Pain is a near-universal human experience. In some cases, it provides a valuable learning experience, without lasting effect, regarding what actions to avoid or adapt in order to prevent pain from re-occurring. In other cases, pain can significantly interfere with the ability to function in daily life on many levels. Pain can be short-term (acute) or long-term (chronic) in duration.
There are two basic types of pain. Nociceptive pain results from direct mechanical, thermal, or chemical trauma and if mechanical in nature, may manifest itself as musculoskeletal pain. Neuropathic pain results from damage to the peripheral or central nervous system tissue or from abnormal processing of pain in the central nervous system (Wilkie, Brown, Corless, Farber, Judge, Shannon, et al, 2001).
Pain is more than a simple annoyance; it can lead to serious physical and psychological consequences across almost every bodily system. Further, if acute pain continues without adequate relief, it can become neuropathic pain, in which the normal pain pathways become altered, making it much more difficult to treat (Wilkie et al, 2001).
It is widely hypothesized that people with disabilities experience more pain with greater severity than the non-disabled population; however, data supporting this hypothesis have not yet been systematically examined or summarized (Chetwynd, Botting, & Hogan, 1993; Ehde, Jensen, Engel, Turner, Hoffman, & Cardenas, 2003).
Pain is also a multidimensional experience, with each dimension influenced by an individual's culture and upbringing. The four dimensions of pain are affective (emotional responses to pain), behavioral (actions taken when pain occurs), cognitive (attitudes and beliefs about pain), and physiological-sensory (the body's internal response to pain) (Wilkie et al, 2001).
Emphasis is often placed on the physiological-sensory dimension with pharmacology (medications) being the first line of defense. While medications can provide pain relief, especially for musculoskeletal pain, it is often introduced when pain has already reached a high enough intensity to seek treatment (Hicks, Martin, Ditor, Latimer, Craven, Bugaresti, McCartney, 2003). It stands to reason that preventing pain, or at least managing it when the intensity is still modest, might be a more beneficial approach. Surgery can be an option to relieve pain in some disabilities, but is generally used after other, less-invasive options have been exhausted (Mailis & Furlan, 2003; Siddle, 2004).
Some people take herbal medications to help relieve pain, based on the assumption that herbal medicines are natural and therefore safe. The truth is that many herbal medications have been associated with numerous adverse effects. This is not surprising considering that medicinal herbs contain pharmacologically active ingredients. Herbal medications are largely unregulated in most countries, which can result in serious safety and quality issues. In addition, herbal medicines taken in conjunction with other medications may cause unexpected herb-drug interactions. A few herbal medications mentioned later in this report seem to hold promise based on initial randomized controlled studies. Further replication and study is needed. As a precaution, it is important to consult with your physician before starting any new treatment, herbal or otherwise (Weiner & Ernst, 2004).
To manage pain most effectively, all four dimensions of pain must be addressed. Each dimension can have a dramatic impact on how pain is experienced. As a result, a multi-modal, multi-disciplinary approach is required. Treatments may need to be introduced initially on a trial-and-error basis. Since pain can be caused by a number of different mechanisms, it may require some experimentation until a treatment or combination of treatments is found to be most effective for each individual (Ambrose, Lyden, & Clauw, 2003; Ehde et al, 2003; Flor, 2002; Jones, Clark, & Bennett, 2002; Middleton, 2003; Nielson & Jensen, 2004; Nyland, Quigley, Huang, Lloyd, Harrow, & Nelson, 2000; Siddle, 2004; Sprott, 2003; Thorsteinsson, 1997; Widerström-Noga, Felipe-Cuervo, & Yezuersji, 2001).
In addition to medications, there are effective non-pharmacological strategies to reduce pain. Education of both the person experiencing pain and their caregivers has been cited in numerous studies as a way to reduce pain by increasing understanding, identifying positive coping strategies, and improving attitudes and self-efficacy (Agre, Rodriquez, & Tafel, 1991; Ambrose et al, 2003; Cedraschi, Desmeules, Rapiti, Baumgartner, Cohen, Finckh, Allaz, Vischer, 2004; Curtis, Tyner, Zachary, Lentell, Brink, Didyk, Gean, Hall, Hooper, Klos, Lesina, Pacillas, 1999; Gilbert-MacLeod, Craig, Rocha, & Mathias, 2000; Häkkinen, 2004; Häkkinen, Sokka, & Hannonen, 2004; Hammond & Freeman, 2004; Iversen, Eaton, & Daltroy, 2004; Kavuncu & Evcik, 2004; Mannerkorpi, Ahlmen, & Ekdahl, 2002; Nyland et al, 2000; Olanow, Watts, & Koller, 2001; Richards & Scott, 2002; Sprott, 2003; Thorsteinsson, 1997; Weigl, Angst, Stucki, Lehmann, & Aeschlimann, 2004; Young, 1989). Education initiatives among people with disabilities have been associated with considerably lower disability scores and decreased pain scores, in many cases to the same degree as a non-steroidal anti-inflammatory drug (NSAID) (Moskowitz, Kelly, Lewallen, & Vangsness, 2004). Education about the condition itself and the variety of treatment options available allows the individual to be an active partner in decision-making that can improve self-efficacy (Häkkinen et al, 2004; Jones & Clark, 2002). Fitness professionals need to become educated about the impact of exercise on people with various disabilities in order to avoid harm and increase function without increasing pain (Houlihan, O'Donnell, Conway, & Stevenson, 2004).
Social support has also been identified as a common factor across disabilities to help reduce pain. An individual's support system includes friends, family members, and caregivers, including professionals (Ambrose et al, 2003; Häkkinen, 2004; Häkkinen et al, 2004; Moskowitz et al, 2004; Olanow et al, 2001; Sharma, Cahue, Song, Hayes, Pai, & Dunlop, 2003; Strumse, Stanghelle, Utne, Utne, & Svendsby, 2003). Being around people who have a positive attitude, offer support, and are optimistic can reduce the amount of pain medication needed by an individual (Sprott, 2003).
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 so he or she can garner the benefits of exercise. 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 in 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 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 and represents one semester of study. New data becomes available every day and there are studies that may not have been identified that could provide additional information.
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