This is going to be a series of blogs looking at a number of topics under this umbrella title as it would turn into more of a book than a blog and although we are on lockdown, ain’t nobody got time for that sh**!

Exercise has become a popular treatment for many musculoskeletal issues over the past few years but surprisingly little is actually understood, even after tons of research, about how to use it in clinical practice and maybe even if it’s worth using?

In this blog we will look the actual question of “does exercise ‘work’ for pain” as ‘works’ tends to be a phrase that gets banded about a lot without much clarity. Similar to “the research shows” when often the deeper you dive into the research the LESS clear it often becomes, especially around pain.

I will write a few more posts on the “everything works/nothing works” perspective, how it might work and how specific we may need to be in future posts.

Well does it work?

 

Well it depends on what you mean by work? Which condition? What are you comparing it against? Do you mean pain? Do you mean disability? Did it have an effect on physical function or some biomotor variable? All of these things are quite different questions that often get lumped into the catch all term ‘works’.

We need to think as well about WHY we might come to a conclusion on if it ‘works’ or does not. Is it because I have read widely in this area? Is it because who I follow on twitter tells me it does or doesn’t or am I simply following my biases? A little bit of epistemology perhaps.

Like ANY intervention, exercise should be thoroughly scrutinised and the basic reality is we have to be prepared that exercise will not work for everybody, it is not a magic bullet or panacea and a lot of what we do is a bunch of informed trial and error really, but we will come back to that later in another post. We have to remember we are dealing with HUMANS who tend to be wonderfully variable in their responses as most biological organisms are.

We now discuss pain as being a complex, multifactorial experience (blah blah blah) so why do we expect one thing to come along and solve it all for everybody? For some it will be revelatory, for some it will do very little and for others even flair them up, so we need a bit of perspective but as a standalone treatment I think there is a lot to like here especially with the benefits for our health and well-being

Just hurry up and tell me…..

 

The whole idea of “it works” could stem from how we have traditionally looked at research. To show a difference between two interventions or ‘usual care’ it has been common to use a significance level of p = 0.05 to indicate something ‘works’, so the observed difference in effect between two groups is likely to be at least as big as reported and this then is used to reject or accept the hypothesis of a study. Generally something like “treatment A WORKS better than treatment B” or something along those lines. Is exercise better than manual therapy? Is it better than usual care? You get the picture. I am no statistician or researcher, only a humble clinician so bear with me here.

So we might say exercise is better than usual care or whatever else, but the real question should be HOW MUCH better or the actual magnitude/size of the difference. The p value is a statistical tool and not a measure of the actual average size of the effect. Something can be statistically significant without really making a difference to our patients and this is where minimal clinical important difference comes in (MCID).

A clinically meaningful change for pain has been discussed as being somewhere between 1-2 points on an 11 point VAS/NPRS dependent on what it is being tested against such as ‘usual care’ or another specific intervention. Other magnitudes of clinical significance have pointed a 20% or 30% change from the baseline and this makes sense as a 2 point change for a baseline of 4 is far more significant than a 2 point change on a baseline of 8 for example.

We have to be aware that these cut off values such as 0.05 are also a bit arbitrary. If we critique the significance of p = 0.05 then we probably have to do the same for MCID too. The real value of any effect may only really be possible via subjective evaluation by the person experiencing them and their expectations of what that change should be.

We may also have to consider how we view the ‘mean effect’ as this may not actually reflect THE effect that MY patient gets (for a whole load of potential reasons). The mean represents the average response and is sensitive to those that respond very highly and also people who respond lowly or even negatively. In trials with small sample sizes, as much of exercise & pain related research is these more extreme values can significantly alter the mean.

We should also take into account the standard deviation of the mean response and this is a measure of the variation within the group of participants being studied. This could mean (get it…) that the variation in response when applying the treatment in clinic could also be pretty wide too. A confidence interval (CI) is another measure of uncertainty/variability around the potential treatment effect on a wider population. The CI reflects the inherent variability/error in the process of sampling taking into account the size and variation within the sample.

The last question here is does exercise research always reflect clinical practice? Personally, I tinker with type of exercise, intensity, frequency, volume etc to ‘optimise’ for the person whether that’s in relation to their response or ability to achieve the program. If I am not getting the desired response then I feel quite at home playing with the variables. Is this right or wrong? I have no idea but standardised programs used to study exercise often don’t do this.

You really didn’t answer the question…..

 

So what was the point of all this, well we can start to see that “it works” is a pretty nebulous term really. It’s the classic clinical conundrum of applying the world of research to our patients and how we should expect them to respond. Predicting the future is always tough and worlds of research and clinical practice is definitely not a game of certainties.

We have to consider the actual size of what ‘works’ and how likely is my patient to actually respond in this way and I see it as a bit of a “probability wrapped up in a probability”. This often makes clinicians feel uncomfortable as we tend to like certainties and sometimes research can be portrayed as more certain than it really is IMO.  But we really have to look at the trials, who they are studying, how many people, what exercise/dosage and what’s the spread of responses amongst other things to even get close to answering the question.

 

Next time we might actually answer the question ; )

 

We probably have to face the fact that most common treatments that we learn such as manual therapy, exercise (yes even exercise) etc are often little more than hugs and kisses for the most costly and burdensome issue in musculoskeletal health today, Lower Back Pain (LBP). Something that is pretty clear however in the murky world of therapy, when it comes to back pain something people suffering from it value one thing highly, INFORMATION!

Before many people even come to see a therapist they search the problem on the internet and consult the medical sage that is DR GOOGLE (and we know how good that often is).

This 2018 paper “What matters most to people in musculoskeletal physiotherapy consultations? A qualitative study” found some clear themes. Firstly that people often have some clear questions they want to ask. Secondly that people required information about their problem and third was the need for collaboration with their therapist.

“In this study the people frequently reported lack of understanding, such that information and an explanation of their condition and a diagnosis was one of the main issues of importance that emerged for all but one participant”

This makes complete sense! People want to know what this is and if it’s a big problem? Is it medically serious? How long might it take to go?  Now rather than 'fancy pants' explanations of neurobiology, load capacity and other poorly define buzz words it might just be basic epidemiology delivered in a reassuring and non-threatening way. The current trend of 'simplicity' in rehab probably applies here to! This can take practice and knowledge and like most simple sounding things can be tough to actually do.

Perhaps if we can satisfy the people engaging our services needs then they might be more likely to trust and engage with the messages that we feel are important? Just a thought!

