I know, I know, it’s a sensational title but what did you expect, it’s social media 😀

But it’s pretty depressing when you read papers like this one that recently was published regarding how effective many treatments are in healthcare. 9 out of 10 are NOT supported by high quality evidence *HERE*

There is a ton of research that doesn’t show amazing results and many interventions don’t reach a minimal clinical important difference (MCID) threshold of 1 to 2 points on a 11-point scale (depending on the comparator). This for me is NOT surprising as there are so many things outside of patients and therapists’ control such as lifestyle, genetics, social determinants of health, comorbidity, and the natural history of a condition not to mention the fact that pain is just an elusive muthafunker.

But before you get too down in the dumps, it is important to remember that people also do get better *HERE*, it may not just be the specific interventions we use that do that, even though some people can mistake this for their own brand of magic *HERE*.

So, if we are being evidence based then what do we do now? Spiralling into a sea of intervention ineffectiveness depression is of course one option but it’s not recommended for any length of time.

As Voltaire eloquently told us a few years back….

“The art of medicine consists of amusing the patient while nature cures the disease.”

“The Art Of Medicine Consists Of Amusing The Patient While Nature Cures The Disease.” (300 × 300 Px)

If I were to give that phrase a 21st century update, it’s not so much about amusement but more about understanding and sense making, reducing the worry and anxiety that can often amplify the problem *HERE*

Let me state this clearly, the point here is NOT to offer this up as an alternative nirvana of treatment that outperforms what we have in terms of current research, I can hear it now “show me the data” (think Jerry Maguire). It’s actually working within the research base we have currently and accepting the lack of treatments that have a large effect. Being a clinician (and a person) is mostly about acceptance in my experience 😀

This for me is a very undervalued part of working with people with painful problems. How do we measure or quantify it? Not really sure (I will leave that to smarter folk than me). Do we need to? Depends on your point of view. Should we do it even if it does not improve outcomes? I think so! Part of the point of the BPS model was to move away from everything being quantified or put into little boxes.

This recent paper points clearly to people with back pain wanting to understand more about their issue *HERE*

How can we do this?

Firstly clinicians understanding the problem really helps! That way we can un pick all the silly bullshit that exists around many MSK issues. So the “muscle is not activating” or “this muscle is tight” or “bones out of alignment”, I don’t need to tell you this as you probably hear it every day. Back pain is literally a pandemic of bollocks and bullshit. You cannot do this if you don’t understand the  problem to begin with and there is huge value in not making the problem WORSE.

Giving accurate and realistic information to help make sense of the issue, for me, is a big deal and major part of helping people. That last word is important, PEOPLE not just pain. Remember we discussed how elusive pain is at the beginning (and that’s EVIDENCE BASED).

It’s not just knowing about the problem and then vomiting ‘education’ all over people, it’s also about understanding what is worrying them and what they would like to know more about. How can you reassure for example if you don’t know what someone is worried about? You can certainly dump information on people and hope it has an effect or you could ask!

This is all really improved if we can connect (as much as possible) and see the value creating a space for open and honest dialogue. This is really the special sauce in working with people, especially if the interventions are not quite there yet.

I have come to see the treatments applied as only part of the value that I and others have to offer. Especially given the data around effectiveness. The process of interaction, communication & sense making should be seen as just as important even if if doesn’t have a huge effect on outcome measures such as pain & disability (in my opinion of course).

Bed rest used to be a key part of treatment for back pain, in fact many still believe that it is *HERE*! Now the guideline advice is to “remain active” and it would seem that rest is yesterday’s news and even a ‘bad’ thing to do for some clinicians.

The world of MSK pain & injury can become polarised very quickly. If something is not superior then it can quickly become inferior, even though it is not. Think core stability exercises for example, they have fallen off the MSK cliff into the abyss but they still ‘work’ as well as anything else in treating back pain, even if the narrative can be unhelpful.

So both advice to rest and remain active are probably a bit rubbish as blanket statements. Part of the role of a clinician should be to help people understand and manage their pain a little better, what is THIS person’s individual presentation and limitations. Not all back pain is the same even if it is labelled in a similar way. This of course is not a revelation or particularly new information with Maitland’s “aggravating factors” still being a key part of understanding and helping others understand their painful problems.

By identifying those things that actually aggravate the problem we can perhaps rest a bit more from those whilst remaining active in other things that don’t aggravate the problem so much. This is really not any more than basic common sense I feel, but given that many people are told either to rest or carry on through painful things without much analysis , this common sense may sometimes be lacking.


As an example I recently had someone with pretty painful Sciatica that tended to flair up at night after gym sessions in the day. Obviously carrying on like this was a problem and rest in some capacity seemed to make sense, to me anyway. One of the bigger problems was that from a psychological coping perspective complete rest was not really an option, as can be  the case with some very active folk. Here a targeted approach of reducing intensity and volume levels to reduce aggravation was helpful whilst also keeping the person moving and (reasonably) happy. Some times persistent/endurance behaviours can be rooted quite deeply and this can be challenging to a complete rest based approach.


Maybe this is where guidance is required and giving people the tools to monitor and adapt aggravating things can be a huge influence on their ability and belief in their ability to manage their problem. Again this is not new, we can go back to the 90’s and the work of Indahl *HERE* to see that basic information about the problem and managing pain was a mainstay of his groups approach.

Now if pain was REALLY bad in a whole bunch of different activities then I see nothing wrong at all with entirely resting for a few days to let the worst pain pass (as it generally does) and equally I see no real need to rest entirely if the pain is pretty mild and only with specific activities. The real nuance comes with the majority of pain presentations in the middle. Painful enough to be limiting and potentially aggravating but maybe not enough to warrant complete rest which can also come with its costs.

I use a really simple grading scale using VAS although irritability of the problem is also another factor to be considered. Hopefully it considers the U shaped nature of physical activity intervention.

