Exercise is another potential non-pharmacological approach to pain management. In a few cases, certain types of exercise may increase pain. It is important to know which activities increase pain in people with a given disability so the activities can be avoided or modified in order to keep a person physically active. In other cases, exercise may not reduce pain, but can be done without increasing pain. This provides assurance to people whose fear of pain prevents them from trying exercise at all. In yet other cases, especially for musculoskeletal pain, exercise can alleviate pain and be a primary factor in increasing function (Ditor, Latimer, Ginis, Arbour, McCartney, & Hicks, 2003; Grainger, & Cicuttini, 2004; Hicks et al, 2003; Kettunen & Kujala, 2004).

Exercise compliance is a key factor in long-term pain management for people with disabilities. As compliance declines, pain may increase (Ambrose et al, 2003; Cedraschi et al, 2004; Ditor et al, 2003; Gowans, & deHueck, 2004; Hicks et al, 2003; Mior, 2001; Redondo, Justo, Moraleda, Velayos, Puche, Zubero, Hernandez, Ortells, Pareja, 2004; Richards & Scott, 2002). Compliance may be increased in people with disabilities through the following tactics:

• Set flexible goals that can change as pain or disease state changes (Ambrose et al, 2003; Fransen, 2004).
• Cultivate positive coping skills in clients with disabilities (Ambrose et al, 2003; Richards & Scott, 2002).
• Utilize pacing (breaking down tasks into shorter manageable segments rather than one longer one) (Agre et al, 1991; Ambrose et al, 2003; Perry, Barnes, & Gronley, 1988; Spector, Gordon, Feuerstein, Sivakumar, Hurley, & Dalal, 1996).
• Provide encouragement and support (Ambrose et al, 2003).
• Maximize self-efficacy by involving the client in decisions about the exercise program, linking exercise with specific benefits and providing specific instruction on how to perform or adapt recommended exercises (Häkkinen et al, 2004; Iversen et al, 2004; Jones & Clark, 2002).
• Provide close supervision to home-based exercise recommendations or supplement home-based exercise with group classes (Fransen, 2004; Kettunen & Kujala, 2004; McCarthy, Mills, Pullen, Roberts, Silman, & Oldham, 2004; Weigl et al, 2004).

If exercise is to be a strong component of community care for people with disabilities, it is necessary to have access to community-based exercise programs that are sensitive to their needs. Lack of individualization is one reason why many people with disabilities are unsuccessful in attending exercise classes at local health clubs (Jones & Clark, 2002). Specific training for community instructors regarding exercise intensity and progression may be needed. One study demonstrated that personal trainers with no previous experience with people with fibromyalgia were successful in adapting their exercise programs after a brief period of education and training (Gowans & deHueck, 2004; Richards & Scott, 2002).

Exercise benefits are abundant for all people, with and without disabilities, but not all relate to pain management or reduction. The exercise recommendations contained in this report are limited to their impact on pain management and should not be taken as a holistic recommendation. Increasing aerobic capacity, strength, mobility, and ability to perform activities of daily living are important benefits not highlighted in this review. Further, this is not a comprehensive review. New data becomes available every day and there are studies that may not have been identified that could provide additional information.