Why is this important info?

 

We should really see the data around what people want from us as market research for therapists! This makes it worth taking notice of what the end user actually wants without just guessing or assuming, which can happen. Rather than meeting and satisfying the needs of those seeking help some of the current approaches actually probably fuel more uptake of the product (smart from a business sense)!

Education forms a key part of the current LBP treatment guidelines and papers such as the recent Lancet series "Prevention and treatment of low back pain: evidence, challenges, and promising directions" but like another guideline staple, exercise, what exactly does ‘education’ mean? Education about what exactly? This is why guidelines are often not followed, they are just too vague. But low and behold we have a lot of research to guide us here on what people would like to know.

What is treatment anyways?

 

We also have to ask ourselves what actually IS treatment when it comes to back pain? Is education really seen as treatment? Often not, but it really should be. The therapists role may shift from DOING treatments to people to helping people understand and navigate their painful situation BETTER.

This recent paper looked at examination as treatment “Evaluation is treatment for low back pain” the authors stated.

“Participants showed a significant reduction in pain through just the history taking and physical exam for both the back with an NPRS reduction of 1.23 and the leg showing a 0.95 NPRS reduction”

It is important to note that this was for first time back pain sufferers and also the pain reduction was in a small timeframe with no longer term follow up but interesting none the less!

So we could suggest that information & assessment IS treatment not just things that we add TO or do BEFORE treatment. I have had therapists suggest to me in the past that this is NOT what people want, they want to be ‘treated’ (in a more traditional sense of stuff being done to them) and certainly for some this is the case but interestingly, when we actually ASK them (I know right, madness!), understanding what is happening does actually seem to be what people want!

What do people want?

 

From looking at the qualitative literature there are theme's that clearly emerge, people want to makes sense of their painful condition, people want to be reassured that its nothing serious and people want to increase their ability to self-manage (we could call this locus of control if we were being fancy)

The nicely titled systematic review “People with low back pain want clear, consistent and personalised information on prognosis, treatment options and self-management strategies” looked at 41 papers and identified the type of information people are really after.

“Participants were keen to learn about simple and basic information regarding LBP”

“patients wanted clear, trustworthy, consistent information about the nature of LBP, its benign prognosis, and advice on both pharmacological and non- pharmacological management strategies”

One thing that was also apparent in this a paper and others was the need for a patient to get a diagnosis. This obviously is extremely challenging currently, but I believe a way to approach this is not to say we don’t know as this is often unhelpful. Instead tell people what it is NOT (99% of the time serious pathology), potential causes of MSK origin, the prognosis (generally good) and what they can do about it, which kind of fits the title of the paper : )

People also want to legitimise and validate their symptoms. Perhaps this is hard to do in the medical system without a clear diagnosis, this may also drive the clear need for imaging that was identified by patients, paradoxically it can make things worse. I feel it is an important message that we let people know that it is entirely plausible to have high levels of pain without an identifiable structural issue and this is inability to give a clear diagnosis is our fault not theirs. Learning to manage diagnostic uncertainty is a emerging challenge.

Is there an 'information' disconnect here?

 

A recent paper looked at the information that experts thought were important to inform people about LBP “Essential key messages about diagnosis, imaging, and self-care for people with low back pain: a modified Delphi study of consumer and expert opinions”.

The authors found that messages that he experts felt were important such as “carrying on with normal activities” ranked 2nd (out of 30) by experts. In comparison this was seen as 24th most important message by consumers, quite a disparity I am sure you will agree. So, what did people see as important? The first three messages ranked by consumers all related to red flags and identification of serious pathology. Other things that were important to people were self management and reassurance information and this was ranked much lower in importance by the experts. It does seem there is a bit of a disconnect between the two groups here. Perhaps with a bit of acknowledgment of people’s needs we can make them more receptive to what WE feel is important too.

How do we use this information?

 

How does this inform us?

Well it certainly means that information on occurrence of serious pathology, screening and a thorough explanation of findings is not an unimportant thing to many people and probably provides a large chunk of reassurance. If we accept that having pain can be a scary scenario for our physical, emotional and functional well being then it’s not so hard to connect the dots. Also helping people answer the question of “what can I do about it myself” seems to be important. Maybe treatment is often seen as something that happens INSIDE the treatment room (it’s even in the name; ) not what happens outside. As life mostly happens outside perhaps this is where 99% of treatment probably really occurs and helping people with this is really important (a future piece me thinks).

This is a great quote from what I feel is a hugely insightful and underrated paper “How Well Do You Expect to Recover, and What Does Recovery Mean, Anyway? Qualitative Study of Expectations After a Musculoskeletal Injury”

“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”

This sums up a bunch of what we deal with on a daily basis with so many non specific painful conditions such as low back pain.

 “What Do Patients with Chronic Spinal Pain Expect from Their Physiotherapist?” again found that people want DIAGNOSIS and information about their problem and this is pretty consistent with the previous papers that have looked at this subject. Interestingly, a reduction in symptoms actually came BEHIND improving quality of life as being important in the responses. Not by a huge amount, 68% found it important versus 66% for pain reduction but this shows the importance people actually put on life and not just pain. Clinical implications here again are the importance of examination and the information that we give alongside finding out what quality of life means to people.

A 2008 paper "Listen to me, tell me': a qualitative study of partnership in care for people with non-specific chronic low back pain" highlighted the tension that exists between people wanting information but also wanting the opportunity to tell their story and this is an important balancing act. Allowing time and creating a safe space to let someone’s story emerge whilst also providing relevant information is again a tough thing to do, especially in the limited time frame many operate within.

To make sure we can get key informationacross perhaps this is where the use of good open questions come in.

“What is most concerning you that you would like me to answer today?”

“Its important we really address your concerns so what would you really like to know?”

“What is worrying you that you would like to talk about?”

Effective reassurance is much more effective if it actually addresses the things people are worried about.

What better way to find that out than to ask?

Next time - How to go about creating a positive narrative around back pain!

Conclusion

 

  • People want simple information about their problem (so you need to know it)
  • People want a good assessment
  • They want a clear diagnosis to validate their symptoms
  • This is REALLY hard!
  • But we can replace it with a clear and concise NARRATIVE around LBP
  • The potential causes, prognosis and management options
  • Effective reassurance targets the problem or worry

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I get the opportunity to chat about back pain now and again around the world and one of the things I often talk about is the current guidelines around back pain. I will admit to often feeling a little apprehensive around this subject as the current guidelines run contrary to the way many HCP treat this common problem.

