The Benefits of Pacing and MovementKatie Lyttle PT, DPT

March 2013

Your body’s response to pain

Pain makes you want to move differently and/or less– This is normal–Motor changes are a response/output to a

perceived threat– Protective response

Movement is protective and helpful in the short term BUT problematic in

the long term

How do you start moving?• Understand the benefits of moving

1. How inactivity affects the tissue2. How the tissues will specifically benefit from movement

• Finding your baseline for various activities

• Doing enough but not too much, or too little

• Log activity/movement

• Progressing activities

• Flare up plan

Continue to assess barriers throughout the whole process.

Activity IS important

• Our bodies rely on movement to maintain overall health

• Without normal movement tissue becomes unhealthy and body systems do not function properly

• movement = unhealthy tissue– Does unhealthy tissue feel good OR bad?– For many pain means activity = unhealthy

tissue– Unhealthy tissue = pain

Activity IS important

Our bodies are DYNAMIC

– Body systems and tissue are continuously changing according to the demands placed on it, positive or negative• Wolf’s Law: form follows function• Use it OR lose it

– We do not have the option to do nothing and stay the same

– Everyday what we choose to do or not do causes a change that could be positive or negative• No movement = negative change in body systems and

tissue

What happens to the body with inactivity

Musculoskeletal system

• Muscle atrophy muscle fatigue and decreased endurance(1)

• Altered neurologic control of muscles– The body “forgets” how to coordinate muscles(1)

• Decreased joint stability(1)

– Increased risk of injury

• Muscle length imbalance around joints(1)

– Short and tight vs. long and weak

What happens to the body with inactivity

Nervous system

• Decreased Nerve mobility(6)

– Decreased oxygen delivery to nerves(3,5)

– Increased nerve sensitivity decreased pain threshold

• Altered sensory perception(3)

• Increased inability to cope with stressors(2)

• Increased susceptibility to depression(2,3)

Benefits of movement

• Increased blood flow(6,7)

– Healthier tissue: muscle, tendon, nerve, bone, etc.

• Increased muscle strength– Improved endurance and activity tolerance– Improved joint support

• Restoration of tissue balance– Lengthen what is short; strengthen what is long and

weak

• Decreased stiffness; increased range of motion– Motion is Lotion

Benefits of movement• Decreased nerve sensitivity(6,7)

– Normalization of pain threshold

• Improved sleep– Improved balance between sympathetic nervous

system and parasympathetic nervous system• Parasympathetic = “rest and digest”• Sympathetic = “fight or flight”

• Improved emotional and stress management

• Activation of the release of endorphins

Bottom Line

•If you don’t move, your pain can increase, even in healthy tissue

•Maximizing motion/function is critical for all joints and tissue

•Exercise interrupts the chronic pain cycle

•Avoiding motion causes more long term problems

Why is pacing important?

• Prevent pain flares

• Prevent “boom/bust” activity increased pain– Extreme bouts of activity followed by an extended

recovery period

• Maximize function; increase function

• Minimize recurrent injury

• Respect rest/activity balance

How do you start moving?• Understand the benefits of moving

• Find your baseline for various activities1. Have to start somewhere to get anywhere

• Do enough but not too much, or too little

• Log activity/movement progress at a week at a time

• Progress activities

• Flare up plan

Continue to assess barriers throughout the whole process.

What is your baseline?

What you CAN do currently without making yourself worse?

Amount that you CAN do…

• without overall making yourself worse the rest of the day

• In a day and and not feel worse the next day

• Each day without needing a full day or more of recovery

Find your baseline1.Take BASELINE pain level

2.How much activity can you do before your pain increases?

3.If your pain level increases, does it return to your baseline when you stop the activity?

• YES; that is a good amount to start with and that is your baseline• NO; that is likely too much activity and you need to start with

less.

4.If you want to be conservative: STOP the activity BEFORE your pain stops you = your baseline

5.If your pain flares the following day and your level of function is significantly affected it was too much

How do you start moving?• Understand the benefits of moving

• Find your baseline for various activities

• Do enough but not too much, or too little– Boom bust vs. just in case

• Log activity/movement

• Progress activities

• Flare up plan

Continue to assess barriers throughout the whole process.

