Painful exercise in rehab – Yes, no or a lot to think about?

Whether rehab exercises should be painful or not has become a recent topic of much discussion. As we have started to value the role of (optimal) loading in rehab, and that we can get patients back to moving and loading pretty early in the rehab process, we have also got to appreciate that this is unlikely to happen without experiencing any pain.

If you have any type of understanding about pain then the simple question of “should we use painful exercise?” suddenly might not look so simple!

Rather than a simple yes or no, there are a bunch of questions to be answered, such as how much pain is OK? Who may or may not benefit? And what is the best way to manage the process? Especially if all does not go to plan!

Research

From a data standpoint it would be great if we had have something that we can use to guide us here. Low and behold we do, and its open access.

Smith et al looked at this question in 2017.

Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis

This systematic review and meta analysis looked at 9 trials in which varying degrees of painful exercise were used. They found that painful exercise did NOT result in statistically worse outcomes across a short, medium or long term follow up. There was a small statistical benefit in the short-term for painful exercises as highlighted by the standardised mean difference of around 0.2 (SMD = effect size for a meta analysis). So from a research standpoint this is positive news.

One thing to note here from a clinical standpoint is, that using painful exercise is no GUARANTEE that it will have a positive effect for your patient. All statistical tests only give us the PROBABILITY of an effect, so the likelihood is that it will, but when we look at the confidence intervals (measure of variability) for the mean SMD for painful exercise, for the majority of the studies we can also see that they cross into a negative effect and in some of the studies quite substantially.

The variable effect of exercise on pain (although over a shorter time frame) was also shown by O Neill et al's recent look at the acute effects of isometrics *Here*. Although, of course, isometric exercise and painful exercise is not the same thing, the point here is the highlighting of the variable effects from exercise. For patients with higher baseline pain isometrics actually increased their pain post exercise and this is the benefit of looking at individual responders within a study not just the group average. Those with lower pain at baseline seemed to receive more analgesia from isometric exercise.

BUT at the very least I think we can say that the likelihood is that it will not have detrimental effect. So as rehab can often be painful we can be reasonably confident but without seeing painful exercise as some sort of fire and forget panacea and also appreciate the individual nature of pain.

We could debate the mechanisms of HOW painful exercise might work from pain habituation to conditioned pain modulation and perceptual mechanisms but in essence we don’t really know at this point in time and this might be different or in different combinations for different people.

Benefits

The benefits can be both physical AND psychological.

Firstly, it allows patients to get in MORE exercise. If they are not being limited by pain (or pain contingent if we are being fancy 🙂 then they can get a greater dosing than if they stopped due to it being painful. It is important to add though that we currently don’t know what optimal dosing is for exercise having an effect on pain!

Secondly, it sends the message that hurt does not equal harm. The problem can be painful and still settle down if managed in the right way. This may give people a new insight into their pain and how they can manage it.

Pain self-efficacy may also be built experientially, so using painful exercise as a tool might be an option to help do this.

Clinical application

So it’s great to have some objective data on this subject, but as we know getting that into clinical application is not always straightforward.

Firstly don’t be afraid of some pain! The likelihood is that it won’t cause a worse outcome. But as we are dealing with thinking, feeling HUMANS, it is OF COURSE not as simple as this, but more on that later.

One of the issues with always looking to be pain free with exercise or continually treating pain, is what does that say ABOUT pain? On one hand we are telling people hurt does not mean harm but our actions might not be saying the same thing. If pain is OK, if it is normal then in the process of getting it better we might have to endure a little bit of it.

But how much is OK is a key question? Studies that have allowed painful exercise have ranged from not increasing baseline symptoms during or post exercise up to 5/10 on the VAS.

We know the limitations of the VAS as a REALLY subjective scale so perhaps we could introduce the idea of pain being tolerable or intolerable rather than a numerical score.

Screen Shot 2019 01 21 At 13.16.00

Now tolerable might be a bit sore but it does not really get in the way. Intolerable might be thought of as getting in the way of our daily activates, maybe having an effect on our sleep and generally making life a bit miserable. This is going to be different for different folk so hence why the concept of tolerable becomes important.

We would also like to know how the pain is settling down. So pain that is not really calming down after the exercise stimulus or keeps on getting progressively worse over a number of days as the exercises are performed is probably not a great idea. We would like to see a nice stimulus response with only slight increases above baseline (tolerable remember : ) that calms down gradually over 24-36 hours, quite similar to delayed onset muscle soreness (DOMS)

So on the issue of DOMS, it is important to identify if the increase in pain is actually the same as the original symptom. Post exercise soreness is quite normal but for those that are unaccustomed to exercise this might not be recognisable especially for a currently painful area. Defining what is pain and what is soreness might be a good sense making exercise for some patients. Although we don’t know that progressive overload is required with exercise in rehab, it probably ia a good idea, so having some sort of tolerable baseline for patients to progress or regress from is a great idea too. This is also might have an effect their self efficacy using exercise too which, of course, is a bonus.

Pain is not the only issue

Potentially the most problematic area with painful exercise, and one that is really under discussed, may be more about the psychological aspects that are associated with the pain and how they can affect the person. One of the best prognostic factors for recovery in a number of body areas appears to be pain self efficacy, *here* is a recent paper from Chester et al and also from Foster et al *here*  Pain self efficacy, something I have written about before also *here*, is the ability to carry on normal functioning despite of pain. It is important to note that those with higher pain self efficacy also tend to adhere to exercise better.

So someone’s pain self efficacy is going to be a KEY factor in whether they are able to tolerate having pain and being able to carry on functioning which maybe a fundamental skill at the heart of painful exercise especially if it can take 24-36 hrs to settle.

Predicted outcome is another key prognostic factor and if someone believes that increased pain will result in a negative outcome then this could have a negative effect on the actual outcome.

Jack et al *here* found that the number one reason for poor adherence to exercise programs was that people did not want to make the problem worse. So painful exercise coupled with negative beliefs about pain, low pain self efficacy and a poor predicted outcome may not sit well together.

A qualitative piece “Exploring experiences, barriers, and enablers to home- and class-based exercise in rotator cuff tendinopathy” from Sandford et al also found that a fear of making the issue worse was a key factor in reduced adherence to exercise.

What can we do?

Firstly you could screen people for these factors if you feel they are required. We have tools such the Pain Self Efficacy Questionnaire  (PSEQ) and the shorter version the PSEQ-2.

One caveat with using questionnaires, in my opinion : ), is it does allow us to get a score to assess confidence and resilience in managing pain but it perhaps does not tell us about things that are specific to our patients. So being able to weave this into a good subjective that teases these more personal parts of the narrative out is a must.

Also ASK about their expected outcome from the treatment and what would it mean to you if it was painful

“Do you feel like this exercise will work for you?”

“Do you have any concerns about doing this exercise?”

It might be that someone tells you that they have tried exercises before and they did not work or that they feel it might make the issue worse, especially if it hurts.

It might also be important to discuss with ALL patients what their beliefs are around pain. These might be that pain indicates they are doing more damage to their bodies or they will not be able to work because they have pain or implications for future functioning. It can often be what the pain MEANS to the patient that is the real issue rather than just the sensation of the pain itself.

A key factor to remember is regardless of whether painful exercise is positive or no worse than non painful exercise, a negative belief may stop your patient from exercising

Education

One of the most powerful tools we have at our disposal is EDUCATION, I am not always a huge fan of this term as it can imply a teacher pupil relationship. But in order to provide effective education to people we first have to build rapport and then understand what they may need to know more about.

