Whilst Exercise CAN be a wonderful tool to use during the rehab process we must remember it is not a stick on, we can’t just fire and forget or plug and play and for every success there are also failures. There just is not such a thing as a magic bullet in rehab.

Sorry about dat!

Before we get to the analogy stuff we might want to first ask WHY we might want to help people understand what is happening to their bodies and how ANALOGY can help with that?

In some cases it can be much more about HOW we do things rather than WHAT we actually do.

WHY?

 

For all the studies we have extolling the virtues of exercise, although make sure you consider the effects sizes, an important question to ask is how generalisable are they to the real world? If I was being all sciencey and shit we could term this the external validity of a study.

Why might these studies lack external validity? In the tightly controlled world of the scientific study participants probably tend to adhere a little bit more to the protocol laid out than they do on their own, otherwise studies would never get finished. Researchers can also employ things like intention to treat analysis (ITT) that are designed to scientifically smooth out things like dropouts and missing data.

Out in the real world when we throw in the complications of life, exercises, however evidence based, in some cases can tend to fall by the wayside. This is a problem with human beings they don’t always just fit neatly into EBM boxes. In fact they can render all the science a touch redundant through things like their beliefs, preferences and lifestyles.

Differences in the definition of adherence used, measurement and estimative of how many patients do not comply with their prescribed exercises vary, but evidence converge on a figure of 50% or higher”  *HERE*

We can all agree that that is a pretty high percentage of shit that is not getting done! What we CAN say is exercise is likely to infer some benefits IF IT GETS DONE! SO how do we go about doing that? And that of course is the $1 million question!

Barriers

 

This is an awesome piece of research that looks at barriers to people adhering to therapeutic exercise programs *HERE* . One of the major reasons that people don’t adhere, or a much better term to use, commit, to exercises or exercise programs when they have pain is the fear of INCREASING that pain

Here is a slide from my recent presentation at the San Diego pain summit.

Now this is completely understandable. Our fears drive our behaviours, so if I am scared of making the problem worse that may drive me to, well, simply not do it. It may then be key to help people make sense of what they feel and how they can manage that.

For a lot of people the science of both pain and exercise are pretty alien subjects. What’s the difference between exercise induced discomfort and actual pain? For someone who has never experienced the former then perhaps not a lot! I have been pretty sore from training before and found some activities really quite painful.

The likelihood of getting some DOMS from prescribed exercises for someone with no real history of exercise and a low ‘zone of homeostasis’ could be pretty high, so it is vital we can put these sensations into perspective, allay fears and help people to SELF manage their rehab.

A useful phrase I picked up a long time ago is “go to the P in Pain not the Y in Agony” which is a really nice way to say go into some discomfort, which of course is normal, but try to avoid rip roaring pain. We still don’t know if painful exercise is actually bad for outcomes but certainly it may dissuade someone from carrying on with it.

Things can and will go wrong and set backs are normal. These setbacks can be influenced by a whole bunch of factors including stress and lifestyle that can negatively affect recovery, and no rehab plan will ever follow a linear upwards trajectory, especially if we are attempting to push the envelope and ‘vaccinate’ against future reoccurrences.

*HERE* we see psychological stress actually impairs recovery from exercise so we must be mindful of this. It may not be the intensity of the sensation that some struggle with but how LONG it goes on for. Desired adaptations such as strength might also be affected by stress too. *HERE*

Pain is often accompanied by worry and stress and could be both a cause and an effect of the current state of the individual. This is why we must be aware that our rehab programs carry the possibility that they could cause an adverse reaction in times of stress.

Analogy

 

Equipping people with the knowledge to both understand AND address these factors is vital for self-efficacy, another key player in the COMMITMENT to a rehab program.

Analogy is a fantastic way of helping people understand subjects that they have very little background in and for many folk both pain and exercise fall neatly into this bracket. One of my favourite analogies for exercise discomfort AND pain is SUNBURN. The reason for this is it (hopefully) places the pain or discomfort into perspective and allows it to be seen as a temporary thing and one that can be easily modified.

Rather than viewing an exercise as simply being WRONG, a comparison to sunburn allows it to be viewed more as an issue with the dosage applied and the bodies response. We generally don’t see the sun as a BAD thing, of course some do but we could put that on the spectrum of fear avoidance! Most people will get sunburn at some point in their lives and just see it is a little bit to much of a GOOD thing!

