Neuropathic pain (also called central pain) is most common and most difficult to treat. Can cause referred pain in other area of body such as shoulder, neck and trapezius muscles in tetraplegia (18,93).

Allodynia (pain with typically non-painful stimulus) is a common type of neuropathic pain (18).

At or above level of lesion, can be back, buttocks/hips, legs/feet, and/or upper extremities (18,66).

Wheelchair use (transfers, propulsion, pressure relief) most commonly associated with shoulder, neck, elbow, wrist, and hand pain (6,11,18,25,50,66,98).

• Wheelchair use (6,18,50,66).
• Longer time with SCI (18,66).
• Advancing age (15,18,66).
• Decreased range of motion (15).
• Overweight or obesity (66).
• Injury at C6 or higher (15).
• Incomplete SCI may cause more pain and spasticity than complete SCI (66).
• Not starting shoulder exercises within 2 weeks on initial SCI (93).
• Lower levels of recreation/physical activity (25,71).
  

Pharmacotherapy (medications), physical therapy, acupuncture, and aromatherapy have not been rated as very helpful (18).

No single treatment has been shown to be effective for any pain problem in persons with SCI. A multidisciplinary / multimodal approach may be best (18,66,98).

Pharmacological

• Non-steroidal ant-inflammatory drugs (66).
  

Non-Pharmacological

• Education (11,66).
• Therapeutic modalities (66).
• Stretching (66).
• Exercise/recreation may reduce pain in addition to improving social integration and reducing depressive symptoms (71).
• Participation in wheelchair sports (mixed results, but study with sedentary wheelers as control showed positive results) (10,25)
• Reduce body fat (66).
  
• Change environment to place frequently viewed objects (TV, computer screen, phone) to appropriate height from wheelchair to minimize neck pain (50).
  
• Consider a wheelchair with a higher (or adjustable) seat height and ability to tilt back or recline trunk to minimize neck pain (50).
  
• Whenever possible, have friends, family and clinicians sit rather than stand while conversing with a wheelchair user (50).
  
• Whenever possible, have wheelchair seat and transfer destination heights equal to minimize upper extremity effort required (66).
  

Little has been studied or noted in regard to exercise and neuropathic pain. One small study showed no neuropathic pain relief with a bicycle ergometry exercise regimen in 4 people with SCI (80).

General Guidelines

• Optimized pain management may lead to greater exercise compliance (15).
  
• Exercise program must be ongoing to provide long-term pain management. As adherence declines, musculoskeletal pain increases (15,39).
  

Frequency recommendations vary from once or twice daily strengthening/stretching shoulder exercises to 2- or 3-times weekly combined cardiovascular endurance and resistance training. Keep in mind that 2x weekly vs. 3x may increase compliance (11,15,39,66).

Aerobic Exercise / Flexibility Training

• Although aerobic endurance and flexibility exercises are important to overall health, there was no data available in this literature search relating to pain relief benefits.

Strength Training

• Begin a shoulder strengthening/stretching exercise regimen within in two weeks of initial SCI (93).
  
• Stretch anterior shoulder musculature including pectoralis and bicep muscles; strengthen posterior shoulder musculature and maintain range of motion in shoulder especially groups which control external rotations, and adduction. Watch for and address any strength deficiencies or imbalances (11,66).
  
• Stretch scapularic protractors; strengthen scapularic retractors (11,66).
  
• Rowing exercises or backward wheeling, through sports or other activities, can strengthen scapularic retractors (25,66).
  
• Wall pulley exercises, free weights, exercise bands, wheelchair friendly weight machine with or without wrist straps can all work well in devising a resistance training program for persons with SCI (11.39).
  

• High pain intensity (18).
  
• Pain in several locations (98).
  
• Gunshot wound etiology (some but not all studies) (18,71).
  
• Social isolation (71).
  

• Phantom Limb Pain. Described as stabbing, throbbing, burning, cramping, shocking, or shooting pain (59,79).
  
• Allodynia (pain with typically non-painful stimulus)
  
• Residual Limb Pain (also called stump pain).