We can educate on a range of things from the effectiveness of exercise for many issues, that painful exercise is often not detrimental, that pain self efficacy is an important prognostic factor and what pain may actually mean and its relationship with physical damage. It may also be worth talking about the process and what to expect, and often that it is a process of trial and error to get the right level and desired response.  

This has to start with understanding the patient, their history and belief structure.

Where you start is not where you have to finish

Do we have to jump straight into painful exercise? I don’t think so. It is not REQUIRED but it is also not harmful.

An important point to make is that for someone with very negative beliefs about pain, reduced pain self efficacy and poor beliefs about the outcome, challenging them right off the bat with painful exercise might not always be the best thing to do. As they build trust in you and confidence in their bodies then pushing into pain progressively might sometimes be a better route.

We know that giving people the option to avoid pain can actually maintain pain avoidance, so whilst not advocating avoidance behaviour confronting these things may take a little time, confidence and education, especially if the person has a lot of negative pain and avoidance based beliefs.

Those that persist in doing painful things that have NOT provide a therapeutic effect may benefit from non painful exercise for a while too. If you feel that pushing into pain has not given the desired response when looking at their history then a break or change in dosage could be just the ticket.

Those with higher levels of pain at baseline on average seem to have worse clinical outcomes so this might also lead me to reason that maintaining this level of pain through exercise might not always be a good idea.

There are no real hard and fast rules here only individuals and individual considerations.

What if it all goes wrong???

This is where self efficacy may come into its own. Empowering your patients to self manage maybe valuable in the exercise process.

As we hopefully have told the patient BEFORE they embark on an exercise program I can often be trial and error. Have we enabled our patients to adapt their exercise dosage if it goes a bit wrong? *Here* is a short piece on dosage in rehab  

So do your patients know what to look out for in terms of symptoms?

Do they know how to adjust the dosage? This could be in exercise frequency, intensity and time, sets and reps (volume).

Are they able to contact you to ask questions? Do they know this?

I think these are all required aspects of pushing into pain.

A patient I saw last week had religiously persisted at pushing into his painful rehab exercises every 48hrs. He believed if he did what he was told he would get better (the trust!). But after 3 months there was not the desired outcome. In this case he was given no indication what to do if this happened, just blind faith on all sides that he would get better.

Key points

  • Painful exercise DOES NOT produce worse outcomes from the research we have
  • Research does not guarantee your patients response to painful exercise
  • It is not just about the PAIN sensation! What does the pain mean and how does it affect behaviour such as exercise adherence?
  • Pain self efficacy and predicted outcome are important psychological measures and can be discussed and measured
  • Think about education around the exercise and the pain response
  • It does not need to start with painful exercise!
  • Empower your patients to self manage

Pain science – A main serving of lived experience and a side of biology please.

The world of the science of pain or ‘pain science’ as its better known can definitely be a polarising topic when it gets discussed. These recent commentaries twitter/social media debates really highlighted this.

The truth about pain science, exercise and movement

The REAL Truth About Pain Science and Body Mechanics: A Response to Criticism

P.s the second one is better - Todd Hargrove is a great writer ; )

I would like to point out that I am by no means a pain researcher and really just a lowly blogger and clinician. It has been suggested this makes my opinions less valid and I am OK with that. So you have been warned!

Before we get into it there are two points I would like to make.

Firstly, the importance of understanding more about pain, from both a clinical standpoint and also a patient perspective should be highlighted.  There can be great value for everybody in this area but one that is still evolving and has more to it than one or two dominant voices.

Secondly, pain can be seen a bit as a ‘special interest’ area. However if someone is working with those in pain and has not received some education on the current concepts around pain, at least to some degree, then a parallel maybe like being a chef who does not know much about the ingredients they cook with! The science of pain is one of the primary areas that clinicians, and anybody working with people in pain, should have some proficiency in.

Stuck on the Biological?

The term biopsychosocial gets thrown around a lot in healthcare. In my opinion there is no more important place for a BPS perspective than when it comes to our understanding of pain. It could be argued however, that the current dominant views and messages within ‘pain science’ in many regards have not really moved beyond the biological.

I would like to say explicitly the point of the this piece is not to say ditch the biological but instead consider that this might be insufficient to truly understand pain and its ramifications on peoples lives. There are also clinicians already advocating for this and combining both aspects.

The vast majority of the information and slogans we have about pain are specifically focused on the biology and anatomy, and the education mainly is grounded in these elements. Although in fairness the intention maybe that this biological message has an effect beyond biology and into behaviour, but the focus seems to be less on the behavioural aspect itself.

The most important message to come from this might be that:

"Hurt does not equal harm"

So that the sensation and its magnitude, severity or however you want to describe it, does not have an ‘isomorphic’ (fancy way of saying simple, direct or 1 to 1) relationship with tissue damage. For many this has been an informative and empowering message but for others may not resonate with their pain experience in the same way.

If we think about the words used to discuss pain such as alarms, nerves, brains, sensors and nociception, they really relate mostly to biology and the stimulus and response process, or essentially the SENSATION of pain. It could be said that the information seems to be of more primary importance than the person it is being applied to.

Pain does not just have a  sensory-discriminative aspect but also the affective-motivational one too that can be equally, and for some maybe more, problematic. The lived experience is more than just the sensation that we feel.

These are two interesting papers that discuss different perspectives on pain.

The sensory-discriminative and affective-motivational aspects of pain

Pain as metaphor: Metaphor and medicine

It might be that I am going to be accused of over complicating all this, and whilst there are simple messages that could have a positive impact, there is also an often-made point in the pain world that oversimplification has led to the discussion of  ‘pain pathways’ and ‘pain receptors’ that are rightly pointed out as problematic for the understanding of pain.  

So to think about pain as only a sensation or an ‘alarm’ may also be a touch incomplete when we view it outside of the biological and move into the psychological and social realms, perhaps this is a simplification of a complex multi dimensional problem? Maybe it cannot be conceptualised into one sentence such as “pain is protection” or “pain is an alarm”. While we cannot exclude the biological aspect of the pain experience, and we should not go down the the baby and bathwater route, the question is, is a biological perspective and explanation sufficient to fully explain how pain impacts on lives? I personally do not believe in many cases it is. 

We seem to be really good at talking about the sensation, how it comes about and the biological processes involved, maybe we are not so proficient at exploring and explaining how this sensation affects lives, emotions and motivation and the overall unique individual experience that we might consider as the wider psychological and social impact.

Looking more at pain through a BioPsychoSocial lens

The real transformation in pain knowledge moving forward and building on the great work already done, from both a clinician and a patient perspective, I believe may come in understanding the impact on the psychological and social aspects of the human experience. Disability and suffering could be described as social aspects of the pain experience rather than a part of the biological ‘alarm’ system.

That pain is normal and occurs often is a key ‘pain science’ message. What differentiates those that do not develop persistent pain and those that are also able to live well with persistent pain from those that are most negatively impacted by pain?

It appears that the people worst affected by pain are perhaps not affected by an increase in the intensity of the sensation but instead by how much pain impacts on their lives as a whole, the ability to work or interact socially and integrate with society as a whole in a positive way.  Now the interpretation of the sensation of course will be part of that but by no means all of it. Pain may have many meanings beyond just damage. Getting to this meaning and giving information that relates to that can be key.

Screen Shot 2019 01 13 At 14.55.39

This fits with Engels wider BPS with biological aspects being at the centre but having much wider ramifications right up to a societal level.

