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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.

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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!)

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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

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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?

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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.

 

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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 ben@cor-kinetic.com

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?

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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

10 evidenced based reasons why you & your patients should EXERCISE

Exercise is great, we know this, right?

Well sort of.

Many people know exercise is good for us on a general level, but the question is, do they know it’s right for them on an individual level and is it the right fix for their problem?

This is an entirely different proposition, applying that general information to the person. This idea that these things are good for us can be quite vague, one of those things we may have glanced over in a newspaper or half heard on the news whilst eating our cornflakes.

People also build up ideas about what is the correct treatment for them. This can be from their own in depth research on the internet (right!), what they have picked up from friends and family or from previous treatment with a therapist. This can lead to some pretty strong ideas about what should and perhaps should not be done to help them.

These beliefs don’t always align with the best available data we have about interventions. A prime example of this is the belief that exercise risks out weight the benefits with back pain (55% of folk in New Zealand).  This stat was taken from this Darlow paper in 2016 HERE.

We know that exercise can be effective with back pain, certainly not a magic bullet, but one of the best things we have at our disposable within a comprehensive treatment plan, especially as it is low cost and low risk too.

Beliefs and expectations

Our beliefs drive our expectations and actions. Predicted expectations are gaining weight as a prognostic factor in recovery over the past decade. They may influence my participation and behaviour in a treatment plan that will ultimately affect the outcome.  If I don’t believe in something I am much less likely to do it.

How can we combat this? Well in my opinion the best tool we have is good quality information we can use to combat the beliefs that may hold people back. A key to start affecting beliefs, again in my opinion, is not to challenge to firmly but inform people using well-evidenced information.One of my favourite one liners is “ That’s what we used to think but we are learning new things all the time, the latest research suggests….”

Here are some small titbits of information that we can use to start informing our patients and clients about the role of exercise in pain AND health, which of course ultimately affects pain too!

Remember that giving people information is really designed to change behaviour rather than just show how smart you are so monitoring what happens is pretty important.

1. Exercise is one of the BEST well EVIDENCE interventions we have for MSK pain

This paper HERE from 2017 in PLOS one shows moderate to strong effectiveness of exercise as an intervention for many MSK issues. This is in contrast to the belief that things need to be zapped, needled or popped back into place.

My therapist only gave me some exercises. Yep. Because they followed the evidence!

2. Exercise won’t make your body WORSE

So many people see the body as a bit of machinery. The more it works the more the parts need replacing. Is this true? Absolutely NOT. The body is an organic organism that adapts both positively and negatively to stimulus. The more active we are (within reason) the stronger we become. The less active, well…..

A classic common belief is that our invertible discs wear out the more we use them. This classic study from Battie HERE (2009) looked at twins to determine the major contributors to disc degeneration. They suggest that the  “commonly held view that disc degeneration is primarily a result of ageing and "wear and tear" from mechanical insults and injuries was not supported by this series of studies”

This study HERE from 2017 found that if you have a rotator cuff tear, the tear getting worse did not appear to be simply related to activity levels. In fact they  suggest pain development is actually associated with LOWER activity levels.

If I had a pound for every time it has been suggested to me that running damages the knees then I would be a rich man. A study of marathon runners HERE showed that they had LESS meniscal abnormalities than non runners.

3. Exercise might actually make the discs in your back healthier!

Two recent studies have shown a POSITIVE effect of activity on intervertebral discs. Firstly this study HERE from 2017 showed that MORE vigorous activity was associated with BETTER disc health on MRI.

Secondly, in this paper from 2016 HERE. Runners were shown to have intervertebral discs that had increase hypertrophy compared to the non athletic group. The authors suggest that running actually strengthens the discs, whether we can infer a causal relationship here is unclear but this goes against activity causing wear and tear which is a common belief.

4. Activity is a pain killer

This study HERE showed that older adults who were MORE active also had better endogenous pain inhibitory mechanisms when their conditioned pain modulation (CPM) was tested. Simply put : ) this means the more active the better their natural pain killing mechanisms were. Which of course is super cool.

5. Exercise is an anti inflammatory

This study HERE showed that regular physical activity caused an increase in interlukin -10 which is an anti inflammatory cytokine that can reduce nociceptor sensitisation.