• Older age at time of amputation (14,23,96,97).
  
• Lower limb amputation (vs. upper limb) (14).
  
• Bilateral amputation (vs. unilateral) (14).
  
• Multiple studies show a correlation between the presence of stump pain and phantom limb pain (14,23,59,99).
  
• Catastrophizing (18,23,97).
  
• Stress and/or anxiety (23,59,79,89).
  
• Etiology of electrical burn (vs. flame burn) in children (85).
  
• Etiology of sudden blood clot in adults (14).
  
• Surgical amputation (vs. congenital) in children (85).
  
• Unemployment may increase intensity of PLP but no other type of pain associated with limb loss (96).
• Presence of chronic pain before amputation (23).

For RLP

• Presence of scar tissue or neuroma on stump, bony spurs, infection, ischemia, necrosis, adhesions, muscle spasm, a poorly fashioned stump, or poorly fitting prosthesis (59).
  

Neuropathic pain is difficult to treat. No single treatment has provided consistent relief in all cases. Trial and error may be necessary. A multidisciplinary / multimodal approach may be best (23,59,79,85).

Pharmacological
For phantom limb pain (PLP):

• Preemptive analgesia before and during surgery (mixed results reported) (23,59,103).
  
• Aggressive postoperative pain management such as epidural infusion, patient-controlled intravenous analgesia, intrathecal opioids or nerve blocks along the adjuvant analgesics such as NSAIDs and paracetamol (59,79).
  
• Sympathetic or regional nerve blocks (59).
  
• Local anesthetic injections in neuromas (79).
  
• Low doses of anticonvulsant and antidepressant drugs (in lower doses than used to treat epilepsy or depression) (23,59,79).
  
• NMDA-receptor antagonists (memantine or ketamine) are thought to be especially helpful with allodynia (mixed results - a recent randomized, double-blinded, placebo-controlled trial of memantine showed it ineffective; another recent study of memantine of the same design showed it effective in reducing PLP when used during amputation surgery. It may be of more value in preventing pain than treating it (23,53,59).
  
• Opioids (23).
  
• Oral methadone found effective in small case report study (n=4). Further study needed (4).

• Botulinum toxin type B injections offered relief of residual limb pain for 10 to 14 weeks in small case report study (n=4) (48).
  
• NSAIDs are especially helpful in treating stump pain (59).
  
• Local anesthetic injections of neuromas (23,79).
• Opioids (18,59).
• Trigger point injections (59)
  

Non-Pharmacologial

• Adaptive coping skills (23,97).
  
• Increasing activity levels.
  
• Support system (23).
  
• Time passage since amputation (14).
  
• Transcutaneous electric nerve stimulation (TENS) (conflicting results) - may involve a bit of trial and error regarding current used and amount and position of electrodes (18,23,59,79).
  
• Spinal cord stimulation (46).
  
• Deep brain stimulation of the thalamic nucleus vertralis caudalis (46).
  
• Motor cortex stimulation. Requires skill in placement of electrode - computer imaging can help with accuracy (46,81).
  
• Psychological therapies to reduce stress, anxiety, and catastrophizing may help since they seem to go hand-in-hand with pain intensity
  
• Use of prosthetic limb in lower limb amputation can reduce pain, but excess use can aggravate - more study needed (96).
  
• Early fitting of prosthesis may significantly reduce incidence of phantom limb pain (59).
  
• Refitting and/or adjusting of prosthetic lower limb to ensure fit with changes that occur in stump after initial fitting.

• Surgical or chemical sympathectomy may be useful in people who describe pain as burning, but can have undesirable complications such as increased pain, new pain, and abnormal sweating - more study needed (54,79).
  
• Surgical interventions such as cordotomies and neuroablation can cause more harm than good and should be tried as last resort. Scar tissue or neuroma removal and stump refashioning are less drastic and may be more helpful surgical options (59).
  
• Surgical removal of neuromas (79).
  

Musculoskeletal Pain

• Back pain, especially with lower limb amputations.
  
• Arthritic pain mainly from prosthetic limb use (96).
  