BPS factors

We perhaps also use wider BPS factors, sleep, stress, beliefs etc more to explain the increase or decrease in the sensation and sensitivity, so essentially contributors to pain. 

The idea that the sensation of pain is a primary concern for patients has already been called into question with disability seemingly more important than pain intensity.

Factors defining care-seeking in low back pain – A meta-analysis of population based surveys

Wider BPS factors can, often be studied in relation to ‘pain sensitivity’ or ‘tolerance’. The increase or decrease in response to a prolonged or painful stimulus can be discussed with relation to the sensation or an increase in ‘sensitivity’.  The focus seems to be more on the effect of these factors on pain rather than the effect of these factors on the person and their quality of life. Shouldn't we be doing both?

Lets take sleep as an example.

Sleep has a bi directional relationship with pain and it is unclear which is the chicken and which is the egg. Poor sleep can really affect my job, my social interaction and quality of life, instead we can focus on this aspect to explain the sensation and then as a modulator of the sensation.

This has also been conceptualised as “pain is telling us something is wrong, we just don’t know what” with regards to a stress or ‘allostatic’ load view of pain.

So whilst pain is often described as being inaccurate in reporting on tissue damage, pain can be seen as reporting more accurately on wider factors that have been associated with pain. Although it does not seem it can tell us exactly what, so insert anything here, to blame for pain.

I will be honest in that I struggle with this concept and have also realised that I have maybe got myself into a mental pickle : ).

Clock 3036245 960 720

In one sense we should see the ‘alarm’ as perhaps being something to not take so much notice of, the idea of being ‘time contingent’ rather than ‘pain contingent’ with exercise for example. Whilst when pain is ‘reporting’ on psychosocial stressors it should be taken much MORE notice of.

It could be, and likely is, that PS factors might be no more isomorphic with pain than tissue damage and our pain experiences to the same ‘stressors’ will remain highly individual. But this is taking a sensation dominant view of course and this is exactly what I am arguing against here.

We also talk about the biology in a very general way. It’s the same for everybody essentially, but does this generic biology result in the same experience? I do not personally believe so.  It is getting from this biology to the lived experience that may prove tricky.

The burning question is how much biology do I need to get across and how much does mostly focusing on the biology help? Of course that answer may prove to be individual rather than a generic singular solution. 

 A common argument for the alarm system is evolutionary based

One of the arguments for the current view of pain is based in an evolutionary perspective. So the ideas of pain as an ‘alarm’ or ‘protection’ look at pain from the need for basic survival.

When we look at pain from a BPS perspective perhaps some of the ideas of protection do not fit as well as when we view them from a more basic evolutionary perspective.

At the most basic level nociception, I think, can be conceptualised as an alarm. The network of a high threshold detection system falls nicely into the bracket of an alarm. But we also know that nociception does not simply equate to pain (remember the oversimplification thing). Pain could arise with the further analysis, or maybe lack of analysis potentially, of the alarm system. So is pain actually our reaction to the alarm?

But I digress.

This conceptualisation of pain maybe focuses less on the impact of pain at a wider level. Whilst there is a ton of research in the psychological domain and some in the social, I don’t think it has really made its way into the most dominant pain messages that are discussed and used with patients. A multi dimensional view of pain does not JUST consider the role of biology and threat but also the wider impact of pain across the BPS spectrum and also the bi-directionality of this.

The alarm conceptualisation does not really give the picture of how pain effects human beings, their psyche’s and the wider societal effects.  Can we explain away disability, suffering and many of the other impacts of pain on our psychological and social functioning as the singular role of an alarm?

Maybe our biology has not kept pace with the changes in our psychological and social environments? The simple alarm system has not adapted to the meanings and emotions we give to it and the wider ramifications on our functioning in society?

What are future directions?

Now, in my opinion, it seems the current dominant approaches of pain science education focus on the biology and slowly works its way out to the psychological and social. Perhaps we should start at a broader point on the effects of pain on life and work our way back down to the biology if required?

Seek first to build rapport and understand the person and their situation before explaining it.

We can talk about pain with people and for some it makes a huge difference. Not for all however and as per all interventions will have individual effects.  

Maybe there is not a universal way to explain pain? There is no flash card set or single conceptualisation that is correct for every experience of pain.

Something I have discussed for a while is making it relevant to the person you are working with. Helping people make sense of THEIR experience and THEIR pain may make it more relevant.

Don’t just apply information to people and expect to their behaviour to change. Define behaviour change and use specific information and experiential approaches to specifically change behaviour, then monitor closely if this has been effective.

Resilience – What is it and why is it a big deal for recovery?

Resilience is a term used more and more by therapists, some might suggest it is a buzz word, so I wanted to put down my thoughts about this complex subject. I have wanted to write this blog for a while and the struggle I have had here is to keep it bloggy, not too academic and above all not too long! I have tried to strike a balance between research and also some personal experiences of resilience I have collected.

Before we get into it, there are 3 main points I would like to make in this blog.

Firstly, resilience is NOT about manning (or womaning) up, it is NOT SIMPLY about just keeping going. It’s a flexible, adaptable state that recognises the importance of specific actions, mental or physical, that have a positive impact on life.

Secondly, resilience is not a binary state between resilience and not resilient. It is a continuum that we move along dependent on a balance of internal and external factors.

Thirdly that resilience looks and feels different between people. What you may regard as resilience MAY NOT be the same as the person you are working with.

What is resilience?

Resilience is defined by Sturgeon *HERE* as,

“Maintenance of positive physical and emotional functioning in spite of significant difficulty or challenge”

So resilience is both a physical and psychological thing. It is important that we don’t separate the two however (much like pain!). Although physical things often signify resilience, they require a strong psychological component to achieve and also give a lot of psychological benefit.

This is also a good read *HERE*

Karoly *HERE* defines resilience as (2006) as

“Effective functioning despite the exposure to stressful circumstances and internal distress”

Both definitions use the word FUNCTIONING and ‘in spite’ or ‘despite’ of pain.

This makes resilience a REALLY individual thing that looks quite different between different folk. We should not make the mistake of assuming what signifies resilience to us is the same as someone else’s.

Pain is definitely a stressful circumstance for many, and it really becomes a problem when it interrupts our functioning. Focusing on the stressor, pain, however could be part of this problem. Essentially resilience should be seen as a problem of function rather than pain. This is an important distinction, as identification and engagement of functions must form the key focus (IMO) rather than the focus that many can have (patient & therapist), pain itself.

Sturgeon writes;

”Attempts to control a chronic stressor like chronic pain are often counterproductive and can magnify the negative effects of the stressor”

Sustainability

Goubert & Trompetter *HERE* introduce the concept of sustainability; this is defined as:

“ability of a person to move towards long-term positive outcomes in life in the presence of adversity”

Here is a nice graphic outlining sustainability vs recovery from their paper.

Screen Shot 2018 10 26 At 07.32.40

Sustainability targets the PERSON in pain rather than the pain itself. Perhaps sometimes the focus can be on the pain going away before function is resumed, but we could view this the other way around with functioning through resilience being the first step.

The concept of sustainability is important, as it looks more at positive traits rather than risk factors. This is a bit like Antonovsky’s Salutogenic approach *HERE* that focuses on health rather than disease.

So to sum up resilience, it is about PEOPLE and FUNCTION more than pain and withstanding pain (IMO). Working through ANY pain or injury will require some element of resilience. Acute back pain, one of the most prevalent painful issues, probably exemplifies the need for resilience, with the first line treatment for back pain being the advice to remain active and engage in your normal activities *HERE* .

Perhaps initial resilience may mediate the transition to more persistent pain states?

