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Exercise - the principles of setting a programme

Stage 1 - Preparation - where is the patient now?

  • Patients’ beliefs/attitudes fundamental to likelihood of starting/continuing exercise. If these are not considered then failure of compliance likely. These will need to be explored and mistakes corrected eg “my spine is crumbling”, “exercise must be bad because every time I do it I have to lie down for a week”. Fear-avoidance is very powerful in preventing activities/exercise due to fear of the consequences. If this fear remains then exercise will not be considered.
  • What stage of change is the patient at? Are they receptive, considering change and accepting the rationale for exercise? Or are they ‘pre-contemplative, unable or unwilling to change at the moment. Remember that ‘resistance seems perfectly valid to the patient. Time may need to be invested to bring the patient round to a different point of view - usually by questioning rather than ‘telling.

Stage 2 - Understanding the over/underactivity cycle.

  • People in pain tend to fall into this counterproductive cycle. On performing an activity they overdo the process, pushing themselves to complete the task even though the pain is becoming intolerable. This results in a significant pain worsening and consequent enforced rest. On recovery the pattern is typically repeated, leading gradually to increased disability.
  • A solution to this is the strategy of pacing. Pacing involves the time measurement of performance of an activity up to the point of significant pain increase. This test level is then reduced by 20% to arrive at a quota for the activity in question. This quota is then adhered to and not breached until some control over the pain is achieved. With time the quota can be increased.
  • If patients understand this problem and the strategy to counteract it, they find it very useful as it both explains their previous behaviours/experiences and gives them a technique to use in setting an exercise programme safely.

Stage 3 - Setting the exercise programme

  • Choice of type of exercise important - needs to suit the participant as they should persist over a long period. Common choices are: walking, running, swimming, cycling, gym training, aerobics, exercises at home, stretching, or a combination. A good programme would include some aerobic work, gym-type work and stretches, not necessarily on the same day.
  • The general principle of setting a quota for any type of exercise is to change the amount of any activity performed from a pain contingent mode to a time contingent one. Patients do not perform activities until the pain stops them but rather stop an activity because the time or the number of repetitions they have decided is up. This is a significant behaviour change and difficult to put into effect.
  • Aerobic exercise - the person needs to choose the activity, which eventually can be done 2-3 times a week for twenty minutes or more. Ask the question “How much of this exercise can you easily do without significantly increasing your pain?” They need to measure this, perhaps several times, to produce an average. 20% less than this level is the quota. This level of activity needs to be performed regularly, regardless whether the person feels it’s too little. Once happy with this it can be increased, but this decision needs to be made before the exercise is performed. Feeling good and deciding to go further whilst doing the activity is the commonest trap.
  • Gym-type activities - it’s easiest to do this in a gym under one of the many exercise-on-prescription schemes around the county. The individual exercises are not of themselves important - the key is to choose exercises for different parts of the body and ones which suit the patient’s individual difficulties. Eg a person with a significant neck problem can do abdominal work in reverse, lifting the legs rather than the head and shoulders. For this reason setting the exercises is best done individually by a qualified person.
  • Choose ten exercises, set the levels of each by repetition, resistance, time as appropriate. Take 20% off as usual to get the quotas, stick to these without variation up or down. Graded increase over time is the aim, with daily repetition of the exercises, and periodic substitution of new exercises (quota tested) to avoid boredom.
  • The biggest problem here may be in the setting of exercise levels by non-pain-management specialists - the tendency is to set levels for the patient, assuming what they can do. What they can actually do is relevant, what anyone thinks they can do is immaterial. It is vital the patient sets the levels themselves, stopping when they feel they need to, before their pain increases to any significant amount. A mistake here, with a severe exacerbation of pain, will inhibit further attempts at exercise.
  • Stretching - patients report this to be very useful, and it can often by continued when increased pain makes the usual exercise regime hard to adhere to. A series of stretches can be taught for calf, thigh, hamstring, low back and shoulder muscle groups. Technique is important here, with a steady 20 second hold for each stretch.

Stage 4 - Review

It is rare for people to take this all on and not have problems of any kind. Review is useful after a month or so and patients appreciate the facility to contact for advice. Long-term compliance and self-management is the aim and such a great behavioural change cannot be accomplished in a short time.

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