So what do we do if we overdose on the sun? Generally just ALTER the dosage, simply get less sun the next day by sitting under the umbrella or covering up my burnt bits with a towel, we may have just tried to rush the natural adaptation.

The negative physical reaction is only temporary, often just like the pain triggered from overdosing on exercise, the angry red skin and spiky feeling when in the shower will of course go away if I just alter the dose and let nature run its course. What we do see if dosed correctly is a slow natural adaptation that leaves us positively glowing.

What do you usually do next after burning? Well just be more careful when re-exposing yourself. Spend less time in the sun or apply a higher factor. We don’t freak out, in fact often we berate ourselves for being stupid! We know this happens after all. We can do the same with our exercises, just take a little time off or reduce the amount we do before building up again.

Why might we overdose? Perhaps we have been previously been under dosed. Just like coming of a long sunless winter, not having exercised for while probably reduces the amount I can tolerate and hence potential adverse reactions. This may explain why just a few sets could leave me pretty sore.

If we have previously been good at a sport we tend to be able to play at a much higher intensity than perhaps we can CURRENTLY handle. In fact being good at something could actually be a risk factor for some! Our skill level may far out weigh our tolerance for the level of intensity we can play at. The same is true of tanning, we tend to remember the lazy long days at the END of a holiday applying Hawaiian tropic rather than the blotchy days at the beginning on factor 30.

Some people can exercise till the cows come home and never feel a thing, a bit like those really annoying people who go an amazing shade of brown by just looking at the sun! We maybe predisposed genetically to being LESS tolerant to physical activity. We see discussion of the role of genetics in sensitivity *HERE*

People with fair skin and red hair are often less tolerant of the sun by nature of their Celtic heritage and those of Mediterranean or African origin far better genetically equipped to handle a greater dosage of the sun.

Now no analogy is free from a negative misinterpretation. Whilst the sun could be seen as having dangerous consequences such as skin cancer from extreme overdosing we also see problems with under dosing such as depression from reduced serotonin. Like all things it has an OPTIMAL dosage, after all too much or little water or oxygen can also kill you too!

How can we alter the dosage?

  • Frequency – How often. More is not always better.
  • Intensity – How heavy or how fast.
  • Volume - How much. Sets, reps and rest.

Read more here about dosage *HERE*

Take Homes

 

 

  • People don't just fit neatly into science
  • Increasing pain is a real worry with rehab exercises
  • Arm people with information about what to expect and what they are feeling
  • Be smart in the first place – Less can be more.
  • Self management. Give them the tools to manage the dosage.
  • Give support. If it does go wrong to help people get back on track

Well, like most things in the world of health there is NEVER a simple answer! Although I am sure you have seen a few articles on social media proclaiming the 5 worst exercises EVER but lets bit a little more analytical.....

We probably have TWO questions here.

Firstly is there even such a thing as a BAD exercise? And is there such a thing as a BAD movement? I ask this second question because it can be suggested an exercise is bad because it takes us into a movement or range of movement (ROM) that is deemed bad.

Lets get after the first one first!

YES I think there is such a thing as a bad exercise! And there are a number of reasons why an exercise may qualify for the status of BAD. But, and it’s a big but, exercises on their own are generally not inherently bad, it’s more the application of those exercises to a specific person or scenario that could be BAD.

One of the major reasons is if the exercise selected has not been properly reasoned with the client or patient in mind. As humans we are driven by biases, conscious or subconscious, and this includes exercise too. Sure we all have our go to exercises we think are beneficial but if EVERYBODY gets the same program then perhaps the individual has not been properly considered.

We can always perform some mental gymnastics and say well EVERYBODY needs to be stronger, move in a specific way or needs to activate a specific muscle so a generic program can be justified, but with the myriad of different goals, injuries, functions and preferences that exist of I find it hard to believe that everyone should get the same exercises all the time.

Another biggie would be if an exercise were just down right dangerous. Balancing on a swiss ball with 100kgs overhead just does not seem particularly sensible to me. The risk reward equation does not really stack up here however ‘functional’ you believe it is. YouTube is littered with dangerous exercises and fails; you can have hours of fun!

BAD

 

I think we can sum up the BAD use of an exercise into three main categories:

BAD timing

Plyometric’s for a sensitive reactive tendinopathy might have a high potential to cause irritation and zig zag hops early in the rehab process for an ACLR both spring to mind. Both of these exercises might be necessary during rehab but the timing might be key.

