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15 Articles in Volume 16, Issue #6
Osteoarthritis and Central Pain
Uncovering the Sources of Osteoarthritis Pain
The Synergistic Effects of Mood and Sleep on Arthritis Pain
Nonsurgical Rx of OA: Analyzing the Guidelines
Osteoarthritis Disability Is Often Underestimated By Rheumatologists
10 Pain Medication Myths
The Use of Medical Marijuana for Pain in Canada
6 Common Concerns Regarding Medical Marijuana
What Pain Specialists Need to Know About Medicinal Cannabis
Applying Kinesiology as a Multipronged Approach to Pain Management: Part 2
Practical Guide to Adding Recreation Therapy Into Pain Management
A Novel Treatment for Acute Complex Regional Pain Syndrome
Genetic Testing in High-Dose Opioid Patients
No More “Fifth Vital Sign”
Letters to the Editor: Disc Herniation, SCS, Arachnoiditis, Tapering Opioids

Practical Guide to Adding Recreation Therapy Into Pain Management

Improving strength and flexibility does not have to be all work and no play. Learn how to get patients to pick up fun sports and hobbies that also strengthen their core, lighten their mood, and reduce their pain.

Deconditioning and immobility are 2 major affects of chronic pain. Therefore, it is important for physicians to encourage patients to participate in a sport or hobby and learn to have fun again.

According to the American Therapeutic Recreation Association, recreation therapy is a treatment service designed to restore, remediate, and rehabilitate a person’s level of functioning and independence in life activities.1 The goals are to promote health and wellness and to reduce, or eliminate, activity limitations caused by a disabling condition that restrict participation in life situations.1

Recreation therapy can be conceptualized as an adult version of child “play therapy,” which has been shown to be effective.2 Unfortunately, research has shown that providers tend to give recreation therapies a lower endorsement compared to other pain management modalities due to their low practical and theoretical exposure to this type of intervention.3

The role of the recreation therapist is to “re-create” a means of activity. Intervention areas vary widely and are based upon patient interests. The following is a practical review of the different intervention areas available in recreation therapy—adapted sports, exercise programming, leisure education, and creative arts (eg, music and fine art).

What Are Adapted Sports?

Adapted sports are based on existing sports but are modified to meet the needs of people with disabilities. Some examples of adapted sports include bowling, golf, equine therapy, and archery. Bowling leagues offer patients the opportunity to learn how to bowl, to improve their skills, or to raise their averages, for example. Bowling leagues expose patients to many different styles of play and types of equipment, and provide opportunities to build comraderey and socialization skills.

Golf, another option, provides an outlet for gaining new experiences as well as reintegrating patients into the community. Golf affects patients in various ways, from increasing their social skills on and off the indoor/outdoor driving range or course, to improving their quality of life. For patients with chronic low back pain or shoulder injuries, they work with a golf professional to address swing deficits and with a physical therapist to eliminate physical limitations. Together, they can help with body and swing mechanics, which will boost enjoyment of this challenging game. In addition, golf therapy can reduce or eliminate golf-related injury pain, improve late-game stamina, develop power for hitting longer drives, and enhance the accuracy and consistency of their short game.

Less common sports include horseback riding and archery. Equine therapy has long been used for recreation therapy purposes. Bonding with a horse is a singularly buoying experience, giving patients an outlet for their fears and anxieties while promoting leadership skills and responsibility. Archery is mainly a competitive sport, but programs usually start with basic safety and then build skills.

What Physical Exercises Should Be Considered?

Exercise is performed for various reasons, including stretching, strengthening, improving cardiovascular health, and enjoyment. Exercise is an effective treatment strategy for various chronic pain disorders, including neck pain, osteoarthritis, headache, fibromyalgia, and low back pain.4 But before a patient launches into a new sport or exercise program, it is important to communicate some key guidelines (Table 1).  

Flexibility exercises, or stretching, can be good tools for managing chronic low back pain and fibromyalgia. Other forms of slow-movement exercises to consider are tai chi and yoga. Yoga has been shown to help with arthritis, back and neck pain, headaches, and osteoporosis.5-9 Regular benefits of yoga include improved sleep, strength and balance, circulation, flexibility, and physical and general well being. There is promising scientific evidence to support the use of yoga and other movement-based exercises for non-cancer pain conditions such as low back pain.10 These exercises may provide a good alternative when endurance-building or strengthening exercises are not recommended.