Adaptability & flexibility

Resilience should not be seen like a brick wall. A resilient person is not simply a cold piece of rock impervious to any stressor. It is not about toughness, it is instead a flexible and adaptive state.

It could be quite the opposite, in that resilient people might be willing to seek out help instead of the strong silent type who may not be as resilient as they appear externally, unable to appear weak or vulnerable by asking for help. Resilience maybe the ability to open the pressure valve and allow the excess to release and lower the stress by identifying things that allow them to do this or provide a balance with stressful situations.

Pain relief vs resilience

Therapy has long been driven by pain relief, and whilst there is no doubt this is a reason why people seek care, they also seek care because pain is disrupting their lives and functioning, perhaps even more so for this reason.

This paper by Ferrara found that disability was a greater reason for care seeking than pain intensity *HERE*

So perhaps to understand resilience we have to understand to understand our patients functioning and what THEY view as key markers to signify resilience. Traditionally VAS scales and physical measures such as strength have been used to measure clinical success. But do these measures capture valued activities and what resilience might mean for the person? Perhaps not. This paper looks at this subject of what is measured clinically vs peoples ACTUAL goals *HERE*.

So in order to help people BE resilient a good place to start is to find out more about how THEY view resilience, what defines their effective functioning and how we might bridge the gap between their current and desired states.

Resilience is PERSONAL

Valued activities may provide balance during stressful situations. Especially people that suffer with persistent pain can lose sight of things they used to do and the things that might define resilience. These are the people that may need a guide or a coach to find some meaning or goal again.

The sustained engagement in cherished activities, or stuff that MEANS stuff, seems to be a huge marker of resilience. To get a better idea of some of the meaningful activities, I asked some of the folk on social media (not in depth research I know) to let me know some of the things they found important during painful times.

Exercise seems to be a really important sign of resilience for people and it was amazing to hear so many success stories against some pretty adverse situations. On a side note, communicating  patient success stories to other patients, delivered at the right time and in the right way, can be a very powerful tool in my experience.

  • Weightlifting
  • Capoeira
  • Yoga
  • Pilates
  • Boxing
  • Bike riding
  • Crossfit
  • Running
  • Walking
  • Bouldering
  • Various sports
  • Gymnastics
  • Dancing
  • Making things
  • Hiking

Work also featured heavily. Just day to day functioning seemed important. Much like exercise, our working lives are pretty varied  from being a therapist to nursing to simply driving. The concept of family also featured heavily with helping and providing for them forming  an important part of resilience for many.

Resilience seems to be a rich tapestry of different things. The clinical implication of this is being able to effectively listen and ask a few questions that allow us to find out more about what activities may signify resilience and then be able to guide someone towards them and also provide planning and support for engagement.

Here are some example questions I use:

“What would your perfect day without pain look like?”

“What have you stopped doing because of the pain?”

“Are there things you feel are important that you avoid because of the pain?”

I also picked out some quotes. I have not used any names : )

“For many years, my default position was to isolate myself, try to power through, and go out of my way not to seek out resources or strategies. I thought that was the way I was supposed to do it; “man up” and push through. For me, I think I discovered (still am) resilience when I learned about acceptance. Getting to acceptance, and I think I still struggle with that a bit to this day, was a difficult time as I had to admit that I could not do this on my own. I hated that feeling”

“Resilience is in all of us, but sometimes we need a guide to help us find our path forward, but there is always a path forward”

“I would say the thing that made me the most resilient was asking for help. From my mentors, friends, counsellors and family. Vulnerability helped me be more resilient”

“I love riding my bike but on a steep hill climb my pain would escalate 10 fold. I persisted and after 30 mins or so off cycling it would go back down to normal levels. The bike ride was more important for my mental well being than the back pain maybe that is why I persisted”

“Resilience for me is knowing that there are things you can and can't control and you put energy and focus into those things you can control/accept”

“Resilience is I get up everyday and work with injuries on others. Sometimes leaving bed is the hardest part”

 It could be balancing the stressful parts of life with things that bring us happiness and joy is most important and when we lose this balance is when we start to become more vulnerable and our job maybe to help with this process.

What components make up resilience?

Both Sturgeon and Goubert outline some positive elements AND some risk factors involved in resilience.

Lets first start with the positive elements.

Optimism & positive emotions

Optimism appears to be a key characteristic, with optimism being related to lower levels of pain and this may support why predicted expectations are related to outcomes. Optimism should be viewed both from a clinician and patient viewpoint and without doubt both viewpoint will interact within the 'third space'.

Here are some good papers *HERE* & *HERE*

Questions we can ask ourselves:

  • Are you a generally optimistic clinician/person?
  • How optimistic are you about a positive outcome?
  • Do you discuss what a positive outcome might look like, especially in regards to improved function?
  • Can we highlight positive aspects from the person’s story/history, previous positive experiences to be optimistic about?

Although it is important to not seem disingenuous, the need for positivity and a positive emotional perspective on life and activity should be highlighted, although this should probably come after a validation of normal negative responses to a tough situation such as persisting pain.

I feel it is also important to highlight the negative aspects of negative thinking and behaviour.

Pain acceptance & sustained engagement in valued activities

Pain acceptance is defined as acknowledging that one has pain, stopping attempts to control pain, and learning to live a richer life in spite of pain. This in turn can lead to more engagement in valued activities.

Sturgeon writes

“individuals with greater levels of activity engagement are better able to bolster their positive emotions through sustained pursuit of valued activities despite their pain”

This appears to be a key factor, both highlighted in the research and also in the in depth qualitative research I performed above on social media ; )

Social support

People who actively seek out social support seem to have lower levels of pain. We know from work such as Riikka Holopainen's *HERE* that people with persisting pain reported that their circle of life had shrunk and they had given up doing things they used to enjoy.

Pain can interrupt positive social interactions that are important for resilience, however pain can also narrow our ability to identify these positive social interactions and positive resilience resources in general.

Risk factors

Pain catastrophisation & avoidance

Higher levels of pain catastrophizing and fear are linked to higher levels of pain and pain catastrophizing can also lead to ineffective coping strategies such as an avoidance approach to coping. This behaviour is consistent with the affective-motivational side of pain that can often motivate people to avoid things such as social interactions and physical activities. Essentially this can limit the enjoyment and positive aspects gained from valued activities, often for fear of pain, and can reduce resilience behaviours. This prolonged avoidance can also lead to depression and disability.

I feel it is important to highlight avoidant approaches and also help someone to rationalise if they are actually helpful for them or not.

But it is also important NOT to simply label people avoiders. Avoidance like all things is complex. Some activities may display avoidance behaviours whilst other things are engaged in. It is a touch harsh to take an area of someone’s life they are struggling with and use it to define them.

Resilience or vulnerability

We must be mindful that resilience does not appear to be a stable state. People are not simply resilient or vulnerable. Instead they appear to have components of both aspects co-existing in a sort of balancing act. Sometimes we maybe more susceptible to vulnerability, even the most resilient is resilient until they are not. We may also be vulnerable in some areas of our lives but not in others. We could be physically resilient but emotionally vulnerable or the other way around. It could switch from day to day. The one thing we know about the experience of pain, and all the dimensions that go into it, is that it pain is predictably unpredictable.

Resilience should really be seen as a continuum. Different injuries may require different levels of resilience and the person will have a current resiliency state dependent on many factors in their life. Some people may be super resilient or the injury type or state may not require much resilience. As with all painful problems this relies on clinical reasoning to apply the right care at the right time.