Back, non-amputated leg or foot, buttocks/hips, neck/shoulders (18).

NOTE: Back pain in some studies and residual limb pain in others is reported as significantly more troublesome and interfering with activities than phantom limb pain (18,56).

• Stress
• Excessive use or too little use of lower limb prosthesis - mixed results; more research needed to determine what level of prosthesis use is most beneficial (96).
  
• Advancing age.

See section on Osteoarthritis for exercise guidelines to manage arthritic pain.

Pain experience with cognitive and communication deficits:

• Requires different method for non-traditional pain assessment. Changes in facial expression, head and body movements, and verbalizations / crying can provide clues to people who know them best. Behaviors typically associated with pain in non-disabled people may or may not indicate pain in intellectually disabled people. Further, lack of behavioral response does not indicate that there is no pain perception (9,12,18,65,102,103).
  

• Fatigue.
  
• Stress.
  
• Greater severity of impairment.
  
• Presence of gastrostomy tube.
  
• Gastrointestinal problems in children with CP.
  
• Higher fat stores in children with CP.
  
• Catastrophizing.
  
• CP-related pain may be under-evaluated and under-treated (9,12,18,26,42).
  
• Depression (65).
  
• Overexertion (77).
• People with intellectual disability appear to have a greater incidence of concurrent health problems that can link to increased pain (12,102)
  
• Children with developmental delays (not necessarily from CP) don't show as much reaction to painful stimuli, and seek less help and comfort than non-delayed children, which may lead to an underestimation of actual pain in these children (26).
  
• Adults with profound intellectual disability may also be at risk of having their pain underestimated due to differences in how pain is perceived and expressed in this population (12).
  
• Adults with mild intellectual disability may under-report pain because they use different words to describe it such as an ache or feeling sore rather than pain. Clinicians may need to spend more time probing and listening to best identify and treat pain (9).
  

• Fatigue,
  
• Stress,
  
• Catastrophizing (thinking overly negative thoughts),
  
• Unrealistic expectations (2).
  

People diagnosed with FM are very heterogeneous and cannot be treated with universally accepted strategies. What works for one person may not work for another. An individualized multidisciplinary, multimodal approach is more effective including (2,44,64,83):

Pharmacological

• Non-steroidal anti-inflammatory drugs (NSAIDs), analgesic drugs, antidepressants, and muscle relaxants improve symptoms such as pain, sleep fatigue, anxiety/depression in the short-term, but many abandon medications because symptoms do not continue to improve. More study needed for long-term effects (44,74,76,83).
  
• Glucocorticoid injections except for those with concomitant carpal tunnel syndrome (83).
  

Non-pharmacological

• Education about FM and self-management techniques may not directly decrease pain but doesn't appear to increase it and may increase quality of life, self-efficacy and satisfaction while minimizing unrealistic expectations (2,7,83).
  
• Stress reduction techniques.
  
• Individually adapted exercise (45,83).
  
• Stretching (44,45).
  
• Cognitive behavioral strategies like biofeedback, counseling, meditation, relaxation, and stress management can lead to an increased sense of control over pain, a belief that one is not necessarily disabled by FM, that pain is not necessarily a sign of damage, decreased guarding, increased use of exercise, increased seeking of support, activity pacing and use of coping self-statements (44,64).
  
• Physical strategies such as graded exercise, increasing activity, and resting (55,76,83).
  
• Social support (2,83).

Other promising alternative treatment approaches that need further study to verify effectiveness and efficacy in treating pain in FM:

• Balnotherapy (sulfur baths) (83).
  
• Osteopathic manipulation (83). NOTE: Spinal manipulation of the cervical vertebrae can lead to serious complications that make it less compelling (95).
  
• Acupuncture (20).
  
• Green algae supplements (Chlorella pyrenoidosa) (20).
  
• S-adenosyl methionine supplements (20).
  
• Massage (20).
  

General Guidelines

• Do a very thorough pre-assessment to determine fitness level (many are extremely deconditioned), any concomitant conditions, medications and any other pain generators such as previous injuries, arthritis, tendonitis, and myofascial trigger points (45).
  