There is always a little gasp when manual therapy, acupuncture and ultrasound get relegated to adjunctive treatments. “Don’t shoot the messenger” is often my get out of jail card.

We know that clinical guidelines around most things within healthcare are not well followed. The big question is why?

We are humans!

Healthcare professionals are humans just like the people we are trying to help and suffer from exactly the same issues. For me there are parallels between getting clinicians to follow guidelines and getting people to be compliant, adherent, committed or whatever you want to call it to exercise programs or health improvement or even taking medications.

We all know that getting fitter is good for us as is reducing smoking, drinking and eating crappy foods. But that does not mean we always implement this knowledge. People still smoke and drink too much and don’t get the recommended dosages of exercise. Big societal messages are needed, but so is how to put them into practice at an individual level.

The big problem I see is how gigantically broad the guidelines are around treatment. Let’s take my favourite subjects’ activity & exercise, the guidelines are clear, movement is good, but the evidence base is not really clear when it comes to putting these recommendations into practice!

We might ask ourselves which exercise? How much? How should they do it? What should it feel like? Might it make the problem worse? How to get people to actually do it? If I look back at my clinical education in back pain treatment mostly it was based around Maitland mobilisations with little about exercise treatment and implementation.

So a simple guideline turns into a much greater clinical problem.

Providing a path

Fundamentally we cannot expect people to implement something without giving them a way to implement it. We need to provide a pathway in much the same way we need to provide a pathway for the patients we work with around exercise.

How can you guide someone in something of you have no idea how to do it yourself?

Imagine getting a bit of flat pack furniture that did not come with any instructions. The pile of pieces that lay in front of you daring you to put them together. Some hardy souls, and probably those with a heap of previous experience, might attempt to put them together. Most normal folk, myself included, would simply put them back in the box and push them to the corner of the room. This conundrum is simply too much to handle.

You have all the pieces of the puzzle, but the problem is putting them together!

Education is another prime example. Education about what? Back pain? Pain? Treatment? Prognosis? All of the above? How to do it? Again there are many questions to unpack within the broad recommendation of education. I received no education in education at undergrad or post grad as I suspect neither have many of you reading this. Again this provides a barrier to implementation at the most basic level.

In the face of uncertainty and low confidence we return to our old habits that are ingrained within us and for many that is not based on current guidelines. Uncertainty provides huge inertia to change.

Support

Support is another factor that is often overlooked. How many people feel they cannot treat how they want to treat because of the working environment they are in and the people around them? This is something I often hear. Support again is a huge part of behaviour change and maintenance of that behaviour. A major part of self efficacy is built around social support and I doubt that it would be different in the work place.

The healthcare system that people work in can be a huge influencer of the way we practice in the same way our social systems affect our overall health and behaviours.

Takeaways

 

• Behaviour change is no different for HCPs than it is for patients

• If we want change we have to provide a path to change and support along the way

After ‘pain science’ and ‘biopsychosocial’ the latest buzz word on our horizon seems to be ‘patient centred care’ or PCC for short.

Now for a buzzword it is pretty poorly defined and we don’t really have a strict description, but I think PCC is really how we should be implementing the BioPsychoSocial (BPS) model and what the BPS model was really meant to be about rather than the more pain focused version we have today.

This blog aims to focus on how we might apply PCC in the context of an active approach to treatment but don’t be surprised if it meanders off course a bit.

Patient or person?

Most of the available literature in this area discusses “patient centred care” but I much prefer “person” centred care as it turns the patient well ….into a person and a much more ‘real’ entity in a two way relationship.

The term ‘patient’ has long been open to discussion and this is an interesting read on the subject and I picked out a couple of quotes.

“Do we need a new word for patients?”

Patient comes from the Latin “patiens,” from “patior,” to suffer or bear. The patient, in this language, is truly passive—bearing whatever suffering is necessary and tolerating patiently the interventions of the outside expert”

“An unequal relationship between the user of healthcare services and the provider”

These are interesting perspectives that highlights the potential perspective of the ‘patient’ as a passive recipient to be told what to do and without concern for them as an individual. After all tissues and pathologies really don’t care how they are treated so why the need to worry about it?

What actually is PCC?

Maybe by definition PCC is tough to define for all? What is person centred for one may not be for another, but there do appear to be some broad themes and ideas that can be discussed.

Patient (person) centred care has previously been defined as:

"willingness to become involved in the full range of difficulties patients bring to their doctors, and not just their biomedical problems" – Stewart 1995

"the physician tries to enter the patient's world, to see the illness through the patient's eyes'' McWhinney 1989

Two person medicine (rather than one person)” – Balint e al 1993

(Quotes in Mead et al 2000)

For me, a good start for PCC is not to see the therapist or technique or method or exercise as the star of the show. It’s about the PERSON that really needs our help. That does not mean fanfares, razzmatazz and pedestals, it really means that we try to think about what THIS person in front of me needs, what is it like to walk a mile THEIR shoes?

Another very simple way to look at it is, how would YOU like to be treated?

Mead et al in “Patient-centredness: a conceptual framework and review of the empirical literature” defined 5 key aspects of a “patient centredness”

  • The biopsychosocial perspective (the patients life)
  • The patient as a person
  • Shared power and responsibility
  • Therapeutic alliance
  • The doctor as a person (Personal qualities such as Humanness)

Wijma et al explored “Patient-centeredness in physiotherapy: What does it entail?”

They defined PCC as

“Patient centeredness in physiotherapy entails the characteristics of offering an individualized treatment, continuous communication (verbal and non-verbal), education during all aspects of treatment, working with patient-defined goals, a treatment in which the patient is supported and empowered, and a physiotherapist with patient-centered social skills, confidence, and knowledge”

What PCC is NOT

There are some criticisms of PCC that seem to centre around the idea of consumer driven healthcare and doing ‘whatever someone wants you to do’. Maybe the idea of ‘shared decision making’, intrinsic to PCC, seems to open up this idea of consumer healthcare for some.

These discussions are often dominated by the type of treatment and the application of more passive modalities and we really need to guard against this reductionist perspective of PCC.

Rather than MAKING the decision based on someone’s preference, PCC instead really should be about people being involved in decisions, a key part of PCC, and this should reflect the best information around treatment that we have available and frank and honest conversations around the best course of action. Not simply “what treatment do you want”.

