach his pre-injury lifting goal, but he was confident of lifting lighter weights. This helped him to plan the type of work he could start considering. It has also helped him to accept that there would be some limits to the amount he could lift.

Aerobic exercises

Another name for aerobic exercise is cardiovascular or cardio-respiratory exercise, whicht means it is a way of exercising the heart (cardio), blood vessels (vascular) and lungs (respiratory) so that the body continues to use oxygen efficiently. The heart itself is a muscle. It needs exercise like other muscles in the body. The function of the heart is to pump blood through the blood vessels to the muscles, and return waste products. The blood carries oxygen from the lungs to the muscles, and carbon dioxide from the muscles to the lungs (from where it is expelled from the body).

Exercising muscles create a demand for more oxygen. The only way the muscles can get their supply of oxygen is for the person to breathe in more air, exercising the lungs, and then for the heart to pump it through the blood vessels, exercising the heart and blood vessels. If you become too puffed after exercise, then you are probably not getting enough oxygen (ie anaerobic exercise) and your body starts to build up too many acids. You can’t keep this up for very long, especially if you are unfit.

The fitness of the heart can be measured by how fast it beats—that is, the pulse rate. A fit heart will give strong, slow contractions to pump the required volume of blood around the body. An unfit heart will give weak, rapid contractions in order to pump the same volume of blood around the body. As you get fitter, so will your heart.

Improved cardiovascular fitness will help to reduce feelings of tiredness and exhaustion. Getting fitter with aerobic exercise can also contribute to your sense of well-being. For exercise to be aerobic, it has to be performed continuously for 15–20 minutes 3–4 times per week with your heart rate within your training heart rate range. The range is calculated as 65–80 per cent of your maximum training heart rate range. Your maximum range is calculated at 220 minus your age. So, if you are 45 years old, your maximum range would be 220 minus 45, which equals 175.

Balance, coordination and skills acquisition

Good balance and coordination are a necessary part of the skills required to perform normal activities, as well as the more demanding skills often required in work places and sporting activities. Balance is a combination of muscle strength and flexibility, joint range of movement, messages being sent along the nervous system to the brain to help control the amount of muscle contraction to maintain balance, and the balance system in the brain.

In normal daily activities, we are using our balance system all the time. After a period of time when you are not moving as freely and as spontaneously as you used to, because of the pain, your balance becomes affected. The good news is that it is possible to retrain this balance system. To begin with, you can try holding on to a solid support you have confidence in while standing on one leg, and then alternating between legs. As you get better at this, try doing it without holding onto something. For more advanced work you should probably see a physiotherapist as he or she will probably have appropriate equipment.

Simon’s case illustrates this point quite well. He had injured his back and shoulder and had been unable to resume playing golf. He identified this as one of his goals. So, along with his exercises he started practising some gentle chip shots with a practice golf ball. Over time, Simon’s confidence improved and he developed a new posture to minimise the use of his shoulder while swinging the club. He started going to the driving range to practice his swing. Although he was not as competitive as he used to be, he found it extremely satisfying to be back playing his sport and socialising with his friends. He had come to terms with the fact that his handicap would be higher, but he realised that was not so important to him.

Maintenance and recording progress

Often the most difficult part of an exercise program is to keep it going. Have a look at Chapter 20 on maintaining your program. One of the important points is that initially you should discipline yourself to do your exercise program in a structured way every day. For example, you should set aside a specific time each day and ensure, as much as possible, that that time is always reserved for your exercise practice.

Ultimately, you could expect to reduce your exercises as you start replacing them with more of your functional tasks—that is, some of the goals you have set yourself. For example, if you have stairs at home or at work, then climbing those regularly could be built into your day. In that case you could leave extra stair climbing out of your exercise program. At the beginning, however, it is important to establish an exercise routine. Just remember that part of your exercise program is to help you become confident with moving.