• Exercise carries both risks and benefits for people with FM. Have a thorough understanding of FM before attempting to develop an exercise program. Some medications commonly taken with FM may increase likelihood of orthostatic hypotension, dizziness, and balance problems. Know potential side effects. As a precaution, gradually change positions from movement to movement (2,43,44,45,83).
  
• If fatigue rather than pain is primary complaint, consider that orthostatic hypotension and/or disrupted sleep (common in FM) may be the cause. Seek medical guidance to manage (45).
  
• Prescribed exercise can be performed in the community by personal trainers previously unfamiliar with the management of people with FM (76).
  
• Exercise is most effective in persons whose pain control is optimized (44,45).
  
• All components of an exercise program (strength, aerobic, flexibility, and balance) can fit and appear safe and beneficial if individually tailored. Customization will increase likelihood of compliance and minimize risks (43,45,74,83).
  
• Spend time teaching how to properly perform the exercises, being aware of bodily signals, and how to modify exercises to match threshold of pain and fatigue, and minimize eccentric contractions in daily activities (45,55).
  
• Educate client that even when exercise is started at a suitable level and progressed slowly, it may produce a small and transient increase in pain that will abate after the first few weeks of exercise (27,44,76).
  
• Exercise prescription should combat deconditioning without triggering pain (45,83).
  
• Start at low intensity and very gradually increase to moderate intensity (months rather than weeks). It may not result in traditional changes associated with fitness, but should minimize the progression of deconditioning while managing pain (27,45).
  
• Exercise program must be ongoing to provide long-term pain management. As adherence declines, musculoskeletal pain increases (2,7,27,60,74,76). Ways to increase compliance may be:
  
  • Designing an exercise program with flexible goals (2).
    
  • Identifying potential high-risk situations before they occur (2).
    
  • For people with a low threshold for pain, exercising in the late afternoon rather than the morning may lessen the perception of pain based on diurnal rhythm patterns (3).
    
  • Developing coping skills (2,76).
    
  • Education on specific techniques to help adjust a program when a relapse or flare occurs (2,55,76).
    
  • Pacing (breaking down tasks into manageable segments
  • multiple short sessions vs. one long session (2).
  • Cognitive reappraisal (changing reaction pattern to flares or set-backs) (2).
    
  • Social support from professionals is as crucial in promoting positive health behaviors as family and friends (2).
    
  • Maximize self-efficacy (belief in one's capabilities) to encourage continued exercise compliance (45).
• An exercise videotape depicting modifications needed for people with FM and other pain-related conditions is available at www.myalgia.com. Proceeds fund FM research (44).

Aerobic Exercise

• Emphasize non-impact loading exercise such as walking, water aerobics in a heated pool, and stationary bicycles to reduce pain (27,45,55).
  
• In general, intensity should be based on perceived exertion and pain limitations (2,44).
  
• People with significant musculoskeletal pain or those who are more fearful that exercise will increase their pain may benefit most from a water-based program (27).
  
• Warm (therapeutic) pools ( 93 F) may reduce pain but can be difficult to find in the community. This makes compliance more difficult, but even pools with a water temperature 85 F will be better tolerated than a standard community pool (27,44).
  
• Some suggest avoiding overhead movements in aerobic activity, even during water activities (44). Others suggest that overhead movements can be tolerated in aerobic exercise if introduced gradually (27).
  
• Stationary bicycles may aggravate gluteal tender points and produce symptoms resembling sciatica (2,45).
  
• In order to engage in a walking program, client must be able to rise from chair and hold the trunk stable. If unable, begin a strength-training program or perform aerobic conditioning while sitting in a chair (45).
  
• Walking should be done at an intensity that makes it possible to talk but not sing (44).
  
• An lower-intensity aerobic exercise program of longer duration may be more effective in FM treatment, resulting in less pain, greater compliance, and more enjoyment than a high-intensity program (2,27,90)
  

• Some experts feel strength training might be the best first step in preparing a deconditioned person with FM to engage in a more comprehensive program that includes other dimensions (43,45). Strategies include:
  
• Actively or passively warm up muscles (44).
  