An advanced balance exercise might be a BAD idea for someone with low movement confidence or HITT exercise for someone with very low fitness or contraindications but this does not simply make them BAD forms of exercise.

A BAD choice

Someone might just HATE a particular exercise and may not enjoy doing it or even want to do it. Both of these elements could affect the outcome through low compliance or lack of effort.

A BAD stimulus

An exercise might not be challenging enough or is far too challenging. Now, how much adaptation required for a positive outcome is up for debate but if the stimulus is just to low then you are not likely to get much, and this could be for either skill or strength. Equally the stimulus could be TOO much and cause irritation. Certain joint positions or ROM’s might also irritate particular injuries, so staying away from these when sensitive is probably a good idea.

WHY?

 

If you BELIEVE an exercise to be inherently BAD then ask yourself, WHY is it bad?

Because some dude on the internet said so?

Because there is some specific data or link to high prevalence of injury?

Because I don’t like it?

We should always question our own beliefs the most. Often critical thinking is mainly reserved for other peoples beliefs though.

MOVEMENT

 

Lets have a look at the second example.

Is there such a thing as a BAD movement?

What a question! Now this is far to big a debate to get into in this short blog but certainly the idea of moving in the wrong way on a MINUTE level is not really supported by the available data.

If you took repeated measures of the SAME movement by the SAME person you would be likely to see subtle or even major differences in the way it is performed. The same is true when you look at two DIFFERENT people move, they in all likely hood will have very different strategies. So the same person will move differently each time and differently from someone else moving differently each time. This means it is pretty complicated shizzle!

What’s the wrong strategy? Who knows! Again if you believe it is bad ask yourself why, does it stand up to scrutiny?

As I said at the beginning it could be suggested an exercise is BAD because it takes us into a too much of a movement deemed to BE bad such as lumbar flexion or knee valgus. A crunch would be a good example of this line of thinking with the amount of lumbar flexion it involves and it has been suggested in some circles it would be best avoided.

Movement of course is only one small part of the equation however; we also have the force generated by how quickly we go through a movement or when an external load is added in. Now I am no biomechanical genius, far from it in fact, but essentially we could go to potentially ‘problematic’ joint ranges very slowly and pose much less danger to the tissue than if moving quickly, so it is not as simple as just the movement or ROM itself.

A question of timing?

 

Again it might all come down to a question of timing? Perhaps we could say that avoidance of a movement that is irritating in the short term COULD be a good thing.

Lets take the example of lumbar flexion, it is part of the rich tapestry of human movement available and somewhere most of us go quite regularly in our daily activities, so we probably WOULD want to get back to going there at some point and build up some tolerance. In the short term avoiding pissing off my back is smart but continuing to avoid flexion over the LONGER term could become an issue if I was to become sensitive, potentially physically and/or psychologically, to a normal movement under normal loads.

We could summarise this simply as the movement itself is not inherently BAD but in SOME contexts, such as when sensitive or under high loads, could be problematic.

Looking at kinematic data from serious injuries such as ACL ruptures highlights this. ACL ruptures tend to happen on a single leg, at high speed with a shallow angle of knee flexion and often the cherry on top is some knee valgus thrown in too!

So knee valgus on its own may not be as likely to be damaging in another context such as a squat or a lateral lunge for example. I don’t know the prevalence of ACL damage squatting but I doubt it is that high.

Please don’t read this as “Go into knee valgus with 200kg on your back it does not matter” as….well….I didn’t say that! The higher the load the greater the force, this highlights the two-sided nature of the movement & force equation. But still, most sports people don’t rupture their ACL in the weights room!

Adaptation

 

Another question is, is someone adapted to these types of movements? If you took a snapshot of Djokovic on the tennis court you might wince at the joint positions he gets into under really HIGH loads. A lesser player may get into SOME similar positions but the games are much less likely to be as intense or long.

djokicic

Why does he not suffer constant knee injuries? Probably because he is well ADAPTED to these movements. The amount he loads into these positions could be PROTECTIVE as we are biological creatures NOT mechanical ones.

The same might be true of some dude in the gym who performs really shitty deadlifts. You have seen him too right? Well why is he not always injured? Maybe because by training them in “shitty” he has adapted to them. Could it be problematic at the same loads for a newbie? Who knows, but potentially the risk becomes greater.

So essentially it comes down to the APPROPRIATNESS of the movement/exercise to the person and their current state not the movement/exercise itself. Take away these movements and the ability to get into these joint positions and it maybe the difference between goodness and greatness!