Strengthening exercises may help to manage chronic low back pain. Cardiovascular (aerobic) exercises can include walking, biking, and swimming, and should be done regularly for a minimum of 30 minutes each. A typical fitness facility should be equipped with a variety of cardiovascular, strength, and conditioning equipment. At times, these facilities also offer aquatic therapy. The unique physical properties of the water make it an ideal medium for rehabilitation for conditions such as lower back pain.11 Typically in aquatic therapy, a therapist attends to the patient receiving treatment in a heated therapy pool.

What Is Leisure Education?

Leisure education focuses on 3 subcategories: sports and recreation, tourism (such as travel), and leisure. Tourism commonly is associated with travel within the community for the purpose of reintegration. Examples of tourism may include trips to local park districts, attractions and tours, community events, and entertainment such as theatre or sports events. Leisure, or free time, is time spent away from other responsibilities, including activities of daily living, such as eating and sleeping. Leisure activities include a very broad range of activities, including the arts and other hobbies. Providers may want to consider encouraging patients to engage in their talents in such areas as music and fine art.

How Do Creative Arts Affect Pain?

A background in music or fine arts is not necessary to have fun. Creative arts therapists make these mediums accessible to all patients. There are various reasons to integrate these forms of therapy into complementary, supportive pain management programs, including that they enhance activity levels and creative capacity; they stimulate positive emotional experiences as well as communication and social interaction; they facilitate coping; and they stimulate imaginative experiences and awareness.12

Music therapy has been shown to help with acute and chronic pain.13,14 Music therapists primarily help patients improve their health by using music experiences such as free improvisation (eg, drum circles) and singing (eg, karaoke). Research suggests that drumming serves as a distraction from pain and promotes the production of endorphins and endogenous opiates.13 Studies also suggest that active singing may have some benefits in terms of active coping, but further research is required to fully explore such effects.14 Research also has shown that music can increase the effectiveness of medical therapies and can be used as an adjuvant with other pain-management programs.15 Music therapy is used in hospitals, cancer centers, schools, alcohol and drug recovery programs, psychiatric hospitals, and correctional facilities.16

The definition of art therapy varies depending on its focus. The art making process can be therapeutic in and of itself, or it can be used in combination with other therapies, such as psychotherapy.17 In art therapy, any type of visual art or art medium can be employed within the therapeutic process, including painting, drawing, sculpting, photography, and digital art to promote healing.18 One phenomenological study examined the meaning of chronic pain using art and found that patients were able to explore their narrative and experience, and providers gained understanding about patients’ journeys.19

Where Does Sex Fit Into Recreation Therapy?

Humans are believed to be one of the only species that have sex for recreation. Based upon recent research, one sexual activity (penile-vaginal intercourse and the orgasmic response to it) is associated with better psychological and physical functioning. Other sexual behaviors (including penile-vaginal intercourse with condoms) are not associated with, or in some cases (such as masturbation and anal intercourse in heterosexual couplings) are inversely associated with, better psychological and physical functioning.20

In studies of the sexual activity of patients who suffer from chronic pain, most reported deterioration in sexual health, including a decrease in frequency and quality.21,22 Although no relationship has been found between pain severity, duration, and frequency and sexual functioning, a relationship has been found between disability status, age, and psychological variables (depression and anxiety), and domains of the sexual response cycle (desire, arousal, and orgasm).23 Thus, to make a comprehensive diagnosis and a recommendation for treatment, providers must include sexual function in their medical review of patients with chronic pain.

What Is Sexual Health?

According to the World Health Organization, sexual health is a state of biopsychosocial well-being in relation to sexuality; it is not merely the absence of dysfunction.24 Sexual dysfunctions are highly prevalent, affecting about 43% of women and 31% of men.25 Sexual desire disorders have been reported in approximately 30% of women and 15% of men.25 Pain or even the fear of pain can decrease desire, making the patient uninterested in sex.