Screen Shot 2018 10 26 At 07.40.13

Take homes

  • Resilience IS NOT TOUGHNESS
  • Resilience is about adaptability and physical and psychological flexibility
  • Resilience lies on a continuum
  • Resilience looks and feels different to different people
  • Optimism is key
  • Sustained engagement in valued activities is key
  • Pain catastrophization and avoidance behaviour are risk factors

 

 

 

 

Common sense exercise and movement guidelines NOW DOWNLOADABLE

Bencormack (8)

Please click on image to download a high quality version for use in clinic. This can be as a patient handout or poster.

Do you want a version in your language? Then look below, we now have 10 languages!

If you don't see one, maybe you would like to translate one? If so, then contact me at [email protected] 

Exercise Tips French

Exercise Tips Norwegian

Exercise Tips German

Exercise Tips Indonesian

Exercise Tips Swedish

Exercise Tips Italian PDF

Exercise Tips Spanish .compressed

Exercise Tips Danish

Exercise Tips Chinese

Exercise Tips Portugese

Exercise Tips Finnish

Exercise Tips Polish

 

 

Self efficacy – A well used term but well understood?

Self efficacy is a term banded around in therapy quite regularly at the moment especially as more active approaches to rehabilitation are being embraced.

So we have to ask exactly what does it mean, why does it matter and how do we improve it?

In fact my twitter friend/colleague Jerry Durham asked me this question whilst I was in the process of writing this blog, talk about great timing! It also shows that we often don’t have a well defined definition for a well used term.

Screen Shot 2018 06 03 At 09.21.05

Lets start with what does it mean?

It was a term first coined by Bandura in the 70’s, he described it is the 'belief of an individual on whether they have the ability to perform behaviours relative to a specific activity'. Self efficacy has also been described as a ‘resilient self belief system’.

I like to describe it as a sense that ‘I have got this’ or ‘I can do this”.

This could be self efficacy in relation to pain, such as the perception of the ability to remain functional and perform activities of daily living whilst you have pain, or it could be treatment related activities such as a specific activity or exercise.

So lets say that your kind therapist has suggested that you go to for a walk to help out with your back pain, do you think that you will be capable of doing this?

Maybe you don’t feel motivated?

Perhaps you don’t feel confident that you physically can?

Could be that you feel you can’t fit it into your busy life?

Low self efficacy may result in challenges, such as changes in behaviour, being seen a threats to be avoided rather than things that can be overcome.

Bandura identified a number of psychological process involved with self efficacy, these being cognitive, motivational and affective (emotional). Having valued goals and activities appears to be a associated with these factors as well and self efficacy and resilience literature points towards valued activities being an important part of this process HERE.

Bandura also identified four main sources of self efficacy.

Mastery

Previous mastery of an activity or action influences our future perception of capabilities. We are starting to learn that human beings use prediction based on past experiences to navigate the uncertain nature of the world around them. If we have been successful at something in the past then it is likely we will perceive that we can overcome it again. This is also related to the ease of the successes. If our successes have being easy then we maybe quickly dissuaded by obstacles. If the successes have been tough then we may also be used to overcoming any obstacles that come our way.

In line with this view we see that previous adherence and participation in exercise has been shown to be important in future exercise adherence HERE.

Experiences

The world around us also influences our perception of capabilities. If people surround you that you perceive as similar, who are achieving similar things that you are being required to achieve, then you will also be more likely see these things as attainable. This could be from the media that we consume to the involvement in social activities or our family circle, this underlines the social aspects of pain that appear to be pretty important.

This is a great recent paper on social factors in pain HERE

Persuasion

Now this can be both positive and negative, and of course it is easier to be influenced negatively than positively! But those that are persuaded, both verbally and experientially, that they are capable of achieving a task are more likely to be able to do so especially if we see previous success as a key factor.

Negative emotions

Strong negative feelings towards an activity or the negative perception around an activity also will influence the level of self efficacy someone has. Self doubt is often an emotion that influences behaviour negatively.

So we have to also ask, why is it important?

It appears that self efficacy has been linked in multiple papers to worse outcomes across various measures of pain and disability. Now we cannot suggest it is causative or even that improving it will simply improve outcomes at this moment in time. But if I were to go out on a limb I think it probably would : ), especially if we are promoting more active approaches to therapy.

Certainly exercise as a treatment relies on it being performed and evidence based medicine falls flat on its face if we cannot apply the treatment to the patient.

Foster, in 2010, found that for people with low back pain, low confidence in their ability to perform normal activities, or low self efficacy, was predictive of a worse outcome in terms of disability at 6 months, in fact better than fear avoidance, catastrophising or depression HERE.

Keedy, 2014, found that those without the ability to engage in pain management related behaviours, pain self efficacy, is related to the outcomes for back pain rehabilitation HERE.

Greater passive behaviour scores were also found to be associated with worse outcomes at a five year follow up for lower back pain by Chen, 2018 HERE. Passive coping strategies rely on external resources for pain control rather than internal resources such as our belief systems HERE that also influence self efficacy.

Self efficacy has also shown to be fundamental to the adherence of exercise interventions. These studies found that low self efficacy was a predictive factor for poor adherence to a home exercise program HERE & HERE. For all the focus on the nuts and bolts of exercise, it is a pretty redundant process if the person does not feel capable of doing it. Time spent in this area rather than a focus on sets and reps may drastically improve adherence and therefore outcomes.

I call this focusing on the hole rather than the donut (the whole!)

Slide2

What can we do to alter it?

Success!

The first steps may simply be to create a successful experience!

Previous successful adherence and progress have been associated with increased self efficacy and this ties in with a Bayesian perspective of human function. So perhaps our aim for those that display low self efficacy should be to set a low threshold for activity that can lead to easy adoption and fast progress. We often aim for a dosage of activity that leads some kind of physical overload and adaptation. This could potentially lead to a negative experience for some and limit increased participation, without a positive initial experience they may not achieve longer term sustainable success. So essentially good for psychology but not so much for physiology in the short term but hopefully leading to greater longer term physiological impact through sustained participation.

It could be that just making an exercise session fun and not boring could be a very beneficial outcome. We often don’t place much importance on these things within medicine though. Why do people play sports? Maybe because they enjoy other aspects beyond just the physical exertion component.

People are often driven by challenge, fun & competition, how often do you incorporate these aspects into your training?

Some questions I often ask to gauge self efficacy around exercise & activity are:

“Would you describe your self as confident around moving and exercising?”

“Do you feel you are currently capable of increasing your activity levels if required?”

“Would you describe yourself as motivated with regards to activity and exercise?”

Motivation

Motivation also appears to be a key aspect to self efficacy. Helping people find something that actually motivates them could also be important and this could be through a goal setting process that identifies valued activities.  We could then break it down into more perceived manageable chunks that create little wins to help motivate the person.

I call this helping them find their ‘why’.

Lots of exercise programs don’t resonate with people, especially if they have not really participated in one before so exercise in itself is not enough of a ‘why’ for them.

We might ask “what would your perfect day look like with regards to activity?” or “what are some things you love to do that you don’t or can’t?”.

Autonomy is another factor factor associated with successful exercise, HERE , so also giving choices and options rather than a 'this is the exercise you have to do' approach.

Planning

Sitting down and planning with people when they might do things and how much might also have an impact on self efficacy. Being able to do this for themselves might be a limiting factor and the participation in activity may feel like too great a challenge without some guidance.

What days might be best?

What time of day?

What type?

For how long?

What kind of effort level?

Set a reminder on the smart phone?

How to progress?

Alternative options if you do not succeed?