Take homes

 

• Exercises can be BAD!
• Not inherently but in their application
• Could be bad timing, a bad choice or a bad stimulus
• If you believe it is bad ask yourself WHY?
• Is movement BAD is a big question!
• Movement is VARIABLE – So what is bad?
• Not just movement BUT also the FORCE generated.
• We may need to AVOID a movement sometimes
• A movement could be worse in some contexts
• Humans adapt and high loads COULD be protective in some movements

A question I often ponder is - "Do we really know the mechanisms behind how exercise might help with pain?" And the honest answer is I don't think we really do!

There is a whole bunch of stuff to consider and pontificate over but actual definitive answers appear to be scarce. We have tons of modern research and commentary on the psychology and neurobiology of pain but our ideas of how this applies to exercise seems to have remained fairly static.

Article at a glance.

  • We are mostly unsure of exactly HOW exercise can help for pain
  • Part or all of this may not be specific to physical factors
  • WHY people get better is not always clear when thinking critically
  • We can under consider the non specific effects of exercise
  • These include altering perceptions, locus of control, self efficacy and predicted expectations of outcome
  • Non specific effects CAN affect more specific physical effects
  • Your bias does NOT predict potential non specific effects
  • There are very REAL neurobiological effects from non specific aspects on pain
  • Collaboration, education and interaction may ALL help elicit non specific effects.

This paper HERE looks at whether exercise ACTUALLY helps, and it can, but HOW is a completely different question that is still mostly unclear.

Exercise in a therapeutic setting is still prescribed in very similar ways to how it is implemented in a non-therapeutic settings, in terms of sets & rep ranges, even though the therapeutic parameters or mechanisms of action maybe quite different and currently remain under explored. I have previously discussed the subject of dosing HERE.

I am increasingly drawn to the concept that a fair proportion of the effects of exercise may NOT be specifically physical in nature. We may not be able to attribute them solely to increasing range of movement, stability, strength, posture or whatever else we choose to measure and then attempt to effect. This article HERE explores some non specific effects.

What makes me think this? Well can we reliably, hand on heart, say that any of these things NEED to change for people to get better? Now before anybody gets their panties in a wad, like all things this probably lies on a spectrum. Some people may need and get a purely physical response, for others the benefit maybe entirely non physical. It is worth reminding ourselves that if we are truly thinking critically, reflecting on ones self being tough to do of course, that any measures that are taken post treatment do not automatically validate the potential deficit we targeted as being the sole cause of changes in how someone feels. ROM, strength or motor control all may be restored once pain subsides rather than being the actual CAUSE of the pain subsiding.

HERE we see a systematic review regarding lower back pain, with changes in strength, flexibility etc appearing to have little correlation with a successful outcome.

We see the same for many of the things that we can assess and measure.

Kinematics - HERE

Muscle firing - HERE

Range of movement - HERE

So why is this? Could it be that there are things that we don’t generally measure? Certainly we cannot really measure in day-to-day practice changes in local physiology or what happens up top cortically and these could almost certainly play a part in pain and its subsidence. We should also consider, however, how someone actually feels about what we are doing TO them or WITH them and how this affects the outcome.

Learning lessons from Manual therapy

 

The current understanding of the mechanisms behind manual therapy have not really aligned with what they were once thought to be since they have been explored in a research setting, even though they DO appear to have an affect on pain. We can take a leaf out of the book of critical thinkers on this subject, such as Zusman HERE and Bialosky HERE, who critiqued the traditional biomechanical explanations and offered some alternative perspectives for WHY these techniques may have a positive effect. Many of these factors will of course be present across lots of interventions, INCLUDING exercise.

So what are these non-specific effects?

 

It would be good to point out here that non specific means that they are not specific to the ACTUAL intervention itself, not that they are in NO WAY specific! They could be specific to someone’s perception of where they are, who they are with or what is being done with them and would include the relevance of the intervention and how that relates to their belief structure. It could be someone’s predicted expectation of the outcome that is the driving factor in their recovery. This paper HERE explores more of the contextual effects in the therapeutic encounter.