Makoul & Clayman in “An integrative model of shared decision making in medical encounters” discuss a number of steps involved with shared decision making

  • Define or explain problem
  • Present options
  • Discuss pros and cons (benefits/risks/costs)
  • Assess patients’ values or preferences
  • Discuss patient ability or self- efficacy
  • Provide doctor knowledge or recommendations
  • Check or clarify understanding
  • Make or explicitly defer decision
  • Arrange follow-up

 

What do people really want?

That leads us nicely into “what DO people want” and this does NOT seem to revolve around their favourite treatment type.

PCC is perhaps thinking about what healthcare can do for the end user, the person rather than how do they fit into the broader healthcare world. What better way is there to do that than ask them : ).

The increase in qualitative research is fantastic and really helps us understand what people think, feel and ultimately need.

This is a really interesting paper regarding a two person perspective in back pain Listen to me, tell me': a qualitative study of partnership in care for people with non-specific chronic low back pain

The authors here identified some key areas.

Partnership with practitioner

“All participants expressed the need for mutual enquiry, problem-solving, negotiation and renegotiation between care-provider and care-seeker to establish mutual therapeutic goals “

‘Ask me’

“All participants reported that engagement with their health care-provider improved if they were explicitly asked for their opinions and goals.”

'Understand me'

“Consideration of life circumstances and preferences was important to all participants in developing therapeutic partnerships and optimising exercise outcomes”

‘Listen to me’

‘Explain it so I can understand’ – Valuing competent and empathetic listener

I know my own body   - Participants framed the ability to ‘know your own body’ as empowering

This sentence particularly resonated with me however

“Tension existed between patients’ wanting a genuine voice in the partnership and them wanting a care-provider to give explicit diagnosis and best management instruction

Does It matter?

A question I often hear asked about person centred care is does PCC actually improve ‘outcomes’? I suppose my response would be does the effect of PPC on outcomes actually matter and which outcomes are we discussing?

Although we know that contextual factors have an affect on outcomes we don't know if PCC specificaly improves the most common outcome measures , but in my opinion it is the RIGHT way to treat other people regardless of if it changes pain, function or whatever. Although we don’t really have much data currently, my biases say for many it would make a difference, if not to common outcome measure then to the persons experience in healthcare (which might be an outcome measure in itself).

 

The application of PCC

Maybe we should NOT see a person centred approach to activity/movement/exercise just about the type of exercise or the sets and reps. Instead it’s about all those things AROUND the moving as well and I will focus mostly on these (you can retain your exercise bias : )

Starting with the end in mind

Unless we define what recovery might look or feel like it is probably hard for anyone to know if they are actually getting there. Really the role of the therapist should be to see where someone wants to get to, where they are currently and then help them bridge that gap.

The best place to start might be with the end in mind and this first and foremost really involves listening. Listening and understanding, is in my opinion the real essence of PCC but many people don’t feel that this always happens in their HealthCare experiences.

This short excerpt is from the excellent From “Non‐encounters” to autonomic agency. Conceptions of patients with low back pain about their encounters in the health care system"  

Holopainen 2018

“Patients felt that they were not being heard. They felt that the encounters were expert driven, and the HCP interrupted them and dismissed what they had to say, without listening to their wishes and opinions”

We also have to acknowledge that for some who have had pain for a long time this process of defining goals or recovery can be really tough. It’s often difficult to see outside of the pain and suffering to have a sense of what ‘life’ actually looks and feels like again.

“Patients identified the effects of pain on their lives. They reported that their circle of life had shrunk and they had given up doing things they used to enjoy” - Holopainen 2018

I try to highlight to people that they are not just moving for the sake of moving (although this can be a positive thing), we are moving to get further towards valued activities and goals that we have discussed and hopefully this can tap into people’s intrinsic motivation.

A big problem, IMO, with goals is that we can measure their success via their effects on more generic measures such as pain or function (certainly in research around physical therapies).

We have a wonderfully personal and specific thing, the goal, and we should actually measure the success of a goal by achieving……the goal! If that involves changes in pain then of course with a person centred approach we have to involve pain in the goal. But we might have no changes in pain (our outcome measure) but reach a valued goal that has a huge effect on someone’s quality of life and may not always be captured by the more generic measures.

I do believe that the ‘WHY’ behind action has to be driven by the person. So much of what happens in therapy is driven by the biases of therapists about the best way to get people pain free or functioning better.

Maybe the ‘methods’ employed often fit better with the identity and values of the therapist rather than the patient?

Shared decisions and responsibilities

As we discussed earlier, PCC and shared decision making is not just doing what someone wants. We need to present the best available information and our professional opinion on the best course of action to properly inform decision making.

Autonomy has been shown to be have an influence on exercise outcomes "Autonomy: A Missing Ingredient of a Successful Program?" . Perhaps some autonomy and choice might lead to better ‘bonding’ with exercise in rehab?

As there are a whole bunch of ways to exercise, move and load it should be not to hard to present a number of options and allow people some choice on the best way forward. Equally it is a therapists responsibility to give their opinion about the best course of action that they think will ‘fit’ the person based on the best data and a sprinkle of experience.

Laying out each others responsibilities in the process is an important step. I always say I am here to guide and help but you have to go and do it and believe in it for it to work. I believe we need accountability towards each other sometimes.

Planning

This for me really is true biopsychosocialism.

We are all people ‘embedded’ in the world with work, family and social pressures. One of the best ways to implement a BPS perspective is to realise that any movement/exercise plan is not going to come at ‘no cost’ in terms of time, effort and sacrificing something else.

People don’t just need a something to do, they also need a plan to be able to do it. A destination is great but we also need a path to get there.

How many things do you never quite get around to doing because you don’t have a clear time, place and structure to get it done?

When’s the best time to do some exercise? Before or after work. How much is OK? What should it feel like? Do they have the required information to facilitate doing it?

Another passage from From'Non‐encounters' to autonomic agency” highlights this.

 “A lack of written instruction prevented them from doing prescribed exercises because they were unsure of what they were supposed to do”

Helping people to navigate their own individual social environments is also a beneficial way to help. We cannot often modify many ‘social’ things but we can help people understand and navigate them better. For example, how might someone access community support with getting more active? Are there free or low cost resources that they can use? Are there support groups or family members or friends that might be able to help.

Acting as a guide rather than healer can be really helpful for many!

Support & motivation

Picking someone’s exercise form apart or highlighting some kind of movement dysfunction really is the opposite of PCC. It shows a complete disregard for how that might make someone else feel and how that might impact on their behaviours. But I suppose if you feel you are just dealing with a pathology then why should that matter?