Now the caveat here is this study was performed in an animal population but as we know that there are associations between inactivity and both acute and chronic pain in humans it is a linked that potentially needs to be better explored.

6. Lack of exercise is associated with chronic pain

This large study HERE looked at the relationship between recreational exercise and chronic pain. Both older and younger folk were studied and the researchers found that for both groups exercise participation was associated with reduced chronic pain. A relationship was also present for the frequency, duration and intensity of that exercise.

7. Lack of exercise as a major cause of chronic diseases.

This comprehensive paper HERE makes a case for a lack of exercise being a primary prevention against 35 chronic conditions suffered by us poor humans. This goes beyond what most of us involved in the musculoskeletal field would have to deal with but also shows the importance of exercise for systemic health too.

8. Its involved in mental health as well.

We are understanding more and more that the mind and the body cannot really be separated. Physical health and mental health are interlinked in the human being and guess what…..exercise plays a role in improving mental health too. This paper HERE explores the mechanisms that may relate to mental health and exercise.

This randomised control trial looked at aerobic exercise and a variety of measures of psychological health HERE. The authors found significant group differences that favoured the exercise group.

9. You want to live longer right?

Strength training in this paper HERE was found to have a significant association with decreased mortality in adults over 65. BUT only a minority of this age group actually meet the current guidelines.

10. Have a healthier heart

This prospective study of 15 years duration HERE found that physical activity was a predictor of cardiovascular disease.

Summing up

There are a whole bunch of others studies that relate to these topics but I just picked a few. I think it demonstrates that physical activity and exercise have an effect on us on a number of different levels, from the heart to the head to pain as well.

  • Do it
  • Do it
  • Do it
  • Do it

Applying pain science education – Live Video on Rethinking Physiotherapy Facebook page

Here is a short video I did on the Rethinking physiotherapy Facebook page on Applying pain science education. ENJOY!!!!

Pain education – What might make it MORE effective?


Pain education is a valuable tool for some, but certainly not all, patients. It can help to provide a narrative or explanation for problems that may remain unexplained by ‘traditional’ medicine or therapy.

This paper HERE regarding chronic lower back pain explores what people are looking for from a visit to a therapist.

more than 90% of patients expected a physical examination, tests or investigations, a diagnosis, reassurance and advice, and clear explanations of causation, symptom management”

How tough is this in many instances with no clear diagnosis or causation available?

Up to 90% of back pain is described as ‘non specific’ for this very reason. We know that uncertainty is a big deal for many patients. Mishel first proposed this in the “theory of uncertainty of illness” HERE.

Carroll's paper HERE How Well Do You Expect to Recover, and What Does Recovery Mean, Anyway? Qualitative Study of Expectations After a Musculoskeletal Injury” also discusses the process of diagnosis, uncertainty and the subsequent effect on expectations of recovery.

But although data suggests pain education can help it can also be very tough to deliver.

This quote from Louis Gifford sums it up nicely.

"The patient that learned from their pain explaining therapist that their pain didn't really mean anything, who suddenly got out of the chair, went home and went riding their bike for the first time in 5 years...just doesn't really exist!”

So how can we improve the delivery of pain education?

A question I often ponder is have we replaced anatomy with neurobiology? Do we now bombard people with complex processes involving brains, nerves and receptors rather than complex biomechanical stories? How much neurobiology or neuroscience is actually required?

In some cases certainly it will be useful, but in many cases maybe it could actually hinder. This does not mean that some of the key concepts such as plasticity, sensitization and the brains role in pain are not important but maybe the minutia of information that can be focused on is unnecessary.

Perhaps we can apply some of the information in this paper HERE. Simplifying MRI reports appears to have a positive effect on how they are received. This may also apply to the delivery of pain education. What does nociception or Ion channel mean to a patient? It could end up very similar to VOMIT (Victims of Medical Imaging Technology) HERE if poorly delivered.

Should the focus now be on the delivery and context of information rather than the information itself?

Contributions

I thought it might be nice to get some other opinions on some of the key elements that go into making successful pain education and reached out to colleagues from around the world, using social media, to pitch in.

Some of the key components I already advocate, but I must admit some others I had not considered and provide valuable food for thought for myself and perhaps also the wider therapeutic community.

I was pleasantly surprised by the elements discussed, almost none related to the actual information itself but instead on the delivery and thought process involved.

Here they are!