Simple scale (VAS)

8-10 - Rest

4-7 - Activity modification

1-3  - Remain active



Screenshot 2021 12 21 At 14.59.19

These are some questions we might ask ourselves with our clinical reasoning for activity modification:

  • Can we do something different entirely?
  • Can we alter volume?
  • Can we alter intensity?
  • Can we alter frequency?
  • What effect does this have?

It is also super important that we make sure to grade a return to full activity as pain changes to avoid creating potential avoidance behaviours in the future. How many people are told to stop doing things and never resume them? A lot in my experience.

Key points

  • Blanket advice is a bit crap
  • Non superiority is not inferiority
  • Basic pain management advice is helpful
  • How can you adapt/modify aggravating activities


My least favourite discussion to see online or god forbid to be involved in is about treatment. I get that treatment is important, but it really does seem to be the largest bone of contention amongst therapists. It’s a subject people certainly get very passionate about and dare I say it, even a little defensive. It is a huge area of uncertainty which lends itself to discussion, or even erm argument, and can often be a little frustrating & disappointing as it seems ‘nothing’ or ‘everything’ works given how the argument is spun.

But here is my issue…..

What I really  wonder is why people get so passionate and even sometimes even form entire identities around what they treat the problem WITH rather than HOW they treat the person with the problem. The discussions never seem so passionate or prominent about all the other stuff that happens during an appointment. If you define yourself by your treatment and that does not ‘work’, which for a fair proportion of people that may be the case, now what?

For me this is entirely the point of the biopsychosocial model that is so often misapplied. The BPS was/is meant to be about the person with the problem rather than the problem itself.

I certainly don’t treat pain, I treat a person with pain and that’s about recognising the significant impact pain has on someone’s life and how THEY feel, their thoughts and feelings about all this stuff that is happening to them. It’s about HOW I go about the whole process of treating them, not just whatever intervention, treatment, modality or whatever we are using to treat their pain or another outcome measure.

This might be a really good reason to become a little more research literate too as with so many big opinions around the treatment evidence base it can be hard to get a balanced view of what actually works and more importantly HOW MUCH it works. It’s also important to remember that what happens clinically might be different to what happens at a population level with a controlled study. This is always the problem of integrating research into clinical practice. My clinical practice involves using evidence to guide me but also being able to change and adapt to the person too when necessary.

There are so many other things that are probably involved in outcomes and even more importantly the process that people go through with a healthcare encounter, regardless of outcomes. These might the assessment (history & physical), communication style, our explanations & reassurance, the support & guidance we give & behaviour change implementation. Treatment is only a small part of an appointment often (for me anyway) and actually all these other things are often involved in the treatment smorgasbord and can also have an impact on the outcome.

In fact, so many things outside of our control can affect the outcome I am not often sure how much of it is actually my treatment anyway. So much of what affects us is rooted in the systems and society we exist in and maybe we should worry more about what we can control such as the processes we go through with a person and how we go about working WITH them rather than simply an outcome from a specific treatment type. I am much more comfortable with that than a blind faith in whatever is being applied.

Some patients may need their health addressing, other’s hands on treatment, another basic reassurance and someone might need to restore confidence in their movement or even a combination of all of the above. Why would we expect everybody, given the complexity of pain & the heterogenous nature of people to require just one thing anyway?



It seems there has been a real backlash against evidence based practice (EBP) of late and part of the issue, I believe, is that there is sometimes a very real MISUNDERSTANDING about what evidence based practice is and is not.

This backlash in part seems to revolve around the idea that EBP is too restrictive and hasn’t got all the answers and that some folk CAN place too much emphasis on ‘evidence’ in their practice, perhaps not with enough critical appraisal leading to rigid and inflexible perspectives.  We do, in my opinion, have to acknowledge that an overly empirical perspective can be as problematic as simply rejecting EBP because it does not provide all the answers or is not correct 100% of the time.

So perhaps a better understanding of EBP is needed? Something being ‘evidence based’ does not create a certainty about what will and will not ‘work’. It’s not a rigid protocol that produces individually consistent results. It is a way of making informed decisions based on a scientific process rather than just someone’s opinion or experiences.

What has become clear is the binary and tribal way that such topics, in this case EBP, are approached in the therapist space. Are you an evidence-based therapist? Are you a manual therapist? Are you an exercise therapist? Are you a pain science therapist? They seem to have become labels that are used to generalise and berate others with.


Maybe, just maybe, this discussion is not really about EBP but also more about how EBP is USED by people? It is a pretty blunt tool if it is not used as Sackett suggested originally in a “judicious” way. EBP is a lot like the BioPsychoSocial model in that it’s much more of a philosophy, a way of thinking, than a step-by-step method to follow.

Both EBP & BPS are far more conceptual and broader than traditional clinical methods/models which is probably both a blessing and a curse and often a criticism is that they do not provide clear clinical application. The biggest flaw I see in how both EBP & BPS approaches are used can be the choosing of one of the domains to justify clinical decision making. The 3 areas of EBP, being research data, clinical experience and patient preference are to be used TOGETHER rather than being trichotomized to support or justify clinical decisions. Housman pointed out this in the use of statistics in his famous quote:

“Some individuals use statistics as a drunk man uses lamp-posts — for support rather than for illumination”

A great example of this bastardisation of EBP is the use of patient preference to satisfy the criteria of EBP. Patient preference is not simply about which intervention someone should receive. There are many decisions beyond intervention that a person could need to be involved in. Maybe a better term would patient perspectives as this encompasses a much wider view of the therapeutic process rather than just “they wanted acupuncture (just an example), so I gave it to them” and this satisfying an EBP requirement and therefore is a justification for it being used.

What are some of the issues?

As someone biased towards EBP its important to confront the problem, issues and perhaps misconceptions that exist with regards to EBP:

EBP does not simply give clear answers

Evidence can often be unclear and conflicting, it does not give a clear un fallible pathway to clinical success. This needs to be accepted as part of the process of using research evidence. Unfortunately, this can also be a reason used by some to reject EBP.