The predicted outcome does seem to be a HUGE factor in the success of a treatment, in part because it may affect the process of that treatment and this would be no different for ANY intervention, exercise included. If someone has had a previous failed experience with exercise, and this could be unrelated to pain, this might affect their perception of your chosen intervention REGARDLESS of the effectiveness shown by all those research papers you have diligently read! This was seen in a recent paper on a comparison rotator cuff exercises HERE, with the closed chain exercise group suffering with dropouts because people felt these exercises were not specific enough. Both of these papers look at predicted expectations.HERE & HERE.

We should also not take a binary view of non specific OR specific effects but realise that these non-specific effects could have a large impact on the specific effects. Lets say I don’t believe that the exercises that I have been given will make me better. I might be less likely to actually do them and therefore would not derive the physical benefit. Even away from the therapeutic use of exercise, psychological factors appear important. HERE we see that exercise works better if you believe it will. and HERE we see reframing physical activity positively had an effect on health.

It could be that someone simply has a better perception of themselves and their capabilities. This means that they view what they are doing more positively and hence they may do more of it. These perceptual factors might influence how incoming sensory information is viewed, so what was previously viewed as threatening is now viewed in a less threatening light and decreasing the need for protective mechanisms such as pain.

We might find that someone’s locus of control changes, moving from being externally focused, a sense of having little control over their current situation including pain levels, to being more internally focused and able to influence what is happening to them. This could also lead to increased self-efficacy meaning that completing tasks and reaching goals is now perceived as being within someone’s reach. All of these factors could increase analgesia acutely through activation of descending inhibitory mechanisms, eloquently described as the drug cabinet in the brain by David Butler, and longer term through changes in perception or prediction of threat or harm.

Bias

 

An important point to keep in mind is that just because a certain type of exercise, or any intervention for that matter, fits your biases and it seems likely it COULD give a large slug of the psychological good stuff does not mean it WILL. The recipient holds the expectations here not the giver, meaning that the person actually doing it could regard the favourite exercise you use as the exact OPPOSITE to you do. Non specific effects are not automatic, however much you believe in them or hope that they will happen. So could strength training increase someone’s perception of their robustness and sense of strength? Absolutely. But this is certainly not automatic and guaranteed; it would depend on the belief structure and perceived relevance of the person doing it! We must also consider the potential for negative non specific effects too.

How might we get some of these non specific effects from exercise?

 

Firstly how we explain the relevance to people and the effect it could have may go a long way to improving outcome. Coupling this with someone’s current perception, belief structure and previous experience may also have positive benefits by addressing negative elements that could alter the acute perceptual response, such as pain increasing, if someone believed exercise was actually going to make them WORSE which can be a very REAL fear.

If something has not previously worked, why would it work this time? Even if it is the most evidence based option. Using something different or exploring why it could work or perhaps did not work in more detail may have an effect on expectations and compliance. Education should not just be seen as something to use with pain in my opinion. This may extend to WHY exercise could be more more relevant than a passive or surgical intervention that is currently perceived as the gold standard or preferred course of action by the recipient. This process may or may NOT be required in exactly the same way that education about pain is not always necessary but to not CONSIDER it EVER is quite another matter entirely.

Preference may also play a huge part. We could say swimming was the BEST way to get fit and the most evidenced course of action, but if someone does not like swimming or has limited access to a pool, the BEST could become the WORST if we have not appreciated the person doing it!

Thinking about the person doing the exercise not just the component body part such as a muscle or tendon could be one of the best ways to integrate some of the lessons we have learned from subjects such as pain science when thinking about therapeutic exercise.

Take homes

 

  • We are mostly unsure of exactly HOW exercise can help for pain
  • Part or all of this may not be specific to physical factors
  • WHY people get better is not always clear when thinking critically
  • We can under consider the non specific effects of exercise
  • These include altering perceptions, locus of control, self efficacy and predicted expectations of outcome
  • Non specific effects can affect more specific physical effects
  • Your bias does NOT predict potential non specific effects
  • There are very real neurobiological effects from non specific aspects on pain
  • Collaboration, education and interaction may all help elicit non specific effects.

 

 

DOSAGE! It is a subject that is not often discussed but may make a HUGE difference in the success of using movement and exercise during rehab. Perhaps MORE than the exercise itself!

Article at a glance

 

  • Dosage is a big deal
  • Intensity, volume and frequency all affect dosage.
  • Both over and under dosing are issues.
  • Try to find minimal effective dose. It can always be progressed.
  • Shared decision making helps find tolerable/effective dose.
  • Define what the right dosage should feel like.
  • Give a regression and progression.
  • Offer support to manage dosage.

 

Doctor holding heap of drugs in a hand

What is dosage?