Takeaways

  • Previous experiences with behaviours is involved with future self efficacy
  • Social environment and support is important
  • Self efficacy can make or break an active approach to treatment
  • Self efficacy is involved in outcomes for pain and disability
  • Self efficacy is important for exercise adherence
  • Create behavioural wins and good experiences
  • Your input in terms of planning and motivation is vital if self efficacy is low

Pain education – How much neuroscience do you really need?

Pain education has for many become an integral part of the treatment process and rightly so, being able to help people understand what is happening to them is a must. One of the most frequently used methods to help people better understand pain is based on the neuroscience and physiology of pain.

In some cases this can be sufficient to help people understand more about pain but is neuroscience ALWAYS required? Many patients may benefit from an explanations that do not include information related to these aspects.

Also, does a neuroscience based approach adequately explain the EXPERIENCE of pain and acknowledge the person EXPERIENCING it?

The neuroscience of pain could be explained in a standard way involving the various bits of neuro anatomy and the associated physiological processes to a room full of people, BUT if we were to interact individually with the PEOPLE in the room we may find that they have wildly varying EXPERIENCES associated with that pain.

Pain as an experience

So neuroscience may explain how the the sensation of pain is created, and many of the oddities that surround it, but does it fully explain the experience? Human beings after all are much more than the sum of their parts, and this is what makes us individuals, and does a generic universal explanation imply that pain is all the same? A neuroscience based approach could be described as an objective view rather than a subjective one, but perhaps it is the subjective that seems to most explain the impact of pain on people’s lives.

A question to ponder is that if structural anatomy, and the damage to it, does not adequately explain pain does neuroanatomy and physiology? It certainly pokes holes in the common belief in a simplistic relationship between damage and pain but does it fall short in explaining the experience and the behavioural responses that have such a profound impact on the wellbeing of the person and those around them?

We could take brain imaging or nociceptor firing thresholds or the dorsal horn sensitivity of anyone and display it on a screen, can I differentiate the different experiences that people have by doing so?

From my perspective I want people to know that pain is MORE then just a sensation to be recorded in a score, rating or questionnaire. It is in an experience that can puncture or our existence in many ways and that many parts of our existence can affect our pain experience as well.

Pain is far more than just physical, it affects our overall well-being and emotional state and this is completely NORMAL. For example our mental health is part of our wellbeing and goes up and down in the same way that physical health does. We often place a much greater stigma on mental health though and we might need to let people know IT IS OK NOT TO BE OK with regards to this facet of their pain experience.

We can feel low, worry about the implications of the pain and have greatly reduced expectations for recovery. These aspects form our individual experience and addressing these aspects for some people could be the key for their recovery.

The common sense model is a great way to start to understand some of the aspects that make up our individual pain representations

Screen Shot 2018 01 07 At 10.15.52

Leventhal - HERE

Hale HERE 

Bunzli HERE

Pain has meaning

The MEANING that someone associates with pain, the emotions and changes in behaviour, the belief structures, these are the things that make the pain experience unique to the individual. These are the things that differentiate one persons experience from another and why some can cope whilst others are disabled by pain that might be of  a similar intensity.

We could say that neuroscience is merely a process involved in that experience, but instead of putting the person at the forefront of that experience do we now place the therapist and the information they hold as the star of the show?

A very simple analogy ( and please remember that they are never perfect!) I use for helping people understand the differing meanings people attribute to pain is that of a Petrol gauge.

We could conceptualise both pain and a petrol gauge as warnings. How we respond to these warnings can be very different. In the case of the petrol gauge some people may be quite comfortable to drive on even though they have the gauge on empty, perhaps they know their car and exactly what it is capable of doing. Someone else may rush to get petrol straight away; their response to the same situation is completely different. Perhaps they have run out of petrol before and remember a bad experience? If we changed the context would that have an impact? Would the comfortable people feel different in someone’s car?

Screen Shot 2018 04 23 At 09.34.27

Individualise it

Education should be something we do WITH people rather than something that is done TO people.

One of the key aspects in the clinical encounter is the individual journey that someone has had in relation to their pain. How do we use our increasing knowledge of pain to adequately explain THEIR therapeutic journey, story and ultimately their overall pain experience.

Qualitative research tells us that people crave an explanation for their problems, that they want a diagnosis HERE & HERE . This is often not possible and so a narrative becomes vital and this can often involve learning more about their pain and the way it behaves. There is a huge difference between helping generate an alternative positive personal narrative and just the application of information about pain however.

Rather than an information dump, the selective use of pain related information should relate to something that is involved in the dialogue that is occurring between two people. A large criticism of, and negative responses to medical interactions appears to be HCP’s not listening to people and talking AT them rather than to them. There is a danger of this with any application of information in a generic way.

This is a fantastic paper on the use of metaphor with people in pain HERE 

Education has many parts

There are many ways in which we can educate people about their experience. Part of this DOES include neuroscience, especially from the perspective of a clinicians understanding of pain. How much of this needs to be part of the educational experience of the person though?

Basic information about a normal timeline for recovery might influence perception and behaviours. Understanding the lack of association between many physical factors and activities and pain might influence perception and behaviours. Here is a recent example for back pain HERE

Some of the factors that are associated with worse outcomes in back pain, such as increased passive coping and low self-efficacy HERE, might actually help change behaviour. Informing people that THEY are the key to their own recovery!

There are many ways in which we can educate people that don’t involve the neuroscience of pain.

Creating a positive experience

Regardless of what type of information provided, the most important thing is to create a positive experience for the person and to try to describe pain as a positive part of the human experience. After all you would not want to live without it!

Another very simple analogy I use, and of course is context dependent, is to compare pain to red wine. A glass of red wine for many is a good experience but have a bottle instead of a glass and that can be to much of a good thing, especially the next day. We would like pain at the appropriate times and the appropriate levels.

With the biopsychosocial model we are opening up many new therapeutic influences and targets for treatments but amongst all these problems we can also work on things that are positive within peoples lives and in negative times, such as during pain, this maybe a great way to alter someone’s current experience. This is a fantastic paper on focusing on resilience and sustainability HERE.

 

Screen Shot 2018 01 05 At 06.32.52

As a recap, these are some key patient messages (IMHO of course)

  • Pain is an experience not just a sensation
  • It is more than just physical it affects our well-being and emotional state and that is NORMAL.
  • It may become more about these affective factors as it persists.
  • The way that we think and feel directly effects recovery
  • Human beings are very complex and much more than anatomy that becomes damaged or even sensitised.
  • Focus on positives factors not just negatives ones.

 

Knowledge is power- What I need people with back pain to know.

Here is some information I would like anyone with back pain to know. Whether it is the first time you have had back pain or you have had it for ages.

I would love others to contribute to building up this information as it is certainly not definitive. So if you are a clinician or have had back pain please email me if you have something to add [email protected]

This has also been turned into a downloadable PDF so you can share with colleagues, patients or anyone you feel it may help. Please click Back Pain Share Pdf to get it!

Back pain information

  • Back pain is normal. Up to 20% of people are likely to get some each year and a whopping 80% of us will get some back pain in our lifetime, in fact it would abnormal not to get back pain.
  • Back pain can last up to 6 weeks – this maybe longer than you anticipated. So if it has been going on for a bit there is no need to unduly worry. Lots of pains only last a number of days but it is still normal for it to last longer.
  • Although we all know someone who has had long term persisting back pain that has caused lots of problems it is actually somewhere between 10% and 25% of people with back pain that lasts longer than normal. So you have good odds it won’t last longer than 6 weeks.
  • Back pain is no different to any other pain in our bodies such as shoulder, ankle or knee pain although people do tend to worry more about it.
  • Pain itself is normal and nothing to be scared of. It is a protective mechanism that has evolved help us out. You would not want to live without it!
  • Pain is not a good at reflecting the physical state of our back or any body part. We can have lots of pain without significant damage. Think about getting a paper cut or a bee sting. They can hurt like hell but don’t really damage us.