We could say that view is quite the opposite to walking a mile in someone else’s shoes.

Perhaps we can think about how we might lift someone up rather than pick them apart. Think about highlighting strengths and positives. We entirely underestimate the power of motivation and optimism in healthcare in my opinion. This is a fundamental part of the role of the coach or trainer in the world of fitness but has been lost in the translation of exercise to the world of medicine.

People even say this themselves!

“patients reported that they needed someone to push them, like a personal trainer” - Holopainen 2018

 

Conclusion

 

  • Person centred care is defined by the person
  • PCC is not just giving people what they want
  • People are people not just patients (passive recipients)
  • Think about “walking a mile in someone else’s shoes”
  • Think more about shared decisions (within evidence base)
  • Start with the end in mind, tie into valued activities
  • Help people navigate their ‘world’
  • Build people up rather than knock them down

 

 

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Key Learning points

 

• Develop GREAT rehab programs for even the most challenging patients


• Latest evidence and best practice guidelines for treating low back pain using an ACTIVE approach  


• Use a flexible, adaptable and simple to implement clinical framework to help navigate the uncertainty of clinical practice from patients with persistent pain to elite athletes.


A look at pain and exercise through a truly biopsychosocial lens.


• Take the complication and rigidity out of exercise prescription – Make it fun and engaging for YOU and your patient. Forget a physio tools or photocopied exercise sheet approach.


Take the mystery out of exercise prescription- when do you need to be specific? And when less so? Learn a comprehensive view of exercise that is more than just sets and reps.


How to sell your patients on exercise – A key factor in rehab success


Learn what you need to know about the psychology of pain and exercise without needing to become a psychologist.


• Learn about pain and how to talk about it without needing to be a neuroscientist. More patient focus and less biology!


Concise and practical reviews of the latest research into pain and exercise to save you time and energy! Perfect for the busy clinician who doesn’t have the time to wade through every piece of new information coming out


How to improve your subjective assessment. How to get all the information and ‘find the hook’ that guides patient beliefs, emotions and commitment to rehab.

 

This is NOT just another exercise course about sets and reps! It is about applying movement and exercise to people in pain. Exercise and movement are fantastic tools to help our patients but the complexity and uncertainty often present in clinical practice can make its application tough especially with painful problems!

What’s the best exercise? Will my patients enjoy or even do it? What if I underload, overload or even make them worse? What does the evidence say I should do? How do I communicate this with my patients?

Couple this with many of the current concepts in exercise & fitness simply not applying well to people in pain and this can be frustrating for therapists and patients alike. . The amount of information out there on this subject can be overwhelming, confusing and time consuming to process and we need to learn how to cut through the noise quickly to get to what really matters to help our patients.

Functional therapeutic movement enables you to navigate this uncertain environment by guiding you in making sense of the evidence around exercise and its application, in a way that will practically apply to your patients in clinic straight away. This can help discard unhelpful, outdated & often detrimental perspectives around movement that are often pervasive, amongst therapists and clinicians, and enable a streamlined, flexible and evidence based approach that is in line with the latest pain and rehabilitation research.  

One of the most widely discussed topics in healthcare and especially in pain circles of late is the Bio Psycho Social model conceived by George Engel.  The BioPsychoSocial (BPS) model was developed in reaction to the dominant biomedical viewpoint that involves reducing medicine to specific diseases or pathologies that can be identified and treated and this model forms the back bone of most western healthcare systems.

Engel felt the biomedical model:

“does not include the patient and his attributes as a person, a human being”

But the question is, have we misinterpreted the BioPsychoSocial model?

Are we simply applying it in the same way as the biomedical model it was trying to replace? 

Its people not just pathology!

We know that people’s experiences of pain and pathology differ. The same painful problem may manifest as huge issue for one person disabling them from work and reducing dramatically their quality of life, whilst another person may remain relatively unaffected. This has to be taken into account both in treating the problem but also how the person is TREATED by their healthcare professional, their family and social network and the wider healthcare system. 

We can see below from Engel's view that it is a bi-directional model that involves the layers in which we exist rather than discreet treatment targets as we now see.

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We could perhaps determine this interaction between layers as the wider impact OF the problem rather than just as impacting ON the problem.

Rather than seeing the BPS as a direct treatment model where we dissect the three domains to find new pain ‘drivers’ to treat, the BPS perspective should really be seen as a CLINICAL philosophy and guide that can be used for improved patient care.  

Here is another interpretation from a recent paper ‘How do physiotherapists solicit and explore patients’ concerns in back pain consultations’

"underpinning the bps model is patient-centred care (pcc) which involves incorporating the patient’s perspective as part of the therapeutic process"

One of the issues that is often encountered in healthcare however is that clinicians AND patients want solutions and treatments rather than philosophies and the conversion into a treatment model conforms to the biomedical perspective that dominates healthcare.

Maybe the BPS asks us, as clinicians to better understand our patients and there subjective experience? And it maybe better defined as a model of care rather than a model of treatment. Now this does not mean we cannot involve a BPS thought process IN specific treatment but remember that this is just not really the major focus of the model, certainly as I understand it anyway.

So it is really treating people and their overall existence, not just treating their painful problem. These differing aspects cannot just be separated and simply targeted without an understanding of the person and the context they exist in, doing that for me is the biopsychosocial model in biomedical clothing.

Other commentators such as Leventhal have looked at concepts such as the disease and the illness *HERE*. The disease being the specific issue and the illness being the wider issues surrounding the problem, in my interpretation this is similar in concept to the BPS. How is this PERSON individually affected by the problem that may even BECOME the problem itself.

Just treat the pain?

I can already hear some readers shouting, “Just treat the pain - then you will not have any more problems”

Well that is the biomedical view in a nutshell!

Firstly we have been attempting top do this for ages, hence why there has been a call for a different model. Often treatments for pain are not successful and people need help in other ways and we treat pathology but pain persists. Perhaps the interaction with healthcare even makes the problem worse!

Can we treat the person and pain? Yes I believe so. We should not forget this, just realize our limitations at doing so and also avoid pain being the only focus.

The question is do we often attempt to treat the person AND the pain? I don’t think this happens as much as we would care to admit.  Maybe treating people rather than their pain can lead to reductions in pain? Maybe we cannot have an impact on people’s pain but affect suffering, disability and quality of life? We may not be able to do this in a pain-focused model and why we end up with repetitive surgeries and the opioid epidemic?