Just because its published does not make it ‘true’

The idea that because it says something in the conclusion of a paper that it magically gets propelled into concrete truth beyond reproach or critique is probably a major flaw in the way EBP is used. This can lead to therapists trading pub med abstracts on various social media platforms, sometimes (fuck it, many times) without the paper even being read. Equally though when it does not fit our biases out comes the fine-tooth comb to find a problem : )

Answers are often not as broad as desired

Clinicians perhaps want more from EBP than it can actually currently provide such as really big questions being answered definitively by a single paper. A popular example is “Does exercise work better than manual therapy”. That question has never, ever been asked (as much as we might want it too : ) because it is way too broad. You have to define the condition you are looking for it to “work” on, how you measure ‘working’, the population you are studying and the way in which the exercise or manual therapy is performed etc etc.

It’s not a binary yes or no

Another issue is this idea of what “works” as a concept. This may stem from the idea of accepting or rejecting a hypothesis such as in a Frequentist approach. Simply put two binary options, so something works or it does not work by accepting or rejecting a hypothesis.

P values have often been used to make these decisions, although thankfully this is being moved away from, they are not really fit for that purpose of making such decisions. P values tell us about the correctness of the statistical model rather than the correctness of a hypothesis. The stats are only as good as the methods used to generate them and why methodology is a big factor in the conclusions taken from a paper.

Not only the data counts

Patient narratives are also a really important part of the evidence we should use to make decisions. Yes this is not double blinded and randomised but also the experiences of THIS person that needs our help. Patient narratives are also far more than just what treatment they received and how successful it was which are often used to point out the unreliability of someone’s narrative

It’s the body of literature not just a single paper

The evidence base around a subject can be vast, take back pain for example. So this needs to be considered rather than just a favourite paper that supports a bias. My paper beats your paper is like a game of top trumps and not really how EBP is supposed to work.

Moving forward

Before we start accepting or rejecting EBP maybe we should formulate our own idea of what it is and what it tells us. What is our personal approach or philosophy in this area? Perhaps too often personal philosophies on this and other subjects are influenced by other people’s rather than taking the time to formulate our own?

What’s my view? Well, EBP does not give us a cast iron answer for the patient in front of us. It does not predict precisely what is going to happen in 2, 6 or 12 weeks and it often does not tell us precisely why something has happened, there are so many things not being controlled for or measured. But it can help us understand probabilities and estimates around a question at a broader population level in a less biased way. It should afford me an estimate or a parameter of what is most likely to happen, provided that there has been sampling reflective of my patient and appropriate methods used.

This is exactly why statisticians appear to be moving away from fisher style hypothesis testing to estimates of effect such as a greater emphasis on confidence intervals. It does also help us control for some of the natural biases that go into making us humans! Things like randomisation & blinding are positives although they can be applied in a very blunt way as criticism of research methods.

Just because EBP is not perfect or provide all the answers does not mean it should simply  be rejected. That is exactly the binary approach that has led us to this point and to accept or reject EBP is not the answer. Imagine if we were not in a position to test methods and interventions? It would be like the wild west of rehab with machines that go bing everywhere. It comes back to the judicious use of evidence that involves an understanding of what EBP is and the current best data on the subject being questioned out there. Evidence may often not tell us exactly what to do, but its value might also lie in telling us what NOT to do and I think there is HUGE value in this.

Probabilities not certainties

So the research base gives me a jumping off point and a way to narrow down my decision making, by simply rejecting research it can be replaced by a heap of other shit that certainly is not optimal healthcare. It doesn’t give me all the answers, but as I understand EBP it’s not meant to.

We need to see therapy as much about informed trial and error rather than a set in stone process predicted by a research paper. The research is the informed part and the application and outcome are often a little more fluid and the trial and error bit.


It’s the middle ground where the truth probably lies in this debate, to be too accepting or reliant on research & evidence and we miss the point of what research is. But the opposite end of dismissing research because it’s not perfect or something worked that had been ‘proven’ not to is not the way forward, I suspect this will actually take us backwards. Instead let’s come back to the judicious use of research fuelled by a better understanding of what it does and does not tell us.

Its nice to have the answer to the problem before you start, that’s why the idea of an exercise prescription is so appealing as it takes away all that nasty uncertainty that makes you have to think : )

But I bet one of the first questions many therapists ask their patients on the second visit is “how did those exercises work for you?”. So, on one hand we want the answers but deep down our experience tells us things don’t always work out the way we want them too.

Why then why do we see it as a prescriptive? Are you treating a condition, outcome measure or an actual person with different needs and functions?

For me, rehab is much more of an adaptive situation that is progressively refined rather than a prescriptive one simply set out at the beginning. We add things, subtract things and adapt things in an iterative process as we gauge the response in chosen outcomes. The intensity, frequency and type are all open to being adjusted according to the person, their needs and the desired outcomes.

Being comfortable with that is key to working with active movement-based interventions in my humble opinion.

Assessment is also a process of refinement; you might change your mind on what the problem as new information comes to light and a hypothesis does not pan out the way you expected it to. Most of what we do is informed trial and error anyway, there I said it!

The initial intervention and its parameters are just a start, a trial to see what happens next, an informed guess even, but this is not really something that seems to be talked about very much. The prescription is much more of a suggestion than we often like to admit perhaps, the supremely funny Trevor Noah describes traffic lights as a “suggestion” in South Africa, which always tickles me.

Even exercise for physical adaptations is becoming less prescriptive. We are discovering that physical adaptations can happen from a whole bunch of rep ranges and loads. Effort and intensity seem to be key to physical adaptations, often the parameters that are never measured in rehab research!

Learning process


Both therapists and their patients should view this as a learning process rather than a failing or being reflective of not knowing what to do. The idea that we have the answers prior is often detrimental as this can the knock confidence in the therapist’s ability and create expectations that are different from the reality of rehab. We often have to experiment and make trade off’s between pain and functional gain.