Diagnosis

Diagnosis can often be challenging with back pain although I know that people often want an answer. We don't always need a definitive answer to help you.

Here is what we do know:

  • The vast majority of back pain is not serious, in fact around 99%. The 1% is mostly fractures, can include cancer, but these a pretty rare occurrences.
  • Around 10% can be pinned down to a specific tissue diagnosis such as a disc or a nerve.
  • These statistics mean that it is unlikely to be a ‘slipped disc’ or a nerve problem and people often throw these terms around as causes without really knowing this for sure. This can often be unhelpful.
  • Therapists have some tests to tell if the problem is in that 10%. These include clinical tests for the nerves and nerve roots as well as muscle strength, sensation and reflex tests.
  • It is very difficult to make a diagnosis from a MRI alone. Lots of MRI findings also exist in people without pain, hence the need for a clinical exam to accompany a scan.
  • MRI’s are not able to show us pain.
  • So we often can’t pin it down to a specific tissue or pathology around 9 out of 10 times. There are lots of different tissues in a small space and if it is irritated or inflamed then it may affect more than one of the tissues.
  • Inflammation is a good thing. It means the body is working well and doing its repair jobs.
  • From a medical perspective this type of back pain is often termed ‘non-specific’ and we should see this as a positive diagnosis as it means nothing serious is wrong. It could still hurt a whole lot though.
  • The term ‘non-specific’ means the tissue, not non-specific to you or has no origin. YOUR PAIN IS ALWAYS REAL AND SPECIFIC.
  • Non-specific pain often responds well to moving and although we cannot give an exact label does not mean we cannot give some ideas to help or an a basic explanation about why you might have back pain.

Other factors

  • Lots of different factors (many which you may have not considered) can affect your back pain.
  • This can mean that you feel your back pain has a life of its own but it maybe that you have not been informed about or considered all of the potential contributing factors.
  • These other factors can include abnormal sleep, lots of life stressors including work and family, feeling that the pain will never go and negative beliefs about your back and performing daily activities.
  • Its probably not your spinal posture, your pelvic tilt, a teeny weeny muscle not firing or something needing to be put back into place causing your back pain. How do we know? We have studied this stuff to death.
  • If you have been told this before it could mean your therapist is not up to date with the latest research in this area. You may have been given lots of opinions previously and it can often be confusing for you and hence the need to be aware of the scientific data in this area.

Treatment

  • There are NO magic treatments for back pain that work for everybody unfortunately.
  • It might not be one singular problem but a few different things happening together. A minor pain might be exacerbated by other things that are making you a bit more sensitive.
  • Your therapist should be able to give you some basic advice or point you in the direction of others who can if it needs more specialist help.
  • Lots of different treatments can help in the short term, such as a few hours or days, but don’t simply put your recovery in someonelse’s hands. This has been shown to often be worse in the long term.
  • You may have to avoid aggravating activities in the short term but make sure you go back to doing them. Nothing should be off limits in the long term. Don’t let anyone tell you otherwise.
  • People who feel they need to protect their backs can also have worse outcomes.
  • Learning more about what helps you and what makes you worse is important to help you manage your back pain. Your therapists should help you do this.
  • Movement and exercise might help.
  • Unfortunately here are no magic exercises for back pain. Find what you enjoy and just do it. This could be Pilates, strength training, sport with friends or simply going for a walk in the park.
  • Don’t feel you have to really push yourself to get stronger or fitter but it is good once in awhile to exert yourself. This gets your body used to doing it.
  • Moving and exercising can help us build confidence in our bodies and this might be key to recovery rather than fixing a physical problem.

Persisting back pain

  • The common term for persisting pain is chronic pain, The term chronic does not mean ‘worse’ it is actually just a general term for pain that has gone on for longer than 3 months.
  • How we respond to back pain might play a role in how long it lasts. If you change what you do in terms of activity such as avoiding things or think very negatively about your pain and your recovery
  • We could see persisting back pain as our protective systems, in this case pain, doing its job too well.
  • Although pain is normal and a good thing, we could see it a lot like red wine. A little bit is great, but sometimes we can have too much of a good thing and it leaves us with a hangover.
  • Persisting pain is currently seen as problem of the protective system itself rather than simply reflective of the state of your body.
  • The more we work the mechanisms that contribute to pain the stronger they can get. It’s a bit like working your bicep in the gym. Just like your muscles the protective system can adapt and get better at protecting you.
  • Unfortunately this means that the things that did not used to cause you pain now can do and may explain why you can be very sensitive to things that used to be normal.
  • All of this does not mean you can't get better but it is not as simple as finding an 'off' switch.

Clinicians advice

  • Sheren Gaulbert - Stay connected with people who matter in your life/engage in activities you value
  • Karen Litzy - Don't consider yourself broken or damaged goods
  • Ash James - Its often better to be at work than at home. You will move more and rest less and get back to normal stuff sooner
  • Kjartan Vibe Fersum - Important to have a shared plan (with your therapist) to move forward with
  • Tom Goom - It’s good to experiment with movement, relax into it and see what helps pain and stiffness. Movement is medicine, and like medicine it has a dosage, experimentation is needed to find the right dose for you
  • Claire Higgins - Your back is designed to be strong. It can so easily be visualised by patients to be a stack of blocks which could be "crushed" or "topple" at any moment. Education on how our backs are super strong and to trust in them is important.
  • Claire Higgins - Focus on the things which turn your pain down, restoring balance e.g. exercise, meeting friends for coffee, being in the great outdoors.

 

Discogenic back pain – Is it more about relevance than prevalence?

The influence of structure on back pain is a discussion I have had twice in the last 3 days.

I would not describe myself as an expert in this area but this area of discussion does leave me a little confused and I do take an interest in it, especially with the whole ‘forgetting the bio in the BPS’ thing.

These are just some thoughts and data, this is certainly not a comprehensive literature review, just information I have been exposed to and to be honest leave me more uncertain than certain.

Undoubtably the disc can be a source of nociception and relevant in back pain. The plausability is not in question here.

My key questions (not really answered yet) are:

1) How do we reliably identify discogenic back pain clinically?
2) How does this influence our management?

WARNING - the data below is likely to leave things much murkier than clear!!!

Prevalence of disc related factors in LBP

So firstly we see that disc degeneration is more prevalent in those with back pain.

MRI Findings of Disc Degeneration are More Prevalent in Adults with Low Back Pain than in Asymptomatic Controls: A Systematic Review and Meta-Analysis

We also see that more findings (3 or more) on an MRI report were more strongly associated with LBP than a single finding.

Is the Number of Different MRI Findings More Strongly Associated With Low Back Pain Than Single MRI Findings?

Here we see those with acute back pain are more likely to have disc herniations

Magnetic Resonance Findings of Acute Severe Lower Back Pain

But we also see lots of the same signs in those with no pain

Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations

Again a high prevalence of the same signs in asymptomatic populations.

A review of the value of MRI signs in low back pain

People with previous back pain also had increased MRI findings but no current pain.

The relationship between findings on magnetic resonance imaging and previous history of low back pain

MRI findings also do not seem to be predictive of back pain.