People can still have pain and live a positive life; the BPS model is really well placed to help them do so and does life simply return to normal even after pain has reduced for all? I would hazard a guess that for many people their lives are fundamentally changed even AFTER persistent pain has decreased.

BPS model of PAIN

A pain oriented BPS model has emerged more recently and two examples of this can be found *here* and *here*. These interpretations should NOT be confused with Engel's model I feel, and perhaps misses the essence of what he was reaching for. Maybe an issue with the BPS model is its breadth and how far ranging it is? It is quite easy to place our interpretation anywhere within it.

The pain focused model looks at how Biological Psychological and Social factors can influence pain.

This diagram is a great example with the arrows pointing solely inwards.

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The problem here is that it is a return to a biomedical view in which the person is less of a focus and instead the disease (in this case pain) has returned to becoming the primary focus. Instead of being a comprehensive BI-DIRECTIONAL clinical philosophy, it has in many cases become a uni directional treatment model.  We also have much more evidence for BPS aspects being associated with pain than we do actual data to support treatment for pain using these BPS aspects.

Seeing PsychoSocial factors simply as pain influencing factors is missing the wood for the tree’s I feel. This would be a multi factorial pain treatment model, not the BPS model set out by Engel.

This has drawn critique, and rightly so, of the BPS model and it's interpretations. A recent paper from Stilwell and Harman can be found here called “An enactive approach - Beyond the BPS model” (Thanks to the authors for the full text link!). This critique, I feel and highlighted by the authors, is not really of the Engel's model but instead the pain focused interpretation that has evolved. We may not need to move beyond the BPS model, more just apply it in its intended way. Lets try to do that before we think beyond it.

Stilwell and Harman go on to say

“Pain is…..a process that emerges or unfolds through a whole person who is inseparable from the world”

but we should also consider the BPS perspective already to consider the whole world and our existence within it and not just its effect on pain!

The very essence of the BPS model was NOT to delve further and further into the microscopic components of biology but instead to also zoom out to encompass the other factors that may be at play in both pain and quality of life.  I have written about this *HERE*. But if we consider most of the discussion, theories and dominant messages around pain they focus on the reductionist view that Engel was trying to get away from.

As an example please insert any painful problem here 'XXXXX'. Even the most uni-factorial biological one you can think of…lets say a fracture.

How does their perception and knowledge, sense making, around the issue affect them and their behaviors?

How does the injury affect their work and family life?
What are their perceived implications for the future?
How confident are they to return to sport or activity?

How motivated are they to engage in rehab or treatment?

This is considering the PERSON and heir engagement and embodiment in the world not just breaking down pain ‘drivers’ as the trend seems to have become and accusations of people forgetting the bio (eye roll).

Straight lines & trichotomies

Some of the criticisms of the BPS pain model focus on the division into three distinct components biological, psychological, and social as well as a perceived linear causality between the associated factors and pain.

My view of Engel's work is that he objected to a linear causality model. Emergent properties such as pain NEVER have simple linear relationships with causes (whatever they are?). Again this is a misinterpretation and application specifically to pain of the original work. Linear causality is a criticism of previous Cartesian pain models but appears to be alive and well in the BPS.

The term ‘non linear’ means that small things can give large effects but also large effects in one area may also give rise to no effects in the targeted area.  There are so many interactions occurring that can affect each other that the same treatment may give rise to DIFFERENT positive or NEGATIVE outcomes dependent on the current state of the organism.

We seem to be happier for this to be the case now biomechanically, but less so biopsychosocially. If we are being honest then we have many more associations WITH pain from what are termed BPS factors than actual data from using these factors to treat pain.

The trend of splitting pain into separates categories of Biological, psychological and social to diagnose and treat is another critique that Stilwell and Hartman highlight in their paper and neatly term a tri-chotomy. I feel Engel’s point was not that they exist distinctly as pathologies to treat but in their own right but to consider these things within the wider appreciation of the patient’s experience.

Conclusion

  • We should really see the BPS model as a CLINICAL PHILOSOPHY and way of incorporating the patient into healthcare.
  • It is intended to understand patients, their lives and contexts.
  • The biopsychosocial model COULD be used as a pain treatment model, but this is probably not how it was intended. This maybe better termed a multi dimensional pain treatment model.
  • There is not really much data on outcomes from treatment using a BPS pain model.
  • BPS factors are not simply linear treatment targets.
  • We may need to better apply the BPS model rather than move beyond it.

There has recently been some discussion around a lack of evidence for the advice to remain active during back pain. I personally believe there is a lot of value in the advice to stay active and here is why!

Firstly this HERE is from the folks over at Cochrane.

“Moderate quality evidence shows that patients with acute LBP may experience small improvements in pain relief and ability to perform everyday activities if they receive advice to stay active compared to advice to rest in bed. However, patients with sciatica experience little or no difference between the two approaches”

It is important to highlight the current state of play with regards to the evidence base, that there is MODERATE evidence of a SMALL relief for pain and this pretty much is in line with most other current recommendations/treatments that we have for back pain at this point.

Now I am going to give you a bit of my opinion as well!

Being active, IMO : ),  is NOT a treatment. Its about being a human being and getting on with your life even though you have this very normal part of the human condition…..back pain.

Its about BELIEF

Certainly we don’t want to demonise the idea of resting or taking it easy if things are too painful, that is not evidence based either, but we also know that the dominant view of back pain seems to be that we should rest it out and that for quite a few people the belief is that activity can be problematic for back pain.

This is highlighted in the two papers below that look at people's opinions around what affects pain pain in the positive AND negative. .

Darlow 2014 - Beliefs about back pain: The confluence of client, clinician and community.

Setchell 2019 What decreases low back pain? A qualitative study of patient perspectives

We also have two recent papers that form an interesting pairing when viewed together. Firstly we have a self reported perspective of what trigger back pain flares from anyone who had had back pain at any previous time point (so maybe more a test of perceptions?). Here they found that physical activities and movements dominated the vast majority of the cited reasons for flare ups

Costa 2019 - What Triggers an LBP Flare? A Content Analysis of Individuals' Perspectives

Then we have a paper that looked at the same subject but asked the people to report it in a different way (longitudinally), at 3-7 day intervals over 6 weeks, and they found that physical activities were not so related to flares of back pain.

Suri 2018 - Do Physical Activities Trigger Flare-ups During an Acute Low Back Pain Episode?

The implication might be that when we ask people to remember what triggered their back pain it is a simple 'go to' blame physical activities (especially when other things are not considered), but when the flare up is more recent, 3-7 days, and presented with different reporting options the association between physical activity and flare ups seems to decrease.