Research data can be used sometimes as a bit of blunt tool, as can clinical experience too of course. It can be assumed that the patients specific condition, the treatment and the effect of the treatment will all be consistent with what is written in a paper. But if we look closer the reporting of data, it has its own in-built estimate of variability so perhaps we can only ever know how it effects our patient AFTER application rather than before.

Our patient and their exact presentation may not be accurately represented in a piece of research. No paper samples the entire population, only a small portion, hence the reason for confidence intervals. This is the challenge of clinical practice, to marry the data with the person.

This is a fantastic paper from Roger Kerry "Expanding our perspectives of research"

“Some individuals use statistics as a drunk man uses lamp-posts — for support rather than for illumination” A. E. Housman

We also need to appreciate that with a modern biopsychosocial understanding we literally don’t have prescriptions for many of the issues we see. I have said before that one the main things I work on is the confidence to use bodies and engage in things again, what’s the prescription for that again?

Also papers often don’t give a clear outline of what they did anyways. Many times they point to another paper or an appendix that is never looked at. When you do look, key variables are often missing such as intensities, rest times etc. So being ‘evidence based’ with rehab is often not quite what people think it is.

Is it controversial to suggest that the research process does not always reflect the clinical one?

It’s a process


Unfortunately, clinical reasoning is just not sexy. It’s much sexier to proclaim a treatment does or does not work, this seems to hit people in the feels. The nuances of clinical practice often get left by the wayside and bias and polarisation rules the land. The tough bit clinically is reconciling research-based information with the persons individual presentation and their experiences/beliefs etc.

This is not a one-time deal though, the reasoning and refining process should go on throughout a period of care, not just a diagnosis then prescription at initial evaluation and a continuation of this repeatedly.

This was a really nice comment made during a conversation on twitter:

“Evidence-based practice doesn't mean throwing available evidences blindly at the patient but rather its a delicate process of discovering best suited strategies for every individual patients you see” - Nihar Palan

In my opinion the great therapist is not the one with the best prescription or plan, but instead the one that knows what to do when it does not go to plan. Someone who can adapt and adjust accordingly to the changing situations and people that you deal with.

Another way


Clinical reasoning

  • Research data
  • History
  • Examination
  • Diagnosis
  • Application


  • What outcome?
  • Over which timeframe?


  • Stick or twist?
  • What to change?



  • Prescriptions are really suggestions
  • We refine based on response over time
  • It’s really informed trial and error
  • Research clearly reflects variation in outcomes
  • Prescriptions are often not clear in pieces of research
  • Knowing how to adapt is a skill, not follow a flow chart
  • Reasoning, response & adaptation is a better model IMO


Interested in exercise, movement & clinical reasoning? Come and join us on the 21/22nd November for the "Therapeutic movement & exercise" course *CLICK HERE* 





Education, education, education. How often do you hear this term in relation to modern MSK practice?

Sorry, I got that wrong. Education & exercise, Education & exercise, Education & exercise : )

All the bloody time is the simple answer!

But education, just like exercise, suffers from the issue that we talk about it in very general terms but have little in the way of actual frameworks for application. Every guideline going seems to point towards these as core treatments but often without any real direction. I can see why therapists fall back on more traditional perspectives faced with uncertainty.

So education about what? When? How? To who? The usual questions come out when we unpick it a bit. Education has been hijacked by PAIN education over the last few years but in reality its formed a backbone of MSK practice…..well forever. Education is something I talk about in class A LOT,  but I do feel people are like hurry up and get to the REAL treatment Ben, i'm getting bored over here.

Is education seen as PROPER treatment? I am not convinced yet.

People ALWAYS have wanted information


This is nothing new!

How often have you had someone come in and say “My back pain has been going on a little bit longer than usual and I thought I had better have it checked out”.  We know back pain, as an example, can last for 2-6 weeks and its perfectly normal for this to happen. But if someone has only ever had the problem before for a few days it’s probably a bit worrying and they want to know what is going on to decrease the worry that can flourish in stressful situations.

People definitely come to see us to get rid of their pain, but they also want to understand their problem, the implications and know how to manage it as well.

Louis Gifford highlighted a few things that is fairly universal amongst people. What is it? How long will it last? What can we do about it? Another question I get asked regularly is “Can I still do….”. People still want to do things but not to make the problem worse but often get scared into reducing activities rather than receive knowledge to sensibly manage them.

Education or knowledge transfer?


We use the term education, but for me that can conjures up images of stern teachers in front of naughty school kids and does not really reflect what we often do with people.  Maybe it is really about helping someone make coherent sense of the issue, decreasing the uncertainty and danger around the problem and providing paths forward. This is more of a partnership perspective that incorporates knowledge transfer than traditional didactic models of teaching. So maybe knowledge transfer or sense making is a better term?

What can we ‘educate’ about?


So many things is the simple answer!

What is it?

Probably the most important thing that people want is a diagnosis. If we know what it is we can effectively treat it right? Er…maybe as we know in so many MSK issues that is simply not possible from a structural perspective. In the absence of this we need a positive & coherent narrative around the problem. That could include pain ed but information about pain does not need to dominate.

“Cases of nonspecific musculoskeletal pain where, although the source of the pain is unclear, diagnostic imaging is not indicated, and the pain may not always be completely alleviated with treatment. In such cases, concrete, clear, and consistent information can help the recovery process, even in the absence of a specific diagnosis” Carroll et al 2016

How long will it take?

Prognosis and the factors that influence it can be really helpful with often unclear diagnosis like back, knee or shoulder pain. Setting realistic expectations is important as well. Too high and it can lead to disappointment when they are not reached, too low and the motivation to engage in the process can limit the outcomes.

What can I do about it?

Health and lifestyle, exercise, activity and self management are all areas that we can help people with. Helping people to effectively create management plans is sorely missing IMO. Again perhaps this is not seen as treatment?

