Returning to exercise safely after a prolonged period of pain, by Peter Tziavrangos. Physiotherapist. – Peter is an APPI Pilates Instructor and Physiotherapist.
Many people with long-term back pain often gradually reduce the amount of exercise and other activities they do as a result of their pain. However, a lot of research supports continuing or resuming exercise, in an appropriate way, as being beneficial in the recovery process from chronic back pain for many reasons. These include the endorphin release during exercise helping to mediate the pain signals, the general health benefits of exercise and the improvement in mood that will also occur. It is important though, to return to activity slowly and with the guidance of your Physiotherapist.
Many people with chronic pain will fall into one of two common errors with exercise:
1. Some withdraw from exercise completely, and find that their overall tolerance level for daily activities also declines. These people end up doing fewer and fewer activities in the fear it will make their pain worse.
2. The ‘Boom and Bust’ cycle - Others will try to continue exercise at the same intensity or level as they previously undertook (even after a long break away from it during their acute pain period). They may push themselves too far or ‘over-do’ things, causing a flare-up of their pain. They then cease exercise for a while, try to return again at a similar (or slightly lower) level, only to have the same process happen again and again. These people also eventually end up doing less and less activity as a result.
So how do you return to exercise safely after a prolonged period of pain and reduced activity? The answer is with appropriately PACING and GRADING your exercise program.
• PACING refers to finding an appropriate level at which you can resume exercise without causing an aggravation of your pain.
• GRADING refers to how you can build on that baseline activity level over time, without causing a flare-up.
PACING
Working out your baseline pace for an exercise involves a few simple steps.
We will use the example of a walking program, as this is a form of exercise which is commonly used and well-tolerated for most people with low back pain.
Firstly work out your baseline level of pain out of 10. Try to start at a time of day when you know your pain is a bit more manageable, and not at its worst.
Next start walking! Time yourself as you go and walk at a pace which is comfortable for you. Once your pain has increased by 1-2 points more out of 10, STOP. Record your time.
Repeat this process on 2 other days.
Be aware that there may be a latent effect from the exercise, giving you soreness 1-2 days later rather than at the time. Therefore you may prefer to leave a 2-3 day break between your walks whilst working out your baseline pace.
Work out the average time of the three days, by adding together the time from each day (in seconds) and dividing by 3. Finally calculate 80% of this average time. This final number is your starting baseline pace for your daily walking program.
See the worked example below:
Mary starts with baseline pain of 5/10. She starts walking, and stops when her pain gets to 6-7/10.
Her times were as following:
• Day 1: 5 minutes (300 seconds)
• Day 2: 4 minutes and 40 seconds (280 seconds)
• Day 3: 5 minutes and 30 seconds (330 seconds)
So her average time was 5 minutes and 3 seconds. (300 + 280 + 330 = 910. 910 divided by 3 = 303.3 seconds).
80% of this is 242.6 seconds, or 4 minutes and 2 seconds. She could round this out to 4 minutes.
GRADING
Once you have been exercising at a certain pace for a while, your body becomes accustomed to the exercise and your progress may plateau unless you start to add a new challenge. Or you may just feel ready to do more.
You can use grading to work out how to safely progress your program without causing a flare-up.
Make sure you have been exercising comfortably at your current level for at least a week before you start increasing the grade of exercise.
Take your current walking pace/time. Convert to seconds to make the calculation easier. Then work out 10% of this time. Add this 10% to your current time to get your new time.
Using the example above:
Mary’s current time is 4 minutes, 2 seconds (242 seconds).
10% of this is 24 seconds.
This makes her new time = 266 seconds (4 minutes and 26 seconds). She could round this up to 4.5 minutes!
Whilst this example may seem small – once you are exercising for longer, you will be increasing by bigger numbers, and it won’t seem like you are making such small steps.
Walking is a great example, because it is an activity most people in low back pain can start with plus it is also a very functional activity to improve on.
The same approach can be used for Pilates exercises.
For example we might be using a simple movement like a Pelvic Tilt, or perhaps Shoulder Bridge, to re-introduce lumbar flexion in a patient with flexion aggravated low back pain. Once we have taught the correct motor task with appropriate core control, we then have to give advice on the dosage of the exercise – how many reps should they do?! Typically a physio would prescribe between 1-3 reps of ten of any exercise, maybe with some advice to stop if it hurts, but is that correct? In the case of chronic pain, we would often use this concept of pacing and grading. So the initial dose could be 1 set of the exercise, with enough reps to only slightly increase pain (as per the walking example above). Then using the 80% rule, apply that to the next set done (on a different day). If that were manageable and became easy to do, then progression of the exercise would be needed. Increasing the number of reps gradually (eg using the 10% rule), or gradually increasing the frequency of the exercise, would be the simplest approach. Beyond that, it would be a matter for the physiotherapist and their patient to decide when they might progress to more challenging flexion movements, for example in sitting and standing. These would be approached in the same careful manner, especially in patients who might be fearful of flexing their spine.
**Remember, Pacing and Grading should always be done in consultation with your Physiotherapist.
By Peter Tziavrangos
Move Physiotherapy & Pilates (5/259 Unley Road, Malvern 5061)
www.movephysio.com.au
APPI Pilates Presenter
Bachelor Applied Science (Physiotherapy) 1996
APA member
Peter graduated in 1996 and worked at a large teaching hospiatal in Adelaide for three years, in addition to working in Sports Private Practice in that time. He then ventured off to the UK travelling and working for 4 years with his now wife Veronica. It was there that they both become interested in Pilates and did their initial training with APPI in London.
Since returning to Adelaide in 2004 Peter has been working in private practice and teaching pilates studio and matwork full time. With a special interest in back pain and headaches the majority of his clinical work focuses on these two areas, using a biopyschosocial approach to management. Pilates is often a crucial component in the management of these conditions.
Peter and Veronica now own and run Move Physiotherapy and Pilates Studio with two clinics in Adelaide, offering a variety of services to help keep people active.
