Training Clients with Chronic Pain

Trainers need to take a different approach to best serve clients with chronic pain.

"My new personal training client was in an accident two years ago, and has had chronic back pain ever since. She has been to numerous specialists who say different things, and she has tried all kinds of painkillers. Her medical clearance form says she may perform 'symptom-limited exercise.' I wasn't sure exactly how much I should or should not push her, so I spoke with her physical therapist. Apparently, if my client lets pain be her guide, she will end up weak, bedridden and in more pain than ever. Instead, she has to start slowly, build gradually, and just accept the fact that some pain will be present. Usually I tell clients to 'stop if it hurts,' but this is not something I should say to her. I wonder what I should say instead. Any ideas?"

Most of the time, pain is a helpful response that motivates people to correct or escape from a situation causing damage to their bodies. For example, if someone sits in the same slumped position for too long, the neck and shoulders start to ache, so he or she will get up, stretch and change position.

Pain that occurs with injury provides a similar motivation: People limit movement while the injury heals. Many illnesses, such as the flu, make people ache all over, which encourages them to stay in bed and give their bodies the rest needed to cope with the illness.

But sometimes pain remains long after an injury has supposedly healed. Sometimes pain develops with chronic conditions, such as arthritis and fibromyalgia. People with chronic pain often avoid physical activity, since it hurts. But avoidance leads to weakness, which in turn leads to a further decline in functional capacity and, ironically, more pain. Weight gain and depression often accompany chronic pain.

Understanding chronic pain

To feel pain, nerves must send information to the brain, and the brain must interpret the information as pain. This is more complicated than it sounds. The brain may amplify sensations that don't really warrant much attention when it senses danger. And the brain is not always in touch with reality. Emotional states such as fear, resentment, anger and sadness may amplify feelings of pain. Similarly, the brain may decide certain sensations are harmless, and not bother to "feel" them. Laughter, happiness, hopefulness and other positive emotional states can help reduce pain intensity.

Researchers believe that chronic pain can be worsened by maladaptive, subconscious habits of perception, where certain nerve pathways have "learned" to amplify and interpret sensations as painful. The pain is very real, of course, but is caused only partly by tissue damage (including tight muscles, scar tissue, inflammation and so forth) and partly by the brain's habitual patterns and conscious and subconscious expectations.

This is not to say that people can think their pain away. But people can learn to lessen the effect pain has on their lives by understanding their pain, and coping as positively as possible with challenges. This process can be very difficult.

Movement is essential

If you are working with clients in chronic pain, they will need medical clearance, and you will need clear guidelines about what types of activities are recommended, and if any particular movements should be avoided. You must be sure that the activities will do no harm. Once clients understand that pain does not indicate harm, they will have more confidence in their ability to become more active.

In general, clients should start with an amount and intensity of activity that does not cause pain to become worse, either during the activity or after. This may be as little as a few minutes of walking. While you can serve as a confident, supportive advisor, clients must monitor their own pain, and take charge of activity levels. Work with clients to slowly push the limits without doing too much too soon. With consistent effort, exercise levels will improve slowly but surely, and clients will begin to feel more in charge of their lives.

Butler, D.S., and G.L. Moseley. Explain Pain. Noigroup Publications: Adelaide, Australia, 2003.
Crombez, G., C. Eccleston, G. Van Hamme and P. De Vlieger. Attempting to solve the problem of pain: A questionnaire study in acute and chronic pain patients. Pain (article in press, corrected proof), 2007.
Harris, R. Embracing your demons: An overview of acceptance and commitment therapy. Psychotherapy in Australia 12(4): 2-8, 2006.
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