• Focus on functional strength and muscle toning rather than "body building" (45)
  
• Use bands, soft weights, machines such as Nautilus or Universal that don't require a tight grip, and sustained contractions (43,45).
  
• Allow a 4-count pause between each repetition to allow return to resting state. Or work the opposing limb during the pause period (43,45).
  
• Minimize eccentric contractions such as walking downhill and using overhead movements (44,45).
  
• Minimize plyometrics, One small study (n=11) showed increased leg pain and reduced neck pain in a strength training regimen that included "explosive" strength training at the end of the 21-week regimen (32).
  
• Increase ratio of contractions near the body midline vs. farther from midline (43).
  
• Maximize the concentric phase (8 count) and minimize the eccentric phase (4 count) (27,43,45).
  
• Start with small sets of 3 to 5 repetitions and add sets as tolerated (43.45).
  
• Be aware that there appears to be a delayed onset of muscle relaxation in people with FM. Consider a twice-weekly program consisting of one day upper-body followed by a day of no strength training, a day of lower body training followed by a day of no strength training (44).
  Flexibility Training
  
• Actively or passively warm up muscles before stretching them (44).
  
• Actively or passively warm up muscles, stretch to point of resistance, but not pain, then hold stretch (27,44,45).
  
• One method to help client identify stop point is to stretch with eyes closed. Use cues that discourage overstretching such as "hang your head toward your chest" rather than "stretch your chin toward your chest" (43,44).
  
• Do not bounce and do not stretch to point of increased pain (45).
  
• Minimize stretching in FM tender point locations. (43).
  
• Care must be taken to avoid overstretching, especially for those with joint hypermobility (27,44).
  Exercise recommendations that may help during a flare:
  
• Stress need for passive warm-up and warm-down using a hot bath or hot tub (45).
  
• Consult with physician regarding medical pain management (45).
  
• Use NSAIDs before exercise (45).
  
• Decrease intensity of exercise before altering frequency or duration (2,45).
  
• If pain continues, discontinue exercise until pain flare has subsided by 75% (45).
  

• About one-third of people with PD attribute their pain to other musculoskeletal disorders aside from PD (72).
  

• Little has been studied or noted in regard to exercise and musculoskeletal pain relief in PD.
  
• See section on osteoarthritis for pain management suggestions since people with PD may also have arthritis (72).
  

• Most commonly described as dull, tingling, aching, cramp sensation, stiffness, and muscle tension (72).
  

• Fatigue (68).
  
• Sleep disturbances (72).
  
• Lower levels of education (72).
  

• Pain often responds to adjustment of antiparkinsonian medications, especially dopamine agonists (68).
  

• Education given in selective amounts depending on stage of disease. Initially don't want to provide too much information as to cause alarm or anxiety but enough to give sense of control (68).
  
• Social support - initially support groups with one-on-one peer support or groups with newly diagnosed people with PD can be more helpful (68).
  
• Employment, even if modifications are needed such as changes in job requirements, fewer hours or workplace environment changes (68).
  
• Physiotherapy (72).
  
• Massage (72).
  

• Include aerobic, strengthening and stretching activities (68).
  
• Aerobic exercise intensity should be 60%-70% of maximum heart rate (68).
  
• Non-weight bearing aerobic exercises may be especially beneficial although few studies exist to confirm this (68).
  
• Consider warm water aerobics. It may reduce rigidity and provide additional sensory cues to help control movements (75).
  
• Strengthening exercise should use lightweight with the goal to improve flexibility and strength but not to add bulk. Emphasize extensor muscles to counteract the flexor postures common with PD (68).
  
• Stretching should be performed when muscles are warm (68).
  
• To minimize impact of fatigue, it may be helpful to learn energy conservation techniques from physical therapist (68).
  
• Identify any comorbidities or limitations such as reduced range of motion to minimize risk of injury (68).
  
• Treadmill training with body weight support may be more effective in improving short-term mobility of people with PD than physical therapy. More study is needed (61).
  
