1. Discover your true physical limitations.

2. Improve activity tolerance through systematic retraining

3. Learn to live within your limitations on a day-by-day basis.

4. Work on better accepting yourself in spite of having physical limitations.

Many persons with chronic pain have become more physically limited than they really need to be. This means that their physical activity level has become less than is really required by their disabling pain condition. They have developed what we call "excess disability." Following are some common causes of excess disability:

Physical Deconditioning Syndrome

People who respond to pain by significantly curtailing their daily physical activities, may develop a deconditioning syndrome. In other words they "get out of shape." Joints become stiff, muscles become flabby, endurance decreases, and some put on excess weight. Unfortunately, the deconditioning syndrome leads to decreased pain tolerance.

Solution - develop and maintain a regular physical exercise program that is individually tailored to your needs.

Physical Compensation (Overuse) Syndrome

Many attempt to compensate for pain in one body part by overusing another body part. For example, if it hurts to walk on the right leg, one may compensate by overusing the left leg. This in turn can put excess strain on the overused body part and new pain problems can develop. Another common form of physical compensation is called "bracing." This occurs when one tries to compensate for painful movement either by making the painful area stiff (e.g., tensing the muscles so it becomes like a brace), or actually wearing some kind of external brace (e.g., a neck collar). Excessive bracing and limiting movement can over time lead to additional deterioration and decreased pain tolerance.

Solution - learn ways to make your body movements as normal as possible.

Excessive Muscle Strain Syndrome

A very common reaction to pain is elevated muscle tension. People also respond to emotional stress with elevated muscle tension. The combination of chronic pain and chronic stress can easily lead to chronically tense muscles. When muscles are held in a state of contraction for prolonged periods of time, pain results. This fact provides another explanation why persons with chronic pain in one area of the body often develop pain in other areas as well. Suppose for example a person named Fred develops chronic low back pain. If Fred responds to his low back pain another other stressors in his life with chronically elevated tension in his neck and shoulder muscles, he may eventually develop pain in these areas as well. The elevated tension in his upper body may also travel up the back of his head causing the development of tension headaches.

Solution - learn how to decrease excess muscle tension through use of deep muscle relaxation exercises and other appropriate physical exercises

Fear and Avoidance

Many persons with chronic pain become afraid of doing certain activities and therefore avoid doing them. Usually, this means that at some time in the past they have experienced an increase in pain while doing these activities. Some develop a condition known as kinesophobia which means "fear of movement." They may hold themselves rigidly or move in a very slow, guarded, and deliberate manner. Most often this is based on misunderstandings regarding the relationship between "hurt" and "harm." It is the mistaken belief that if you experience hurt by doing something you are actually causing harm or damage to your body. People with this fear often view their bodies as being extremely fragile. For example, they may fear that their spines will break, nerves will become damaged, or they will end up even more impaired (e.g., confined to bed or wheelchair).

Solution - Consult your doctor or physical therapist and get their input. Increased pain intensity while doing certain activities does not necessarily mean that you are damaging your body. Hurt does not mean harm. Reduce risk of damage by increasing your physical activity level gradually.

Depression

It is common for persons with chronic pain to become depressed. Common symptoms of depression are decreased energy, loss of motivation and initiative, and withdrawal from people and activities. People who are depressed may use their pain as an excuse to avoid certain activities. Unfortunately, people who are depressed become even more preoccupied by their pain and misery.

Solution - work on ways to overcome your depression.

Distorted, "All or Nothing" Thinking

Some persons with chronic pain approach certain physical activities with an "all or none" attitude which says, "either I do it the way I used to do it, or I won't do it at all." Rather than making modifications and compromises in how they go about doing certain tasks, they avoid doing them all together.

Solution - learn how to make modifications in the way you approach and complete certain physical chores and activities. Learn how to pace yourself, take rest breaks, find short cuts, or ask for assistance.

Pain Payoffs

Pain payoffs occur when people avoid doing certain activities, not because they can't do them, but rather because they really don't want to do them. Pain can become a very convenient excuse to get out of doing certain chores and responsibilities that you really would rather not do. Although it is certainly possible to fool other people, it is also possible to fool yourself. Rather than admit to yourself that you really don't want to do certain jobs or tasks, you tell yourself that you are not capable of doing them because of your pain condition.

Solution - begin with an honest self-examination. All of us have to do certain chores and responsibilities that we would prefer not to do. Don't use your pain as an excuse.

Discover your true physical limitations on your own. Don't put all the responsibility on doctors to determine what you can and cannot do. All they can do is make educated guesses. Let your own experience be your guide. Discover for yourself, on a trial-and-error basis, what you can and what you cannot do. While you are discovering your capabilities, use good common sense and approach physical activities cautiously and gradually.

Which of the above factors may have resulted in excessive disability for you?
 
 What can you do about it?
 

Some physical activities which have been limited as a result of your pain condition can be improved by following a systematic procedure sometimes referred to as the quota system. Two examples will be offered here: intolerance for prolonged sitting and intolerance for walking extended distances.

Establishing a baseline

The first step is to establish a baseline of your current tolerance level for the specific activity. This means actually measuring the extent to which you can engage in the activity without being overwhelmed with pain. The unit of measurement which you use will depend on the activity in question. In the case of sitting intolerance, the obvious choice would be time. Thus, you would measure how long you can sit in a particular chair before the pain becomes too uncomfortable. In the case of walking intolerance, you might chose distance as the measure. That is, how far can you walk (in feet or yards) on a particular terrain before it becomes too uncomfortable? Since it is likely that there will be some variability. You may have to take several measures (say 4 or 5) and then compute an average. This will be your baseline or starting point. Please note that the baseline should not be the point where the pain becomes excruciating. Rather, it should be at that point where it starts becoming noticeably uncomfortable.