What does the person want to know?


For really effective transfer of knowledge maybe taking the time to find out what the person WANTS  to know is important. Just throwing out information might lead to important questions remaining unanswered. There are so many questions that people have that we may not have considered or we feel are not important. If they are important to the person they should be important to us!

“What concerns you the most about your problem?”

“Do you have any major concerns you would like to talk to me about?”

“Whats your biggest fear about this?”

"What’s the most important question I can answer for you today?"



It needs to make “biological and biographical sense” as my friend Joletta Belton would say. This was the great failing of pain education IMO, it does not automatically integrate with the person story, it’s like talking to a stranger in a pub when they are telling you about their life story and you are being talked AT without he conversation ever relating to YOU. A friend that just talks about themselves is another example, you just want to get the hell out of there, or . So make sure your knowledge transfer actually fits the person and their story in a way that relates.



Maybe this is why some of the things we expect to be helpful don’t succeed? Without a knowledge of what to do, why they are doing it and how it is going to help, exercise, as an example, does not relate to the person and their problem?

Lots of my failures (professional ones : ) may have come from not aligning in terms of treatment philosophy with the person I am working with. My vision of what to do does not match theirs and in part that might stem from my inability or failure to ‘educate’ about the what, why’s and how’s.



  • Education IS treatment
  • What does it really mean?
  • People have always wanted information from therapists
  • Think person centred rather than teacher style
  • What is it? How long will it take? What can I do about it?
  • Find out what the person wants to know
  • Apply information in context

Here is a recording of last weeks webinar on "The clinical conundrum of exercise and pain"


Yeah controversial I know……..dragged you in though : )

But hang on, hear me out.

Self-efficacy is another one of these fancy terms that can now gets used to justify why the things that health care professionals do ‘work’….....

“oh it probably improves self efficacy”

This coincides with the emergence of self-efficacy as a important prognostic factor for recovery as we see here and here. Firstly, it is important to highlight prognostic data is often not interventional, so improving self-efficacy to improve outcomes makes sense but not yet fully supported by interventional data.

But is self efficacy actually a thing that can be low, high or improved? No!


The point of self-efficacy is that it relates to something SPECIFIC.

"There is no all-purpose measure of perceived self-efficacy. The “one measure fits all” approach usually has limited explanatory and predictive value because most of the items in an all-purpose test may have little or no relevance to the domain of functioning” - Bandura HERE

So self-efficacy for what exactly, rather than just ‘self-efficacy’ is a really important question and one that is consistently missed out when discussing self-efficacy.

"self-efficacy is a judgment of capability to execute GIVEN types of performances

Bandura also makes some distinctions on some common terms that are often not well defined

"Perceived efficacy is a judgment of capability”

"Self-esteem is a judgment of self- worth”

"Locus of control is concerned, not with perceived capability, but with belief about outcome contingencies—whether outcomes are determined by one’s actions or by forces outside one’s control”

So essentially self-efficacy is simply not a stand-alone ‘thing’, it has to actually relate to something and I am going to use an example from Adam Meakins who made a good point to me in a recent discussion

"How much self-efficacy do you have around repairing your car?”

Now I might consider myself to have pretty high self-efficacy when it comes to most things using my body such as playing sports or general daily activities but take me outside of those and ask me to tile a bathroom or fix my car and suddenly it drops, significantly

Self efficacy for what?

We have so many self efficacy scales because they relate to different things.

The most common used is the PSEQ (pain self efficacy scale). This relates specifically to doing things WITH PAIN. So it’s not just self efficacy for anything….its moving IN pain!

Still fit with your narrative?


“assesses the confidence people with ongoing pain have in performing activities while in pain”

We also have the SEE which is the self efficacy for exercise scale, guess what that relates to? Um yeah….exercise.

Now because I am a critical B****** we could say that this whilst being DOMAIN specific to pain, it is still not activity or movement specific and if used without further questioning could miss the actual things that are actually bothering people.

Bandura's scale for pain management is really quite specific to controlling pain in comparison to the more general PSEQ.


Screen Shot 2020 07 28 At 08.00.13

Perhaps it is more low pain CONFIDENCE as a general measure?

Bandura himself distinguished the difference between self efficacy and self confidence as one being a more general measure (self confidence) and one a more specific (Self efficacy) measure. Perhaps it is best seen as a spectrum rather than simply one or the other, but it still relates to a domain or a specific within that domain rather than just simply SELF EFFICACY as a stand-alone thing.

Is the way we often discuss self-efficacy more a proxy for self-confidence, general functioning or coping? Is that important? I think it is if we start looking at self-efficacy from an interventional standpoint using the theory put forward by Bandura to justify ways of building self-efficacy as they relate specifically, well to the specifics!

Most questionnaires lack specifics and often need a proper conversation around them to tease out more specific movements, activities etc, the Fear Avoidance Belief Questionnaire suffers from this issue as well IMO. This is a common criticism of PROMS.

And this bring us onto the next point…..

General versus specific

Always a big question in therapy is “how specific do we need to be?” and this is no different with self efficacy.

The way I view it is, the more specific the problem then the more specific the answer probably needs to be. Problem is with a more general domain-based scale it’s pretty tough to know how specific we need to be. A specific approach may relate better to something general than a general thing might relate to something specific is a thought I often have.

So if the problem is a one of more general low confidence of using our bodies then doing general exercise or loading will probably have good results.

Is that confusing? Yeah probably : )

Exposure therapy

The most common way that we interact with self-efficacy or confidence is to simply practice or exposure to doing things we don’t currently or normally do. Clinically I think we often expose people to things that build their confidence in their bodies rather than change any physical measures.

Perhaps we are really helping keep the persons pain expectations more in line with the probable reality, that the current situation is bothersome but not inherently dangerous, and therefore normal life can resume. This helps avoid exaggerated cognitive responses that can limit engagement in activities and create disability and increased pain.