Beginning and Progressing Activity

How do you start moving?• Understand the benefits of moving

• Find your baseline for various activities

• Do enough but not too much, or too little

• Log activity/movement – progress at a week at a time

• Progress activities

• Flare up plan

Continue to assess barriers throughout the whole process.

Log, keep track of activityAllows you to…

• Manage flares more accurately– Identify cause of the flare – Change activity accordingly if a flare occurred

• See your progress– Motivation

• How– Calendars– Online exercise/activity journals– Grids– Apps?

How do you start moving?• Understand the benefits of moving

• Find your baseline for various activities

• Do enough but not too much, or too little

• Log activity/movement

• Progress activities– Progress by an amount you KNOW you can

successfully do.

• Flare up plan

Continue to assess barriers throughout the whole process.

How to progress your activity

• Increase a small amount every week or two

• Progressions should be easy and attainable– Increase in baby steps– *Small increases you know you can successfully do*

• If you flare up after you progress your activity, you increased too much, too soon

• Keep progressing!

• You should always be progressing until you reach your goal

How do you start moving?• Understand the benefits of moving

• Find your baseline for various activities

• Do enough but not too much, or too little

• Log activity/movement

• Progress activities

• Flare up plan

Continue to assess barriers throughout the whole process.

Flare-up PlanIs it realistic to think that you will NEVER have a set-back?

1. Do not PANIC– Use heat, ice, movement, reasonable rest periods, TENS, relaxation

to decrease the flare

2. Keep track of what triggered your set-back– Use the information to prevent the same flare from happening again

3. Maybe decrease your level of activity in order to prevent further exacerbation– Prioritize your responsibilities– Say NO to unnecessary demands until you’re function is back at

your before flare baseline– Ask for help

4. Don’t stop all activity, KEEP MOVING

How do you start moving?• Understand the benefits of moving

• Find your baseline for various activities

• Do enough but not too much, or too little

• Log activity/movement

• Progress activities

• Flare up plan

Continue to assess barriers throughout the whole process.

Barriers: what keeps you from moving forward

• Ambivalence to change– Interested in change, but not ready to commit– Cost vs. benefit– 30 days of rehearsed behavior change takes

another 3 months of practice to stick.

• Priorities– Daily, weekly, long term

• Boundaries– Expectations from others and self– If I change, others (family, children, friends) may

have to as well

Barriers: what keeps you from moving forward

• Values

o What do you care about most? o What are your basic assumptions about what

makes you a good person, life worth living? o How do you define your self-worth?o Most people discover some values/assumptions

that can sabotage their recovery efforts. o If you feel stuck in your progress, it may be

connected to a deeply-held value that is interfering with progress.

ReferencesReferences:1. Knight J, Jones A, Nigam Y. Effects of bedrest 3: musculoskeletal and immune

systems, skin and self-perception. Nursing Times. 2009; 105: 23,18-22.2. Nicholas M, Molloy A, Tonkin L, Beeston L. Using Pacing to Overcome the

Effects of Chronic Pain on Activities. Practical and Positive Ways of Adapting to Chronic Pain, Manage Your Pain. London: Souvenir Press Ltd; 2003: Chapter 7.

3. Knight J, Jones A, Nigam Y. Effects of bedrest 2: gastrointestinal, endocrine, renal, reproductive and nervous systems. Nursing Times. 2009; 105: 22,24-27.

4. Knight J, Jones A, Nigam Y. Effects of bedrest 1: cardiovascular, respiratory and haematological systems. Nursing Times. 2009; 105: 21,16-20.

5. Butler D, Moseley L. Explain Pain. Australia: Noigroup; 2003.6. Butler D, The NOI Team. Mobilization of the Nervous System Course. Neuro

Orthopaedic Institute (Australia). 20th Edition. January 2010 – USA 2 day.7. Butler D, Moseley L. Explain Pain Course. Neuro Orthopaedic Institute 2009.8. The McKenzie Institute USA. Mechanical Diagnosis & Therapy: The Lumbar

Spine Part A. The McKenzie Institute International 2007.9. Moore, Pete. The Pain & Self Care Toolkit. Pete Moore & Dr Frances Cole. 2009.