Does magnetic resonance imaging predict future low back pain? A systematic review

Changes in MRI are also similar in symptomatic and asymptomatic populations

Prospective Comparison of Changes in Lumbar Spine MRI Findings over Time between Individuals with Acute Low Back Pain and Controls: An Exploratory Study

So maybe we need to think more about relevance than prevalence here? If both groups can have MRI findings then we cannot just assume.

Do symptoms of lower back pain correlate with structure?

These papers below would suggest it is not that simple to correlate the symptoms that people experience compared to imaging. Again this suggests that if there is nociception from the disc it is not the only factor at play.

Do more MRI findings imply worse disability or more intense low backpain?

Associations between back pain history and lumbar MRI findings

Back pain and MRI changes in the thoraco-lumbar spine of young elite Mogul skiers

The associations between magnetic resonance imaging findings and low back pain: A 10-year longitudinal analysis

Diagnosis

It does appear to be difficult to diagnose discogenic pain with 90% being labelled as non specific. So we know it can be prevalent but it is difficult to find if it is relevant for your patient. Ultimately we need to be able to identify clinically to make the link in my opinion.

Diagnostic triage for low back pain: a practical approach for primary care

These are some recent clinical classification guidelines.

Clinical classification in low back pain: best-evidence diagnostic rules based on systematic reviews

There is some support for centralisation in identifying discogenic pain.

Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power

This paper is pretty certain in being able to identify discogenic pain

Lumbar discogenic pain: state-of-the-art review

This paper suggests that internal disc disruption is not a real thing!

Diagnostic criteria for the clinical syndrome of internal disc disruption: Are they reliable?

How does this change management?

It was suggested to me that we would treat an annular sprain much the same as we would a sprained ankle. This would be through the concept of optimal or tolerable loading and could be done both via the magnitude of load and manipulating the load different movements might place on the disc through spinal kinematics.

I think this sounds fair however it brings us to the second point I raised of does this information make a big change in the management of LBP. We could treat a non specific LBP in a similar way so again I am left a little confused.

Over the longer term for conditions such as disc degeneration the famous Battie twin study would suggest loading has limited influence.

The Twin Spine Study: contributions to a changing view of disc degeneration

We can't draw to many conclusions from these two papers below, as they are observational, but perhaps they tell us that activity is not detrimental and MIGHT BE beneficial.

In Vivo Correlates Between Daily Physical Activity and Intervertebral Disc

Running exercise strengthens the intervertebral disc

 

 

Will any old exercise help your patient?

So the real question should be, how specific should we be with our exercise prescription?

(Now this could have turned into an epic blog, but I have decided to keep it brief and readable!)

In my opinion WE SHOULD ALWAYS BE SPECIFIC.

Now that’s a pretty emphatic statement so I should probably add a bit of nuance to that.

For some people the term specific means that we should use a SPECIFIC exercise for a SPECIFIC problem.

The world of therapy is littered with exercises that have been held up as the ‘best’ exercise to fix a certain issue and not achieved that status, think TvA activation exercises for back pain or VMO exercise for knee pain. Being specific in this way does not appear to be warranted with the current evidence base we have.

We could also be specific to some form of physical quality like strength or range of movement. We see that in many cases when it comes to MSK pain going after a specific physical quality also does not seem to yield better results, there ARE a couple of examples of when being specific is important and I will discuss those later.

I might be bold and stick my neck out and say that non specific pain (meaning we cannot pinpoint the source), of which we seem to have a bunch of around the body, probably needs a non specific approach to exercise. This means that we cannot strongly suggest a singular exercise or a type of exercise that focuses on a physical/biomotor quality.

So why the need for Specificity?

So everything I have said so far may seem to point towards there being no real need to be specific. Does that mean that we can just give someone any old exercise and expect to see a positive result from it?

I don’t think so.

Any application of exercise should come with some form of reasoning and we should start with the end in mind.

What SPECIFIC effect do we want from our exercise?

This will be SPECIFIC to the person and their current issue or goal. This means that the reasoning approach is always specific but the application may not always be the same.

So rather than be SPECIFIC to a type of exercise or presentation we are being SPECIFIC to the PERSON standing in front of us.

WHAT do we want?

Screen Shot 2017 04 10 At 17.33.20

There are many different outcomes that we may want to achieve from our application of exercise and we find we can influence lots of different elements of human function.

To make things a bit simpler and more organised we could make some broad categories.

Capacity

This could be tolerance of a specific tissue such as a tendon or muscle although we still have not quite worked out the relationship between pathology and pain here.

There may also be clearly defined scenarios where we do see the need for specific biomotor qualities, such as strength needing to be addressed post operatively.

Pain

Pain relief maybe another specific outcome that you want to achieve from your exercise prescription.

It seems here that lots of types of exercise may create analgesic effects. Isometrics are the flavour of the month at the moment but both strength training and cardio training also have the potential to create analgesic responses.

I am still slightly on the fence about the usefulness of short term responses for all but I can see a clinical need with some groups of patients.

Belief

As we start to move away from a tissue focused view of exercise and movement the concept of beliefs around exercise become much more important

Concepts such as fear avoidance and exposure based therapies are starting to gain traction, and rightly so, especially as their role in actually getting people moving is starting to be appreciated more and more.

We might have to be very SPECIFIC to a movement but that movement is probably very SPECIFC to the individual as well.

Adherence

It might not matter what the exercise or its aims are if it doesn’t get done in the first place.

This is a great example of when non specific is really quite specific.

We may have to be specific in

  • Location
  • Type of equipment
  • Preferences & enjoyment

To get someone moving again.

Movement

It has been hard to pin down many SPECIFIC movement ‘problems’ that we reliably see as a cause for pain.

Our understanding of the mechanisms behind the pain experience are broadening and we see modern concepts such as the decoupling of SPECIFIC movements from pain responses as a plausible reason for using a movement based approach but again these seem to be quite SPECIFIC to the individual.

Variability that is either too high OR too low might be relevant to pain, maintenance of pain and injury. Or not! Who knows.

It might be that just MOVING is what many people need!

Being specific – Where’s your data!

This does not mean that there are NO specifics we should aim for across people but they DO need to be clearly defined. An example here might be return to play for ACLR rehab. Better outcomes have been shown if patients achieve RTP markers of almost equal, within 10%, of quadriceps strength and also hop performance. We also see the specific use of eccentric contractions with the prevention of hamstring injuries over concentric strength work.

The key here is if you ARE being specific that you have some form of data to back it up.

Remain vigilant to the specific response

All exercise gives individual responses, its not just fire and forget. Lots of exercise research is based around comparing the means of two different groups to look for a statistical significant difference or variation between the two groups.

While this type of analysis does point towards a trend for an effect, in reality it gives us little idea about individual responses to exercise so it is important to monitor someone’s response rather than just expect your reasoning process to have a successful outcome.

An exercise could make someone better, worse or simply have no difference. It is important to know that many exercise interventions don’t achieve spectacular results. The actual effect is often around the minimal clinically important difference (MCID). The MCID is smallest difference that a patient is likely to see as important to them. Although this number varies across studies is generally around 2 points on a 11 point 0-10 VAS scale.

We must always be prepared to adjust the exercise type or dosage based on the SPECIFIC response from the patient.

Summing up

  • We always need to be SPECIFIC
  • Not always in the same way
  • Always ask "what do we want?" from the exercise
  • Lots of different effects across the BPS spectrum
  • Want to be specific? Have data!
  • Always remain vigilant to the effectiveness of your exercise