This is not really the true ‘exposure therapy’ that we may see around psychopathology such as the fears or phobias that we see in literature such as Craske et al as an example, but a ‘soft’ exposure I suspect can have a positive effect on confidence, violate expectancies and improve clinical outcomes. We should not confuse this though with more specific situations were general confidence building probably won’t make a huge difference.

‘Soft exposure’

I think this process happens a bunch in rehab.

We expose people to different things such as lifting weights, that are pretty general interventions and can have a really good effect on peoples levels of general belief and confidence in their bodies. But they might not have the same effect on someone who has very low self-efficacy around a specific task involving lifting say, in this case a deadlift might not cut it if I need to be contextually specific as we see in true exposure therapy.

So if a general thing helped then perhaps the problem was not that specific?

Many years ago in the 90’s I worked as a gym instructor. That pretty much was using exposure to improve the self-efficacy of people who had never come to the gym before. It involved relationship building, coaching and doing the thing they wanted to gain more confidence in, in this case a basic gym routine. Guess what? After a few weeks of doing I with a bit of support and getting comfortable in the surroundings and building a bit of a habit they improved their self efficacy!

Is it normal anyway?

If I have pain or have never done something before such as weight lifting then having low self-efficacy for this might be completely normal. I don’t see this as a clinically significant low self-efficacy, say under 30, as has been discussed, on the PSEQ and rarely gets measured anyway clinically.

People are a bit worried, their confidence has dropped, they are often more cautious of experiencing pain and using their bodies. Rather than an abnormal response it might be something quite normal. Perhaps it is the duration of these beliefs beyond what might be considered normal that is the problem?

Take away’s


• Self-efficacy is a not a thing

• The scale used generally relates to the thing

• The scale used to measure the thing can miss the thing

• General interventions work on general things

• Specific interventions work on specific things

• Exposure and confidence go hand in hand

One of the most common questions I get asked, after “which exercise is best to fix back pain?” is....

“How often should my patient do their exercises?”

One of the things we have to remember is that “how often” or FREQUENCY is tied into the INTENSITY and EFFORT and therefore need for REST & RECOVERY, and the one thing underdiscussed and often unreported in studies is intensity!! We could do 3x10 or 5x5 or whatever, but without the accompanying intensity the sets and reps don’t really mean that much.

Intensity and effort often get used interchangeably, if there is a technical difference to discern then intensity is more about the objective measures we make e.g. heart rate whilst running, and effort is more how hard we perceive this to be, so rate of perceived exertion (RPE) would be a subjective measure with the Borg scale designed to relate to current working heart rate. So whilst technically not exactly the same, intensity & effort do have a strong relationship in my opinion and RPE can be used clinically as a simple, rudimentary measure of intensity.

This does not mean that all exercises have to be intense, it might need to fit the current sensitivity of the patient and this lower intensity can often be done more regularly, and for many just moving in a non threatening way might suffice. But there may also need to be progression and this can be where lots of therapeutic exercise programs can fall down as they are looking for a single exercise/dosage.

Based on the current data with exercise my personal belief is that the dosing such as intensity and frequency are probably more important than the TYPE for some people!

I wrote about this a while back -  "Exercise dosing for pain is not he same as exercise doing for fitness"

What is the aim of the exercise?


Your clinical reasoning should really determine which exercise, how much, and how OFTEN!

Now there is a fair bit of discussion of whether ‘general exercise’ is better than ‘specific’ exercise whatever those two things are exactly, but my personal belief is we should always have some reasoning around WHY we are doing something. Unfortunately, although it’s a simple answer I just don’t really see “just do some exercise” as being THE answer to back pain for example.

So what is the aim? Well we often have two main types, a more physical adaptation aim or a pain/function focused aim.

Lets start with the physical adaptation side of reasoning.


So strength and strengthening often get used interchangeably but might be different. Actually increasing force production or strength can require some intense exercise and higher effort levels. Sets and reps are often programmed but not the intensity as previously discussed. You could do strength programming variables but without sufficient intensity, and therefore you may not need the same rest as with more intense training but also might not get the same benefit. The load here should really dictate the reps as stopping at 5 reps with another 5 in the bank because the load is too light isn’t really going to cut it.

Our views of programming are changing with regards to strength and hypertrophy but intensity matters here and therefore frequency does too.

Load/tissue tolerance

This is a common aim, the concept of ‘strengthening’ an area to take a bit more load or activity.  A common mistake is to assume painful movement or being intolerant to an activity or load is CAUSED by excess load. Load is a very catch all term and ANY painful movement or joint could be described as being load ‘intolerant’ if it causes pain, this would be a basic correlation NOT causation mistake.

Generally heavier loads are advocated and therefore higher intensities and lower frequencies although we really don’t know that much here, load tolerance I doubt is a solely tissue phenomenon.

In some cases a load tolerance approach might work by actually taking away load as much as a stimulus to increase tolerance, so addition by subtraction. We simply keep the body moving whilst taking away an aggravating load is a plausible rationale especially with exercises of limited intensity.

How does your exercise prescription also fit in with the other stuff the person is doing? This also should tie into your reasoning around frequency. With very active people, where volume might be an issue, sometimes LOWER intensity exercise performed more FREQUENTLY can also be of benefit.

The spanner in the works & graded approaches


It would all be so easy if therapeutic exercise was just about physical variables such as strengh, but unfortunately it’s not. We all know it’s great to get parameters to work with but anyone who has been in clinic knows that the real test is in how the person RESPONDS.

Screen Shot 2020 06 23 At 09.44.41

It’s the interplay between intensity, frequency and PAIN that’s that really should guide us rather than theoretical parameters for fitness. And it’s not just pain as a sensation but the persons beliefs and behaviours in response to and around pain in general that also need to be considered.