• Consider music therapy to help bradykinesia and rigidity by providing external rhythmic cues that may stimulate different sensory pathways and enhance mood (69,75).
  

• Obesity (58,78,94).
  
• Fear that exercise will aggravate their pain (58).
  
• Age (78).
  
• Greater proprioceptive inaccuracy (for knee OA) (78).
  
• Higher pain intensity (78).
  
• Concomitant disorders, especially pulmonary diseases, other mobility problems (94).
  
• Joint malalignment or laxity (24,78).
  
• Muscle imbalances (22,24).
  

Pharmacological

• There is no set combination of medications that will consistently relieve pain for all people with OA (63).
  
• Paracetamol (some say acetaminophen) as first-line defense followed by NSAIDs or COX-2 inhibitors if paracetamol fails to provide adequate pain relief (28,63,94).
  
• Two well-designed studies of oral glucosamine sulfate confirmed a 20% to 25% reduction in pain in patients with mild to moderate knee OA (28).
  
• Topical application of glucosamine sulfate and chondroitin sulfate may be effective in reducing pain from knee OA (28).
  
• Opioids, such as codeine, in combination with paracetamol can provide better pain relief but are not tolerated well, requiring discontinuation of opioids by up to a third of people prescribed this regimen (28,63).
  
• Synthetic opioids, like tramadol, are better tolerated but are contraindicated in seizure disorders (28,63).
  
• Intra-articular injections of synthetic long-chain hyaluronan preparations for knee OA decrease pain over 6 months but are very expensive and not covered by insurance, limiting their widespread application (28,63).
  
• Intra-articular injections of glucocorticoids usually provide a modest short-lived decrease in pain. However, in some patients there are dramatic and sustained results, but there is no way of predicting which people will respond (28,63).
• Intra-articular injections of steroids are not particularly effective for reducing pain in OA (28).
  
• Topical capsaicin has a modest pain-relieving effect for knee OA either alone if systemic analgesics are not tolerated, or in combination with simple analgesics (28,63,95).
  
• Use of topical agents in hip OA have not been studied. Intra-articular injections of glucocorticoids have not been well studied for hip OA and intra-articular hyaluronic acid is not approved for hip OA (28).

• A review of 7 randomized controlled trials has shown that transcutaneous electrical nerve stimulation (TENS) may offer effective pain relief for people with OA of the knee (24).
  
• In a double-blind randomized control trial, infrared low-power Gallium-Arsenide (Ga-As) laser therapies in conjunction with exercise offered significantly more pain relief than placebo (30).
  
• Physical strategies such as exercise, physiotherapy, physical therapy, hydrotherapy, swimming, thermal therapy, and massage (58,63,78,94).
  
• Assistive devices such as canes, walkers, orthotics, wedged insoles, taping and unloader braces may reduce pain by addressing abnormal biomechanics, joint malalignment, and muscle imbalances (63).
  
• Self-efficacy - belief in one's capacity to meet given demands (78).
  
• Social support (63,78).
  
• Weight reduction if overweight or obese (28,63).
  
• Education of disease process, exercise instruction, prognosis and rationale, and implications of managing their condition. In many cases, education is as effective in managing pain as NSAIDs (28,63,94).

• Total joint arthroplasty relieves pain and improves function over at least a decade. Revision arthroplasty is more complicated, so it may be best to postpone arthroplasty in younger people with OA (28,94).

Other promising alternative treatment approaches that need further study to verify effectiveness and efficacy in treating pain in OA:

• Pulsed electro-magnetic fields to manage pain in knee OA (24).
  
• Devil's claw (H. procumbens) has shown favorable results in pain relief in 8 randomized controlled trials (RCTs) for OA and other musculoskeletal conditions (20,95).
  
• Avocado-soybean unsaponifiables shows favorable results in 4 RCTs (20, 95).

General Guidelines

• There are many possible reasons for OA pain. The ability to accurately identify the cause of OA pain significantly increases the ability to manage pain (63).
  