This highlights for me societal beliefs around the back and its relationships with activity and that we should be counteracting this idea in healthcare as much as possible!

Its about POSITIVE messages

Overcoming some of the negative beliefs that we have around the body, pain and physical activity should be a goal of healthcare interactions. There are SO many NEGATIVE messages that we need some positive ones too.

I think the advice to remain active is such a message. Trust your body, get on with things, you will be OK! This is a strong, simple and important message from my perspective.

There is the very real potential that there is not that much that can be done in the short term for acute back pain with advice and reassurance being pretty much all we have.

But could our short term attitudes impact on the longer term?

Short vs longer term

What we do seem to have some data on is that having low pain self efficacy, or the ability to go about our lives WITH back pain, does appear to have some relationship with outcomes of back pain in the longer term (this also seems to be apparent in other MSK conditions). In this paper HERE from Foster - 2010, we see that low pain self efficacy is related to worse disability outcomes at 6 months. The question is how do our own attitudes, and others peoples attitudes as well, towards our backs influence our behaviours? Food for though perhaps?

Key messages from advice to remain active

Hurt does not equal harm – Its OK to function with some pain, especially if it is not worsening and within tolerable levels. Pain does not give a reliable indicator of what’s happening within our bodies.

Rest is not the best treatment – Resting the back is unlikely to simply make it better and not much is likely to significantly change how the back responds in the short term.

Activity is not bad – Activity is not simply related to pain or damage. In fact limiting activities you enjoy might actually make the impact of back pain on your life worse.

Exercise dosage in rehab is still one of the biggest areas of uncertainty in clinical practice. On one hand we have modern thinking that promotes higher loading & dosage for patients and on the other hand we have the traditional model of lower load and lower dosage that has probably evolved to minimise the risk of adverse scenarios such as increased pain and decreased patient confidence in the therapist.

Currently we have some basic dosage guidelines for rehab that focus on the physical qualities that we know can be a PART of rehab. But if we take the primary target of the majority of rehab, PAIN, and if we are being honest with our current knowledge base, we don’t really have the sets and reps, or other dosage parameters that we can use to achieve a reliable outcome on our patients pain.

If we look at the current research base for rehab exercise we regularly see that the confidence intervals around the mean effect for pain cross zero meaning that the possibility of a large, small, no or even an adverse effect are all still a possibility.

Rough current physical dosage parameters

  • Endurance 12+. 2-3 sets.
  • Hypertrophy 6-12, 3-6 sets.
  • Strength 6 or less, 2-6 sets
  • Power 1-2 reps, 3-5 sets.

Unfortunately NONE of these things relate well to pain and that makes a lot of sense but also throws in some confounding. We know pain is a multi dimensional experience so for one factor to reliably relate well to pain makes little sense, but the issue is that the one factor (exercise) may also have an effect on multiple dimensions associated with pain as well, so this becomes a little confusing : ). Maybe the key here is the word reliable?

So if we want to improve these physical aspects in rehab then we do have some parameters to work with. The question is can we simply port over what we know about exercise over to rehab exercise and pain?

I don’t personally believe so.

So Lets NOT say physical parameters are unimportant but also acknowledge that expecting a traditional view of exercise and exercise dosing to have a predictable effect on pain may not be prudent or correct.

A principle often discussed in relation to exercise programing is the SAID principle, Specific Adaptation to Imposed Demand, this means that the body will always adapt to the stimulus applied. Now this is a principle that will hold true always, although HOW the body adapts is still pretty individual and often not easy to predict.  

BUT the problem is that we expect the thing we can specifically target with our current dosing knowledge, lets say strength with a rep range of 6 or under and a load that reflects that, will have a predictable and specific relationship with ANOTHER therapeutic target, PAIN.

So we are not really being specific in this case at all as there is a disconnect between the targeted physical outcome, and associated dosing parameters, and the outcome of pain.

Rather than just physical adaptations, a modern view of rehab might start to think about some of the things that exercise might affect that have a positive impact on patients. To get a specific effect from these things we might have to think about programming specifically to achieve these outcomes rather than suggest our current rehab dosing will automatically improve them.

Therapeutic exercise targets:

  • Pain (the big confounder)
  • Specific functions (physical qualities are a part of but not all of this)
  • Fear avoidance & psychological measures (proving very important in outcomes & prognosis)
  • Confidence & motivation
  • Freedom of movement/relaxation
  • Movement strategy
  • Adherence

Exercise Research

If we take recent work by O’Neill HERE that looked at acute analgesia (instant pain relief) we see that the set dosage used in this study, looking at individual responses, produced variable responses on pain, even INCREASING pain, especially if the patients baseline pain was already high. 5

Another paper HERE looks at different exercise types  effect on pain and an interesting recent paper HERE discussing mechanisms and individuality with pain responses to exercise.

Lets take a look at some exercise comparison studies where pain was part of the primary outcome measure. We see that different programs with different dosing parameters have similar outcomes.  We also have to be aware that if we are looking at the mean effect of exercise on pain this may mask the low and high responders to the differing dosage levels.

This study HERE compared low and high load exercise programs for rotator cuff tendinopathy

This study HERE compared high (deadlifts) and low load (motor control exercises) for back pain. The conclusion from this group’s research was that higher load was more applicable for those with lower pain.

This study HERE looked at different loading programs for Achilles tendinopathy

Tolerance

Exercise for pain perhaps should not always be seen as something that will reduce pain in the short term, as we might see with the concept of exercising/moving to change symptoms. Instead it might be moving with a TOLERABLE amount of pain that increases pain self efficacy and keeps the body moving during pain is an equally important scenario.

 Remember tolerance should really be PATIENT DEFINED. Exercise has the potential to increases our patients pain as well as reduce it and anyone in clinical practice who has flared a patient up with exercise knows this! The concept of optimal loading is really about tissue/physiological adaptations, but perhaps we also need to apply this optimal loading concept to pain adaptations, increases in pain, staying within current symptomatic levels and also decreases in pain.

We know that exercising WITH pain does not produce worse outcomes HERE. I have previously written about this HERE

Current state of the patient

So within the concept of tolerance we have to consider the current state of our patient with regards to dosage. It is tough to reconcile the concept of tolerance within a model of changing strength, ROM etc for me, as this does not consider things that might affect our patient’s tolerance to exercise.