 

Simply put, it is intensity, volume and frequency!

Intensity will be affected by the amount of weight we used or how fast we move the weight; both will affect the amount of force applied to a tissue and this is simply expressed as F = MA. The individual measure of intensity will be moderated by someone’s current tolerance.

The amount of repetitions and sets defines the volume. This can be manipulated and will have an affect on the overall overload.

Frequency is another aspect. You could have the most applicable exercise but if we do it 10 times a day (you have all had THAT person) that could be TOO MUCH of a good thing. So an exercise focused on changes in movement skill or quality (whatever that is!) could be done MORE frequently potentially than an exercise focusing on tissue load where you need time for POSITIVE adaptation to occur at a cellular level.

We can manipulate all three to achieve the desired response. Much more than 3 sets of 10 I am sure you will agree! The reasoning process behind movement/exercise is as important as any other aspect of rehab but not always considered.

This could be increasing intensity and decreasing volume, or increasing volume while decreasing intensity, or leaving those the same and changing frequency. There are a whole bunch of ways that dosage can be manipulated for large or smaller changes in overload.

Smaller changes can be REALLY important to get positive affects as large changes in dosage could have the opposite negative outcome. I have ballsed up a few times by changing the intensity in terms of load and not decreasing volume and have had negative outcomes.

Under dosing

 

If we under dose then potentially we will get no real adaptation. If you are looking for a change in whatever targeted aspect you are aiming for, lets say strength or load tolerance, if your manipulation of the variables is not on point then you won’t get much adaptation.

The caveat here is maybe there is no need to change the targeted aspect. Many studies have shown NO change in kinematics, posture, ROM or strength but a change in pain.

The caveat to the caveat might be that we don’t often measure the long term trajectory of injuries meaning that although we have a short term successful outcome in changes in pain that show up in studies many people often still suffer longer term with reoccurrence of an injury. This is different to chronicity because it may not be continuous and hence why it is often hard to simply define painful problems as acute or chronic. Perhaps we need some adaptation to affect these things longer term, but I am just thinking out loud.

Perhaps we are altering things we don’t or cannot measure such as local physiology, cellular adaptations, neurophysiology (nociceptive apparatus) or central changes such as can happen in the cortex with sensory and motor representations.

Under dosing could be frustrating as it is less likely to have an effect on the problem and not speed up (if we ever do!) the process of feeling better. This is potentially why we have seen a rise in the use of strength training as with a greater load we are less likely to under dose.

Over dosing

 

The opposite end of spectrum is giving too great a dose. To a sensitized system this could most definitely be an issue and cause an adverse response and could be why many therapeutic exercises are quite low in the overload stakes using minimal body weight or therabands.

Making someone’s pain worse can have a real effect on how they perceive the care you are giving, your competence and therefore the therapeutic relationship and trust bond. It is also really quite frustrating for them, people want to be able to get back to the activities they enjoy, they want hope and this is often fostered by progression.

Unfortunately it is very difficult to gauge what someone’s response maybe. Much like pain itself this will be dependent on many factors occurring in someone’s life at the this precise moment in time from stress to sleep to their emotional state.

Everybody has managed to make someone worse with a really minimal dose and also thought they have may have crossed the line with too great a dosage to find out that the person handled it just fine.

In reality we never really know where that line is!

Minimal effective dose

 

A minimal effective dose simply is trying to find a dosage that you think will cause an overload on whatever you are trying to effect but minimizes any potential for side effects. Remember you can always incrementally increase or decrease dosage later.

20 ibuprofen would get rid of your headache but would also expose us to other potential complications. So 2 tablets, or 200mg, is deemed a dosage that is effective but reduces complications.

Unfortunately the biochemistry of medication seems to be more generalizable across the population OR has been more widely studied with large clinical trials. Exercise dosage is still something that needs to be better quantified in the research base.

We could do this through looking at the person’s previous history such as chronicity or frequency of the same injury, the amount of a stimulus that may aggravate their problem such as time or load and then how long it takes to settle down after it rears its ugly head. If you flair your back up when picking up a biro and it takes 3 days to calm down then the dosage should reflect this, especially initially.

We can then adapt the intensity it terms of weight, speed or reps or the frequency of how often they do the exercise(s).

How can we make our dosing more effective?

 

Firstly we should think about shared decision making and discussing the potential outcomes of the variables being manipulated.