Sexual arousal disorders (eg, erectile dysfunction in men, loss of lubrication in women) have been reported in 10% to 20% of both men and women.25 Sometimes chronic pain may hinder or block sexual excitement, causing the man to have trouble achieving an erection or a woman to secrete vaginal fluid. If a patient becomes excited but the act causes pain, the excitement may be reversed.

Orgasmic disorders have been reported in 10% to 15% of women.25 Inability to have an orgasm can sometimes be related to lack of knowledge about how women orgasm and the appropriate (most often clitoral) stimulation needed for women to reach climax. Reportedly, men on average reach climax in 2.8 minutes, while women on average achieve orgasm in 13 minutes. In other cases, the inability to reach orgasm may be related to either neuropathy (nerve damage related to disease processes such as chronic disc disease) or may be medication-induced (eg, antidepressants and pain medications). As they alter sensation, pain medications may increase the time to climax/orgasm or completely stop the climax from occurring. The pain sensation itself also can prevent people from reaching climax during sex.

Finally, sexual pain disorders have been reported in 10% to 15% of women and less than 5% of men.25 Sexual pain disorders in women typically occur in the vulvar area and most commonly are related to hormonal deficiency (such as a local estrogen deficiency) and/or muscle hypertonicity. Sexual pain disorders in men typically involve groin pain and may be related to infection or trauma to the groin area.

Sexual health also requires a positive and respectful approach to sexuality and sexual relationships that are consensual among adults.23 Sometimes chronic pain can alter the way patients feel about themselves. It may cause them to have low self-esteem or to feel depressed; these feelings can interfere with sexual desire. Many patients find that chronic pain strains their relationships with their sexual partners because of their mood. As a result, they tend not to be very attentive to their partners, which may cause their partners to become impatient and feel differently toward them.

Despite the pairing (whether heterosexual or homosexual in nature), the relationship is the key to sexuality. If the relationship is in conflict, then the pairing may need reconciliation or conflict resolution. There are different sexual needs when one person in a pairing has an illness, such as chronic pain. With therapy, patients are taught to take responsibility for their own sexual satisfaction and worry less about holding their partner accountable. Thus, good communication is essential, and the couple may need psychological counseling or enrichment programming.

Finding the Right Position

Chronic pain may hinder a patient’s ability to move freely and, thus, limit the positions they can get into to have sex. Sometimes chronic pain requires partners change their usual sexual positions or acts to find a position that doesn’t cause pain. There are several different sexual positions recommended to prevent patients from hurting their back (see image below).26,27 Aids, such as a pillow, are used during the sexual act, and body posture, such as knee and hip alignment, remains important. Again, it’s important that couples spend time touching, kissing, and hugging during foreplay, after sex, and even when they don’t have sex but want to express affection towards one another.

If a patient with chronic pain continues to report sexual dysfunction, a referral to a sexual health clinic may be beneficial. Sexual health clinics may provide different services, including sex education, evaluation and treatment for sexual dysfunction, contraception (condoms and birth control), physical examinations, laboratory workups (hormone levels), sexually transmitted infection testing and treatment, and vaccinations (eg, hepatitis A/B and human papillomavirus, or HPV). Sexual health clinicians also will evaluate patients to determine what factors or drugs may be affecting their sexual function. There are several factors that affect sexual dysfunction, including chronic medical illness (eg, diabetes, cardiovascular, and hypertension),28 psychiatric illness (eg, depression and bipolar disorder),29 trauma or surgery (eg, Peyronie’s disease, prostatectomy, and radiotherapy),30 and modifiable risk factors (eg, smoking tobacco, using alcohol, sedentary lifestyle, and obesity).31

There also are several types of substances that can negatively affect sexual function, including medications (eg, antihypertensives, antidepressants, antihistamines) and illicit drugs (eg, opiates, cocaine, methadone).32 Sexual health care professionals also can provide various treatment options, including coaching,33 sensate focus (discovering erogenous zones through non-genital stimulation),34 vacuum devices and intracavernosal injections,35 and pharmacologic agents and herbs.36


Last updated on: August 5, 2016
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A Novel Treatment for Acute Complex Regional Pain Syndrome

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