Things that might affect our patients pain tolerance

  • Current/previous levels of exercising
  • Stress levels
  • Sleep behaviour
  • Anything that is associated with increased pain sensitivity to stimulus

One of my favourite clinical reasoning tools is the SIN analysis from Maitland. Lets not go too much into the Nature (type of pain), but severity (how much it currently hurts) and irritability (how long it hurts vs stimulus applied) really equal the modern concept of sensitivity. One of the key factors in ‘sensitivity’ is disproportionate stimulus and response (level and duration of pain or severity and irritability). This then would inform our clinical reasoning by reducing the stimulus or exercise dosage in line with current levels of sensitivity.

Rate of perceived exertion  (RPE)

One of the measures I use to gauge dosage is effort level via the borg scale. This is far more subjective than using sets and reps in a traditional fixed sense and remember pain is a pretty subjective experience!

Borg

One of the hardest things is to keep our exercise dosing within tolerable limits in the beginning, or dose titration, when we have limited or no knowledge of our patients response. I tend to use a pain VAS (yes I know it’s a crap measure!) vs RPE. So if VAS is high then I make sure effort level is lower. I tend to find this keeps responses within tolerable limits, but of course not always.

I call this the rule of 10, so both numbers add up to…..you guessed it 10! Example would be if pain is a VAS of 7 then I would keep RPE to a 3. If pain was low, say 3 on the VAS then I would maybe take the RPE up to 7.

Screen Shot 2018 03 03 At 13.01.03

But if you feel your patient is highly stressed, fearful or under slept then any of these things might have to be factored in to the dosage thought process if you want to keep the dosage within a tolerable response.

Monitor response to dose!

The most important thing is to monitor the response to the dose. Lets say we play it sensible and keep RPE low because of a higher VAS, and the patient finds it easily tolerable well then we know we can push it a bit harder and load em up.  If we get an adverse reaction even though we kept the effort or load down then we may have to drop it even further. 

Screen Shot 2019 04 23 At 17.24.27

Be OK in the grey

We will never really know what the dosage should be until we actually apply the dosage and then monitor the response. So its OK not know what’s going to happen, just use your ‘loaf of bread (head)’ and be OK with sometimes getting it wrong. Don’t panic, just adjust the dosage and educate that this is normal, it’s definitely not an exact science and often trial and error.

People will always want some kind of directions

One of the issues can be that people want to know how much to do and have some kind of direction. This usually end ups as 3x10 once a day (be honest, you have said this!) and I can understand why this is given as it is really quite difficult to be more specific. This is why explaining that it is a bit of trial and error with some good reasoning and also helping the patient to understand what a flair up might be/mean is important.

Conclusion

  • We currently don’t have an exercise dosage for pain
  • Pain does not respond consistently to current dosing parameters
  • There are other therapeutic targets apart from physical aspects
  • Exercise data does not support current dosing ideas in rehab
  • Think about the current state of the patient with regards to dosing levels
  • Use clinical reasoning
  • Be OK in the grey

This is the first in the series of a few mini/micro blogs of about 500 words (famous last words) and in this first one I wanted to kick off by talking about making movement and exercise meaningful.

This is a term that is being banded about more and more in rehab but still has the feel of a buzzword rather than something well defined.

So what the hell does it mean……..

Firstly lets separate the idea of meaningful from what many describe as ‘functional’. Meaningful exercise does not have to look or recreate movements, mechanics or even physical qualities that people may need.

Lets PLEASE not go down that road again. PLEASE.

Something being meaningful is much more about the WHY behind doing it or the meaning it holds (as the title suggests : )

Too often it’s the therapists why, but it really should be the PERSON doing it’s WHY! As therapists we often have a bunch of why’s, ROM, strength and other outcome measures that are often not really very well aligned with the patients WHY.

 Put yourself in the other person’s boots - why am I actually doing this? And ultimately, by doing it, how can it help me? We pretty much do this calculation for a lot of things in life.

What makes this person tick when it comes to moving…..

Now it could be argued getting out of pain should be a big enough WHY. But when it comes to exercise, especially for rehab, we know that is not enough from the data around adherence (commitment is a much better word btw) and this also extends to adherence to drugs and general health advice.

So really we have to consider HOW to get to peoples WHY. Well I think this really has to come from HOW we as HCPs interact with our patients. Without knowing what they want to achieve or their valued activities it is very hard to create a real relevance, MEANING, or as I like to call it a ‘finding a HOOK’.

Essentially any movement could be framed as being meaningful with the right explanation and the link to a motivating and meaningful goal. Learning more about sets and reps might not improve your outcomes!
Recent research has shown some very good effect sizes for using goal-setting interventions in back pain *HERE*

Here is real life an example from a course I gave last weekend in Melbourne. An attendee was discussing Jiu Jitsu training. He said 50% of the reason he goes is for the social aspect. Firstly imagine the impact firstly of NOT going on life (more than just pain!), secondly the motivation to get BACK to going.  

Rehab should tap into the meaning to that person’s life and what they gain from doing it, not just doing an exercise because someone told me too.

The problem has been one of therapeutic exercise about finding an exercise to fix the problem, such as VMO firing for knee pain or core firing for back pain. Potentially we could call this targeting the muscle but missing the person.  So we are now talking about movements not muscles, but how about talking people? Getting people moving perhaps needs a GOAL, a HOOK, a MEANING?

Maybe one of the benefits of working with a sporting or active population is that the WHY is often clear-cut, sometimes people can even be over motivated.  The meaning is built in to the process.

The challenge with persisting pain maybe the motivation is not so clear cut, we need to dig a bit deeper as pain can narrowed peoples focus and reduced the amount of options they feel they have available to lead a full life.  This is where ‘finding a hook’ can be really important I feel.

Meaningful movement tips

  • Listen and ‘find the hook’
  • Take time to explain WHY moving will help
  • Relate the explanations back to the ‘hook’
  • Spend time building confidence and positive movement experiences
  • Think person rather than exercise

P.s I was close – 650 words ; )

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

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

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

Research

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

Smith et al looked at this question in 2017.

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

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

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

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

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

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

Benefits

The benefits can be both physical AND psychological.

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

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

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

Clinical application

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

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

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

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

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

Screen Shot 2019 01 21 At 13.16.00

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

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

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

Pain is not the only issue

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

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

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

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

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

What can we do?

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

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

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

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

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

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

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

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

Education

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

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

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

Where you start is not where you have to finish

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

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

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

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

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

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

What if it all goes wrong???

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

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

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

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

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

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

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

Key points

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