This helps people be better informed, and able to rationalize, what is happening to them especially if we explain WHY they may be feeling what they are feeling and what this ACTUALLY means for them. This hopefully avoids any uncertainty to be filled in by misinformation or investigation on the internet.

Explain that rehab is not a linear process and we don’t always know what the correct dosage should always be, hence why they need to be an active participant in the process.

All of this hopefully adds up to a greater internal locus of control.

Actually perform the dosage, or new dosage, with them and find out how it feels and how comfortable they are with it. If we are adapting a dosage then ask if they feel more comfortable increasing intensity, volume or frequency. Sometimes they maybe more willing to add more load than more reps or sets and sometimes the other way around, maybe they are happy now to do them daily rather than every other day.

Secondly the ability to independently manipulate dosage can be a really big deal. Often there are weeks between contacts so a dosage that is ineffective or aggravating could go unchecked for quite a while.

Here are my 5A's of self management.

5as

Even in the face of increasing pain many folk STILL keep going with their exercises. They blindly believe that it will still make them better, hence if we arm people with some knowledge about what they should be feeling they could limit or adapt what they are doing and minimizing adverse effects.

Part of any exercise prescription (I hate THAT word BTW in relation to exercise) should be the ability to regress or progress based on an agreed level of discomfort, e.g. exercise soreness or actual pain. This could be based on a VAS score or some other personal measure.

If an exercise really hurts, both immediately or 24hr response, could you regress to an isometric? Or if already an isometric could you regress to a lower level of effort or frequency?

If it is not having much of an overload, perhaps gauged by muscle soreness, then could you add in more weight or reps and sets or how often it is performed? Again this offers people a greater internal locus of control.

Offering people support BETWEEN appointments could also be another way to better manage dosage and done via phone or email.

Conclusion

 

  • Dosage is a big deal
  • Intensity, volume and frequency all affect dosage.
  • Both over and under dosing are issues.
  • Try to find minimal effective dose. It can always be progressed.
  • Shared decision making helps find tolerable/effective dose.
  • Define what the right dosage should feel like.
  • Give a regression and progression.
  • Offer support to manage dosage.

 

 

 

 

 

 

Please click on the large image of all the cards below to download the FREE pain flash cards. You will be redirected to a drop box link containing all 6.

This is a resource aimed at anyone who has an interest in pain and some of the science (what we have looked at so far!) behind the way it works.

Please feel free to share with anyone who you think would benefit.

Subjects covered:

  • Pain
  • Pain & stress
  • Nociception
  • Central sensitisation
  • Descending inhibition
  • Peripheral inhibition

Each one contains approx 500 words on each subject split into:

  • Complex bit
  • Simple bit
  • Simple story to use
  • Reading list

pain-cards-montage

Why do I still hurt?

Why is it not going away this time?

Why am I so sensitive?

Why does it keep happening?

why

People want answers

 

These are all questions that people regularly ask regarding their pain and injuries and they want to know a reason why. The bottom line is people want answers and in the absence of satisfactory answers will often jump to the worst possible conclusion.

Perhaps questions like these are indicators for the need for a different type of explanation beyond the pathoanatomical model?

Uncertainty

 

Uncertainty can be present in both acute and chronic pain. Mishel first proposed this in the “theory of uncertainty of illness” HERE. Uncertainty is a cognitive stressor and can be at its height during the diagnosis phase. This was defined as “an inability to determine illness related events”, the sufferer is unable to estimate what the issue is and unable to accurately predict what the outcome will be.

Mishel outlined 3 major points in the “theory of uncertainty of illness”:

    1. Antecedents of uncertainty- Things that occur previously to the illness. These can affect the patient's thinking such as pain, prior experiences and perception.
    2. Appraisal of uncertainty- Procedure of placing a value on the uncertain situation.
    3. Coping with uncertainty- Activities that are used in dealing with uncertainty.

 

Uncertainty has been linked with increased pain sensitivity, increased psychological distress and maladaptive coping HERE. Higher levels of disability and depression were found in LBP patients who felt their pain was due to diagnostic uncertainty HEREHERE we see experimental data on uncertainty having an effect on the pain people experience.

Getting an answer

 

The perception can often be an answer or a diagnosis hopefully provides us with a pathway of what to do next and a fix, solution or a cure. Answers are often quite abundant, they are given out by all manner of therapists, trainers, medical doctors and of course everybody’s favorite doctor….doctor google. A key aspect in the expectation of recovery, a very important factor in actual recovery HERE, is a diagnosis and part of this includes diagnostic imaging HERE. Unfortunately we also know that it is not as simple as that HERE.