• OA at different sites requires different approaches. Range of motion exercises may increase pain in OA of the hip, and knee extension exercises can increase pain in OA of the knee. Modify the program as symptoms or disease activity change (28, 63).
  
• Knee pain in OA has been most frequently studied. Hip pain to a lesser extent (49,73).
  
• At least in the short term, exercise improves pain, muscular strength, and function in older people with mild OA of the knee or hip (49).
  
• In the long-term, people with knee and hip OA can experience a substantial reduction in pain through a comprehensive inpatient rehabilitation program followed by an individualized home-based program. Other reviews indicate that there is not enough evidence to draw this same conclusion for hip OA (24,58,73).
  
• While this benefit is true, it is based on averages. There will be individuals whose pain may worsen with exercise (58).
  
• Avoid exercise associated with greater risk of injury or high-impact loads (49).
  
• The goal of exercise program for a person with OA is to reduce pain and disability by strengthening muscle, improving joint stability, increasing the range of movement, and improving aerobic fitness (28).
  
• Exercise programs have varied widely in studies leaving insufficient data to offer specific recommendation on optimal dosage or optimal program content (49,73).
  
• Like all populations, both disabled and non-disabled, long-term compliance to exercise is critical to long-term health benefits and reduction in pain. As compliance declines, pain may increase (49,58,94).
  
• A contributing factor in lack of compliance may be the difficulty in maintaining standard exercise and dietary weight loss programs in previously sedentary, overweight adults with mobility challenges (58).
  
• People with arthritis that exercised in their youth perceive greater benefits from exercise and may be more compliant (94).
  
• Adherence problems may be greater in home-based programs vs. facility-based programs although other studies indicate they are similarly effective. The benefit of the home-based programs appears to be highly associated with the frequency of home monitoring (24,49,94).
  
• A randomized controlled clinical trial showed ineffective pain improvement from a 6-month home-based exercise program (5 exercises over 30 minutes, 4x per week) primarily due to noncompliance (73).
  
• Supplementing a home exercise program with a group class appears to increase compliance and reduce pain more effectively in the long-term than home-based exercise alone (57).
  
• If knee replacement occurs, participation in no-impact or low-impact sports is fine, but participation in high-impact sports should be prohibited. (49)
  
• The combination of diet and exercise produced greater pain relief after an 18-month intervention than either diet or exercise alone (58).

Aerobic Exercise

• Both high- and low-intensity stationary cycling have been shown to improve pain with OA of the knee (49).
  

Strength Training

• Both isokinetic and progressive resistance exercise improve pain, although progressive resistance exercise showed a little better improvement. It also has the benefit of being less expensive, more easily performed, and more efficient than isokinetic exercise (22).
  
• Progressive muscle strengthening is shown in multiple studies to reduce pain in OA. Home-based strengthening programs also shown to be effective in reducing pain in compliant people with OA (49,67).
  
• A 6-month home-exercise strength-training program resulted in a reduction of pain in OA of the knee with the most relief achieved from those who were most compliant (67).
  

Flexibility Training

• In a small randomized, controlled trial (n=17), yoga was shown to reduce hand pain in OA and decrease tenderness of finger joints (20).
  
• Stretch tight muscles and maintain existing range of motion (49).
  

Musculoskeletal Pain

• Joint pain (also called arthritic pain) (18,52,88)
  
• Muscle pain
  
• Myofascial pain (86, 88)
  
• Upper extremity and trunk pain usually described as aching and may indicate muscle overuse (100).
  
• Lower-extremity pain usually described as cramping (100).
  

• There is no known test specific for PPS, so diagnosis is made by exclusion. Co-existing medical conditions can make diagnosis and treatment difficult (86).
  
• Spinal stenosis, which has similar symptoms, can be confused with PPS (52).
  
• Many people with PPS also have fibromyalgia or borderline fibromyalgia (86,87).
  
• Physical exertion (37,92,100).
  
• Chronic overuse of less- affected muscles (1,70,87,92).
  
• Muscle imbalances (70).
  
• Muscle disuse leading to further atrophy (1,51,100).
  
• Aging (1,87).
  