Slide1

Listening

The most consistent point made by the contributors as a whole was listening.

Listening is a key clinical tool. Although pain education is often thought of as the delivery of information, it should start with listening. I think this is advocated on many fronts but as we know patients can often be interrupted pretty quickly HERE and this is always worth keeping in mind.

The desire to be listened to also appears to be valued from a patient perspective and helps to build therapeutic alliance HERE. This is probably vital for those receiving and processing the information. delivered.

This is a good paper on ‘listening as therapy’ HERE

Validation

A couple of patients also contributed to the discussion and they felt that someone listening to and validating their experiences was a big part of their recovery. This also ties into the paper above regarding a patient’s perspective. If symptoms cannot be ‘medically’ explained or solved by traditional interventions, then patients may feel that they are being seen to ‘make it up’ or exaggerate their painful experience. All pain is real and although it can often be hard to describe it is also exactly the way that someone says it is. It cannot be anything else!

Individualisation

Another of the key points consistently put forward was about individualizing the delivery and placing into a relevant context. Now I personally have a bias for placing pain education in context with someone’s current situation. By weaving it into their story and using their painful examples to tie in some of the key concepts I think we are more likely to get some elements of comprehension.

This fits well with the key component of listening. Without listening we cannot place the information in the context of the patients narrative.

The question is, is this more effective than information generically delivered? I just don’t know. I think this would be an interesting comparison to study.

Asking!

One thing I must admit to NOT asking was simply “do you want to know more about pain?” This was brought up by a number of people. This may avoid the very real problem of ramming pain science where it is not wanted. Pain science should be judiciously applied where it is needed AND wanted rather than a therapist dropping knowledge bombs expecting an instant epiphany.

It is not a passive exchange

Remember there are two equal people involved in this. It is not simply a teacher pupil relationship. Patients lived experiences are also important. The therapist can also learn from the patient, especially when it comes to the patient experiences. Perhaps it should be seen as a journey by two people to find mutual meaning in a negative situation rather than simply an educational experience.

Pain science is a way of thinking not an intervention

One of the criticisms that I have seen recently of the application of pain education is that it is seen as a standalone intervention. So rather than bombarding people with statements or analogies that have been previously heard for explaining pain, the concepts and ideas should affect the way we reason, interact, explain and apply the treatment provided.

Experiences are as powerful as talking

It’s not just about talking; doing is also a powerful educator. Perhaps sometimes talking is needed before and after the doing, but without the actual doing we cannot ‘prove’ the point. Beliefs about the body are a good example of this. Without SEEING or FEELING a different, positive outcome to that expected, potentially a number of times, a belief may remain in place.

Again listening is key. What are the key experiences that need to be reconceptualised in a physical sense as well as a cognitive sense.

Find out HOW your education has been interpreted

As with any part of the therapy process, pain education has the potential to have a NEGATIVE outcome as well as a positive one. We may well baffle people with talk of brains and outputs etc and HOW they interpret this information is the arbiter of success, however well meaning or comprehensive the input by the therapist.

This may boil down to wording, health literacy and therapeutic alliance. The list of potential influencers is endless, but essentially the ability to mitigate any negative effects could be dependent on simply asking!

We may be able to influence this interpretation by being clear and concise, using bite sized chunks of information, avoiding confrontation regarding beliefs and also avoiding negative or long winded medical or anatomical jargon and terms.

Reflective questioning

Don't just providing statements, also use reflective questioning. This may help to facilitate understanding and apply this new information to their own personal experiences and think critically about some of the beliefs they may hold.

Lets say someone has a negative belief regarding about their back because of a slipped disk a number of years ago. We could suggest that structure and symptoms don’t always display a consistent relationship. We could follow this up by asking if their symptoms come and go (as long term back pain generally does) and would this be a sole cause if the ‘slipped’ disc remained a constant.

Of course this is just some opinion/s but collectively they could be valuable!

Key points

  • People are looking for answers
  • Uncertainty makes things worse
  • Pain education may provide some explanation
  • It is tough and often fails

Some things may make it more effective

  • Listening
  • Validation
  • Individualisation
  • Asking If it is wanted/needed
  • It is not a passive exchange
  • Pain science is a way of thinking not an intervention
  • Experience is as powerful as talking.
  • Find out HOW your education has been interpreted
  • Reflective questioning