Graded activity and exercise are concepts that relate a bit more to habituating to pain and graded exposure to cognitive factors such as fear or catastrophising. Here we don’t have ANY real parameters apart from those that are based around physical ability and pain tolerance. So frequency is really a thing that is tough to set BEFORE you work with someone. This is part of the inherent uncertainty in therapy that we have to get used too but ca be guided by a thorough history of pain and exercise participation.

Graded activity & exercise

These are approaches that originally looked at improving chronic fatigue but are equally applicable to pain too. Again the intensity is important, if we are pushing the level of grading towards the more intense then longer rests and decreased frequency might be important. If more about building a movement HABIT then less intense and more frequent.

Graded exposure

Graded exposure is slightly different in that it is more about cognitive factor such as fear and anxiety around moving than pain or actually than a physical change. But frequency is NO LESS important. True exposure sessions are mentally fatiguing and because of this physically and emotionally tiring. If we want to reinforce this with additional work at home we would have to consider this in terms of frequency and individual levels of fatigue.

Reasoning in action


Here is how my reasoning might work with the two different aims. I like to use effort level as a guide to intensity as it is a simple subjective measure that is easy to use clinically across a variety of exercises/activities and I find rate of perceived exertion (RPE) is good for this. Now intensity and effort are NOT the same thing but generally the more intense an exercise the more effort is required especially the more of it you do.


Although the data around adaptation and reps/sets/intensity is definitely changing compared with what I was taught back in the 90’s, I still think that intensity is key for physical adaptation. With more intensity we need more rest so frequency might only be 2/3 times per week. Bodybuilders were smart at training regions of the body on different days to maximise recovery whilst also getting in their overall training needs.

So we probably need at least a 7/10 RPE.  If you are looking for strength (force production) then I would say we should probably bias heavier mass to create that intensity too.

Tolerance might be different in that intensity could be created by a lighter load but you have to get in more reps to make the intensity. If we think about all the different activities and types of loads coupled with access to loading equipment then adjusting load and reps for intensity helps us a bunch. Remember that all this also ties in with their current level of sensitivity too and we often have to adjust this based on responses.


My reasoning here would be how can we build a HABIT of moving. HABITS are built more by frequency than intensity.

So let’s identify something that is going to be valued or ties into the values. We don’t always have to enjoy things but we do have to see a worth in doing them to continue to do them. Based on how someone’s pain behaves in terms of types of activities that trigger, severity of pain and how much it takes to do so (irritability) we can start to build a picture and reason a  dose of that activity.

So although we still have to be guided by the persons RESPONSE, I would aim for intensity lower (3-5 RPE) and a frequency of daily or every other day, remember it does not have to be the SAME activity/exercise that is performed each time.

It is important to remember where you start with frequency and intensity should not be where you finish with it, but sometimes we need to start lower to get higher!

Key points


  • Just go do some exercise might be why lots of exercise programs ultimately fail
  • Sets and reps also need intensity/effort
  • Intensity is relative to what you want to achieve and intensity dictates frequency
  • It’s often about trial and error
  • Get used to it!

The biopsychosocial (BPS) model is one of those things you probably feel like you should be doing but maybe don’t know exactly how or you don’t have the skills? There does seem to be a fair amount of uncertainty and a bit of anxiety associated with the BPS model HERE and even the papers that discuss it rarely seem to actually define it!

This take on the Dan Ariely "big data" quote sums it up quite nicely (kudos to the author!)

Biopsychosocial management of back pain

Is like teenage sex;

Everybody talks about it;

Nobody really knows how to do it;

Everyone thinks everyone is doing it;

So everybody claims to be doing it.

But maybe we don’t need to FULLY define or understand the BPS to start to implement it in some way. The first thing we need to do is actually know MORE about it. I was told recently that the BPS model is “old and we should move on” in a twitter discussion. A little bit further into the discussion it turned out the other party had not read much about it, I think this happens a lot. We all seem to have our own interpretations around what BPS is and is not, so this is my attempt!

What is it?


There seem to be two main perspectives that are summed up in these quite differing quotes:

“The centre of interest in biopsychosocial model is not the disease but a sick individual” Havelka  

 “The Biopsychosocial model was first conceptualised by George Engel in 1977, suggesting that to understand a person's medical condition it is not simply the biological factors to consider, but also the psychological and social factors” Physiopedia

The first is focused more on the person we are treating and the second more focused on the condition or problem, so no wonder we have a bunch of confusion and NEITHER really give much guidance about what to do next.

One of the perspectives that I feel gets lost in some views of the BPS model is the focus on the ‘humanisation’ of healthcare which is a feature of Engel's writing. To understand the biopsychosocial model we also have to understand why we needed it in the first place and this was to come away from the reduction of healthcare to pathology and numbers that was the biomedical model.

Isn’t it fascinating we now quantify the success of a BPS approach simply by an outcome measure!?

Philosophy of care and person focus


Maybe this is the real spirit of the BPS? A ‘philosophy of care’ and a person focus.

The cool thing is it does not require extensive training to implement, instead it simply requires us to appreciate there is another person who is more than a disc or a tendon or whatever issue they have. They also will have a history and experiences that shape their emotions, perspectives and ultimately behaviours.

This for me is summed up nicely in this quote.

“Look at the world through the patients eyes and walk through the world in the patients shoes” -   

 This quote from Joanne Bourke also sums up how we can focus more on the pain than the person who has it.

‘Pain’, rather than a person-in-pain, is given agency. A pain-event always belongs to the individual’s life; it is a part of her life story”  

When it comes to the human side of the BPS perhaps we can get stuck on the idea that everything we do has to result in a better outcome e.g. a change in pain. So this interaction is measured and judged via change in pain, empathy is measured via change in pain, you get the idea. This is exactly the positivist/empirical perspective Engel seemed to be arguing against, reducing everything to a hyperfocus on the problem and then measuring its change! We should be being aware of how we interact NOT just to get a better outcome measure but also because its the RIGHT THING TO DO!

Evidence based medicine is important but not at the expense of a person. We really need to zoom out to the whole often rather than separating into smaller parts and descending DOWN Engel's hierarchy of systems.