• Exposure to cold weather (37,100).
  
• Fatigue (92,100).
  
• Greater residual effects from or greater severity of acute polio (1,8,86).
  
• Weight gain (1,70,86,92).
  
• Belief promoted in acute polio era that use of assistive aids such as canes, crutches, slings, braces. or wheelchairs are a sign of weakness or "giving in" (70,86,101).
  
• Depression (86).
  

Pharmacological

• Analgesics such as acetaminophen or NSAIDs (86,88100).
  
• Antidepressants for myofascial pain (86).

Non-pharmacological

• Identify and treat co-existing pain causing conditions such as fibromyalgia (87).
  
• Warmer climate ( 77 F) (84).
  
• Physiotherapy (84).
  
• Swimming activities (84).
  
• Social and local community support (84).
  
• Education on techniques to reduce or avoid pain and protect joints during activities of daily living may help (1,86,101).
  
• Assistive devices and technical aids to conserve energy and help alleviate muscle imbalances to minimize overuse. The typical approach allows short-distance walking without assistive devices for those who fight their use. NOTE: Crutches and canes can be contraindicated if shoulder musculature is very weak or would be bearing too much extra weight (86).
  
• Rest - orthoses can be used to rest muscles (1,37,70,88,100).
  
• Heat/warmth (37,86,100).
  
• Electrical stimulation such as transcutaneous electrical neural stimulation (TENS), or trigger point injections (86,88).
  
• Stretching exercises (86,92).
  
• Modified muscle strengthening surrounding painful joints as tolerated without fatigue and pain (86).
  
• Weight loss (86).
  
• A randomized controlled trial (RCT) of static magnetic fields (300-500 Gauss) found significant and prompt pain relief of musculoskeletal pain in PPS. More study needed to replicate results (88).
  

Surgical:

• Spinal fusion (for progressive paralytic scoliosis) (86).
  
• Correction of obstructive contractures (70).

To date there is insufficient data available to offer specific recommendations on intensity, duration, frequency, and type of exercise that will benefit people with PPS. The few studies that exist are very heterogeneous in design and intervention, and mainly focus on strength gains and increases in aerobic capacity rather than pain relief. Additionally, people with PPS are also heterogeneous, making it difficult to determine the right exercise regimen to gain the most benefits with the least overwork (21,82).

General Guidelines

• Plan exercise at time of day when pain is lowest (37).
  
• Find a balance between exercise intensity and avoiding fatigue (86).
  
• Exercise regimen must be realistic with a limited selection of muscles that will improve function without increasing fatigue and pain. If exercise intensity is too great or the number of [remaining] motor units too few, damage can occur (1,86).
  
• Be aware that standard measures of manual muscle strength significantly overestimate actual strength of damaged muscles (measured quantitatively) in people with PPS (1,70,101).
  
• Use a pacing strategy (breaking down tasks into manageable segments - multiple short sessions vs. one long one) to minimize fatigue (1,70,82).
  
• Allow longer rests between repetitions, sets, and exercises in strength training (82).
  
• Recovery may take longer in people with PPS (70).
  
• Use orthoses, walking aids and wheelchairs as a means of decreasing demands placed on muscles while preserving function (70).
  
• Gait analysis can be a helpful tool in assessing where muscle weakness exists and how an individual compensates in order to develop a multi-disciplinary plan to achieve better muscle balance and avoid further overuse/abuse of some muscles and under-use/disuse of others (51,70).
  
• Monitor person with PPS very closely for signs of fatigue and pain. Exercise should never be performed to point of pain or fatigue (82,101).
  

Aerobic Exercise / Flexibility Training

• Although aerobic and flexibility exercises are important to overall health, there was no data available in this literature search relating to pain relief benefits.
  

Strength Training

• Strength training, if possible, may help alleviate or at least not aggravate joint pain (82.92).
  
• Emphasize concentric contractions in strength training to minimize muscle damage (82).
  
• To avoid muscle trauma, a 3-repetition maximum test (3RM) may be safer than a 1RM in determining intensity for strength training (82).

• Radicular pain.