Establishing activity quotas

Once you have established your baseline or starting point, the goal is to gradually and systematically increase your tolerance by setting quotas. The quota refers the activity level you are aiming for (e.g., length of time sitting, or distance walked). The activity quota should begin with a very small increase over your baseline. For example, let's say that your baseline sitting tolerance is 30 minutes. You may want to begin your first quota with 35 minutes, or even less if you think that the 5 minute increase is too much. In the case of walking distance, let's say for example that your baseline is 50 yards. You may then want to set your first quota increase to 55 yards. It is very important that you set your quota at a level that will enable you to experience success. Once you feel comfortable at a particular quota level, you should increase it again and again. If at any point during the training process you are unable to reach your quota, you should either lower the quota or stay at the previous quota level until you feel ready to increase it once again.

You find it very helpful to make use of mental pain coping techniques (e.g., distraction or positive self-statements) while you are doing the target activity. Some like to reward themselves with a special treat when they reach a particular quota. Most people also find it very useful to make a graph or chart of their progress. This can serve as a visual indication of the progress you have made. Obviously, at some point you will reach an upper limit as to how far you can go with the quota increases. That's okay. Remember in pain self-management, we always view improvement as relative. Any improvement is better than no improvement at all.

Knowing your physical limitations and putting this knowledge into practice are two different things. Although some persons know better, they find themselves frequently overdoing it and exceeding their physical limitations. Keep the following principles in mind:

Maintain a Balanced, Healthy Activity Level

Avoid the extremes of underactivity and overactivity. Watch our for the overactivity - crash and burn cycle. Discover an activity balance that is right for you.

Use Good Pacing Procedures

Pacing is probably the most important principle to master. You should plan in advance how you want to approach certain physical tasks. Break the activity down into smaller chunks. Depending on the nature of your pain condition, you may need to avoid staying in one position too long or avoid specific repetitive movements for extended periods of time. Vary your routine. Take rest breaks before your pain significantly increases. Monitor your distorted thinking and challenge yourself by asking, "what is the rush?" or "who says I must complete this job all at once?" Think about completing tasks in a parallel manner (working on several tasks simultaneously) rather than serially (moving to a new task only after you have completed the previous task).

Use Good Body Mechanics

Be aware of your posture and body position while you do certain activities like bending, lifting, pushing, pulling, or carrying things. Avoid excessive and unnecessary strain.

Do Warm-up Exercises

Before athletes begin their sporting activities they do warm-up exercises. If you are planning to do some activity that is likely to put a strain on your pain area, you might benefit from some stretching and limbering up exercises first. For example, if you suffer from chronic low back pain and plan to do an activity or chore which might put a strain on your back, you can do some pelvic tilts or other back exercises before you start the activity.

Use Caution During Danger Times

Many persons tend to overdo it and exceed their physical limitations during certain danger times. Here are some common examples of danger times:

1. Days when you feel good. Many of you have good days and bad days. Good days occur when you are feeling good and are not feeling as much pain. Be careful that you don't turn a good day into a bad day by becoming careless and overconfident in your physical activities.

2. While doing some physical activity that you enjoy. Enjoyable physical activities are wonderful ways to distract your attention away from pain. Unfortunately, they can also distract your attention from using good pacing techniques. Be careful that you don't become so engrossed in an enjoyable activity, that you forget to pace yourself.

3. While competing with other people. Competition is a great motivator, but it can also get you into trouble. Don't let competition trick you into exceeding your physical limitations.

4. While trying to please other people. It is nice to please others, but don't let this lead to neglecting your own need to stay within your limits.

5. When you are feeling rushed, pressured, or emotionally upset. These are times when you can become careless and forget to use good judgment while doing physical activities.

Unfortunately, many persons with a disabling chronic pain condition suffer a significant blow to their self-esteem. Inability to accept yourself, because of having physical limitations, can really get you into trouble. It can lead to dependency, depression, or chronic frustration, anger, and bitterness. Following are some general guidelines for improving your self-acceptance and self-esteem:

1. Remember That Physical Limitations Do Not Make You A Less Valuable or Worthwhile Person.

Who says that a person's worth is determined by their physical capabilities? When you really think about it, just about everyone has some physical limitations. Also, everyone develops more physical limitations as they get older. Just because you can't do all of the physical tasks you did when you were in your late teens and early twenties, doesn't make you a less valuable person. Some have pointed out that a very destructive irrational belief is the tendency to equate one's worth as a person with his or her physical accomplishments. People who are severely disabled have no less worth as a human being than an able bodied person.

2. Focus on What You Can Do Rather Than on What You Can No Longer Do.

Rather than dwelling on those activities you can no longer do as before, try to focus instead on all those things you still can do. Try to promote an attitude of gratitude for what you have rather than an attitude of regret for what you no longer have. Think of the severely disabled spinal cord injured person who considered it a great achievement when he learned to feed himself on his own (something the rest of us take for granted).

3. Develop New Knowledge and Skills.

It will become easier to focus on your positive abilities if you direct your energy to developing new knowledge and skills that are not as physically demanding. In our society, the people who earn the most money are those who have special knowledge and skills rather than those who have the biggest muscles and strongest backs.

4. What Really Counts is Doing the Best You Can With Your Abilities.

Build your self-esteem on making the best use of your knowledge, skills, and abilities. It doesn't matter what others can do or what you used to do. What really matters is that you do your best today.

5. Find Ways To Be a Better Person.

All of us have room for self-improvement. Self-improvement does not necessarily require physical achievements. There are many ways to be a better person, like working on your character. Developing more positive attitudes, healthier ways of living, improving your social relationships, giving of yourself to other people, and spiritual growth are all ways to become a better person.

What can you do to improve your own self-esteem and self-acceptance?

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