One of the best ways to help you establish this routine is to record your progress each day in a type of diary or a chart. Write down or tick off each time you do your stretches, or how many repetitions of each exercise you have done. The strengthening exercise chart on page 132 is a good place to start this process.

Sports and chronic pain

If you want to resume some of your sporting activities you may have to consider what are realistic and achievable goals. Resuming your previous sports may not always be realistic, but you could consider resuming some form of sport. Bowls, bocce, boules and tenpin bowling are excellent examples of how you could use your lunging exercises. Obviously you would have to build up your grip strength to hold your bowl, but that could be included in your exercise goals. As you start focusing on more functional goals, it may become necessary to start setting new goals to help build up your tolerance for some new activities.

Can you think how it may be possible to return to golf? You understand your abdominal hollowing and your shoulderblade stability. When you assume your stance for golf, you would be aware of hollowing your abdominals to stabilise your lumbar spine, bending your hips and knees, keeping your upper body posture relaxed and having a relaxed grip of the club. The movement then should come from your hips and pelvis, with some movement of the feet. As you complete the backswing, the buckle of your belt should be facing away from the hole. As you allow the pelvis and hips to rotate 180 degrees, you end up with your buckle facing the hole. The club has just easily swung through to hit the ball sweetly onto the green. And all this has been done with your lumbar spine stable and your neck and shoulders relaxed.

Whichever realistically achievable sport you choose, the principle of setting baselines and pacing applies. For example, with your golf, to start, just do two or three short relaxed swings on the first day, then stop. Next day, attempt another few swings. Then calculate your average and take 80 per cent of that figure as your baseline. Then gradually upgrade your program to hit light practice balls and then progress to hitting actual golf balls. The important part is to progress slowly and steadily, not to feel that the only way to play is go out competitively for 18 holes. This is one of the hard things to do.

Susan was a perfect example of ‘the typical golfer’. She suffered with neck pain and headaches that were restricting all aspects of her life. She was isolating herself, her marriage was failing and she lived in constant anxiety about getting to her chiropractor for an ‘adjustment’ every time she had a flare-up of pain. Susan was also a perfectionist. Her beliefs were that if she wasn’t out playing competitive golf to attempt to reduce her handicap every game, then it wasn’t worth playing. This was Susan’s attitude when we first saw her. What she described was happening with her golf was that she was slamming the club through so hard that it hit the ground, sent a jolt through her neck and of course set up a pattern of pain with which she was unable to cope. Naturally, she stopped playing golf.

Susan attended the three-week ADAPT program at the hospital. By the end of the program, she had developed the confidence and knowledge to deal with the flare-ups in pain. She was using pacing, stretches, exercises and relaxation, as well as applying cognitive challenging to unhelpful thought patterns. She also started a few gentle golf swings, if somewhat skeptically to begin with. She was also able to manage her own flare-ups of pain without depending on her chiropractor to give her some short-term relief.

Susan came back to see us 12 months later. At this time she was relaxed and confident, she was enjoying a satisfying marriage and although she was seeing her chiropractor infrequently, she was not dependent on him to help her cope with her pain. When asked about her golf, she replied, ‘I wouldn’t have got out of bed 12 months ago for the kind of golf I am playing now’. What did Susan mean? She explained that she was enjoying her golf so much with a great group of women who also enjoy their golf, their lunches and the parties they organise.

Do you see what had changed? Her attitude. No longer was it so important to have the lowest score for the day, but the pleasure of the game was more important. Applying the program’s strategies and thought challenging to her golf, along with the same simple tips given throughout this book had made a huge difference to Susan.

You will have noted that Susan was skeptical about her ability to return to golf. This is not an uncommon attitude for people starting out on this program of ‘self-management’.

One of the pioneers in the field of pain management, clinical psychologist Professor Bill Fordyce at the University of Washington in the United States, once said that ‘What matters is not what you thought at the beginning of a program like this, but rather what you think at the end’. Clearly, providing you are willing to give it a go despite your concerns, you are giving yourself a chance of managing your pain better.