The aspect of the BPS model that is probably most important is our own self reflection on how we think, act and interact but I have rarely seen this discussed. Just reflecting on how we communicate or care for the other party or conduct ourselves is enormously valuable.

The thing is that if we want the BPS to be an effective treatment tool then it probably requires the human aspect that is being discussed here. Many psychosocial factors that relate to pain require changes in behaviour. These changes also require trust and belief in what we are saying and this can be tough when it is contrary to all the other concepts and ideas around pain that people get exposed to.

There are a number of points that we can appreciate to implement a more person focused version of the BPS model that are NOT directly treatment focused but might have an effect on the process.

  • Having pain can affect our emotions as much as our emotions might affect pain. It is a BI DIRECTIONAL model.
  • Socioeconomic status and health literacy directly affect the entire therapeutic process
  • Appreciate how beliefs are in part formed at a societal level and this can make them pretty sticky. They often don’t simply change in a session
  • Having pain is HARD and can limit motivation and belief in recovery
  • This person may have had to tell their story multiple times and this can be very frustrating
  • A constant search for the answer can be frustrating and tiring. Modern medicine can paint the picture there is one to be found
  • Uncertainty and the worry it brings makes people feel worse. Not just their pain but also their well being
  • Hope, motivation, optimism and instilling confidence are important not just for pain but also for LIFE and the person

None of these things are treatments but do help us understand the person and their levels of engagement, optimism and outlook for the future. The appreciation of these points also does not require a huge amount of training to impliment.

Causes and Treatment focus


A more traditional diagnostic and treatment focused use of the BPS seems to be the most popular way it is interpreted and implemented and perhaps this can cause a bunch of the issues for both clinicians and patients. To treat thing’s specifically the thought is we have to kind of know what the problem IS first and we can get hyper focused on finding the CAUSE of the problem, but now we have way more potential problems across lots more areas to confuse us! Sticking to traditional pathologies can be hard enough and this is without having to be an expert in other fields too!

I think there is a case that we could see this as a biomedical application of the BPS as we could treat multiple BPS 'factors' WITHOUT actually treating the person in the spirit of the BPS and with a focus on person-centred care. A real aim would be to successfully implement a person AND pain focused model.  Many of the factors we need to identify to implement a pain focused model actually need the person-centred model to make them work anyway. Without a good therapeutic relationship and trust and rapport how do we get people to tell us the information we need? How do we help implement the behaviour changes that are often required? The simple answer is we don’t.

Triggers not causes


Maybe a better way to see this all would be factors/behaviours that TRIGGER pain not always viewing it through a causation lens. Many things might trigger, exacerbate or modulate a painful state. Is this semantics? Potentially, but maybe less focus on CAUSE might take the pressure off clinicians to pin point a cause and does not feed people’s desire to find the one thing that they need to fix their pain. We might swap disc/nerve/alignment for stress/sleep/job and a triggers perspective may help people make sense of their pain situation rather than search for the cure or fix in the same way that can often prove frustrating and demoralising.

As we can see HERE 9, yes 9 psychological factors were identified as being involved with rotator cuff tendinopathy pain, function and quality of life. No wonder a BPS find and fix it model is seriously daunting for most clinicians.

A good analogy might be that of a cut that is grumbling away in the background. Sometimes I am unaware of it, others it is giving a slight twinge. But get something in it that irritates it and it’s a whole other story. This added element has interacted with the cut and triggered a response. Without the cut it might not have done so perhaps on its own we might not see it as a casual element. There is a sometimes a danger we simply swap biomechanical impairments for psychosocial ones.

The interaction of BPS factors is inherently messy. Humans are a complex web of interrelating systems that display non linear responses between things acting on the system and the responses it makes. This can mean we could have huge changes in a variable such as stress but only minor changes in how it affects a target variable such as pain. We also might target one variable, that may not change significantly, but another mediating variable changes and this changes a target variable. This maybe different to the sometimes linear approaches that we can see in research and clinical models that involve a primary outcome measure and intervention.

If we approach the BPS model as a simple view of linear causation and impairment fixing this kind of goes straight back to a biomedical perspective.


Positives not negatives?


There are positives and negatives to this messy non linearity of the BPS with treatment. Positive in that treatments can have wide ranging effects across many variables and the negative that they also might not! Exercise can have implications for general health, mental health and pain through a whole bunch of different mediating variables. One way to start to approach the BPS model is not in trying to fix an impairment but improve aspects we know are beneficial and may provide an overall effect. This would fit with Antonoskys salutogenic model of focusing on wellness rather than illness.

Screen Shot 2020 06 10 At 11.04.02


Perhaps an issue is we now see it as “just do some exercise” and the person will be ok.

Exercise ‘works’ is a common perspective but this really does not tell the story of the data. It is not so much if it ‘works’ at a population level but how much effect does it have for this person in front of me. For all this potential to have wide ranging effects we still don’t see dramatic benefits in the research and often clinically too on the outcome measure of pain. Maybe this is because we expect exercise to automatically transfer to whatever the issues are? Effects on strength, sleep, mental health and ultimately pain are all potential effects/mediators that we see in the research base but we are not GUARANTEED these effects. This paper found HERE found that strength and power scores did not make people feel automatically ready to return to play. Although physical conditioning MIGHT make people FEEL mentally stronger it is not an automatic and linear relationship.

Summing up


We probably need a bit of both perspectives to make things work effectively.

If we put this into a context, firstly we need to consider the effects we might want from exercise based on finding out more about the person we are working with. Do we want to improve health? Wellbeing? Function? Exposure? We might have to set up exercise in some different ways to achieve these different aims. Secondly our deeper knowledge of this person and their journey might help use frame, explain and implement the exercise in some different ways that could have a better potential to have the desired effect.

If a BPS approach just ends up in do some exercise because it CAN have wide ranging effects I think we have lost sight of what the BPS just might be!