Without a clear diagnosis we may see expectations of recovery also diminish. We do as well as we think we will do! HERE.

Increasing stress and pain have a negative relationship, uncertainty can increases psychological stress and therefore potentially leads to increased pain levels too. Higher levels of acute pain have been cited as a risk factor for the development of chronic pain HERE.

Unfortunately there is lots we still don’t know and may never do, many painful situations have an unclear cause and diagnosis, and symptoms can be unpredictable.

Potentially this is why we have so many theories and syndromes that try and fill the gaps by supplying us with information about our postures being ‘bad’, joints being out of place or having dysfunctional movement patterns. In situations where people demand answers it is easy to reel off a basic, simple but often untrue explanations. Read more HERE and HERE.  Although uncertainty maybe reduced it can be replaced by negative beliefs that cause more stress or negatively modify behaviours such as the avoidance of movement or reliance on being ‘put back into place’ by their therapist.

Maybe the answer, in part, with the scenarios that arise from these types of questions lies in understanding more about the myriad of changes that can occur within the systems that are involved with the experience of pain itself. In the absence of a plausible explanation the myths that pervade about the human body can continue to flourish and fill the void that people desperately want filled. The premise of pain education in essence is separating the pain someone experiences from the state of their bodies and not simply being reflective of the state of the tissue. Pain not being a measure of increasing harm.

This reconceptualization of what the problem might be really is a tough thing to be able to do. The question is are simple metaphors enough? How far does our knowledge have to go to really help people?

That of course may depend on the person, their education level and how much they really want to know. For some the science may baffle and bemuse and be counter productive as we often see in response to scan reports. Others may need the level of detail to high to make it believable and plausible. Finding the balance between being potentially too superficial and metaphorical and too heavy and science based is important but tough.

Whatever the route you take it is unlikely to be quick or simple with epiphanies all over the place.

Einstein told us “if you can’t explain it simply you don’t know it well enough” but also left us with “ make it things as simple as possible but no simpler”. Maybe these quotes sums up explaining pain quite well. Sometimes it needs to be simple and other times complex things must remain complex.

einstein

Perhaps we need layers to how we explain complex things like pain. Superficial metaphors and stories to help with concepts and backed up by a deeper knowledge of changes that can occur at multiple levels from the periphery, dorsal horn, spinal cord and up in the brain too.

Maybe this is why we have more recent problems with some of the issues surrounding the idea, or mantra as some have described it, that ‘pain is in the brain’ and the negative influence that that can have if the recipient misconstrues it as a purely psychological issue HERE. There are very physical and biochemical changes that can occur and discussing these as well as psychological factors might help fulfill some of the more uncertain aspects.

Armed with knowledge and how to get it across

 

The key to reassurance, a most powerful pain killer –Gifford, and that there really is nothing serious maybe the ability to perform a good clinical exam and being able to speak from a position of confidence that everything is likely to be ok.

Louw et al discuss the need for a good clinical exam in their recent paper HERE. Making sure that this base is covered before moving and finding out if someone is “interested in finding out why they still hurt”.

We have to appreciate that people may not need or want to know more about why they hurt. This aspect should not be seen as standalone or sufficient for recovery in the majority of situations but instead part of a multidimensional approach to care. Education seems to be more effective when combined with other stuff. Does this suggest that pain is not "in the brain"?

But if it is required is the key to reconceptualising also to have a similar level of knowledge and confidence about the subject that you are espousing on?

Wijma et al HERE look at classifying the type of pain to be then able to give a more detailed diagnosis of the source. They look at classifying pain as being mechanism based, the classification being based on history and sensation as nociceptive, neuropathic or central sensitized. This allows a pathway to explain the mechanisms involved in the pain rather than a more traditional pathoanotomical model of damage or alignment driven pain.

Nijs et al wrote a great paper HERE and also Lotze & Moseley HERE on the subject.

A criticism of research is bridging gap between academia and therapist and then between the therapist and person and being able to provide applicability. This can prove challenging in the area of pain with topics such as the level of complexity of the biochemistry and there may not be a substitute for having a decent grasp of the underpinning science.

The point of the blog is that people want a thorough explanation. Is don’t worry about pain enough?

Pain is an alarm!

Pain is in the brain!

It’s a perception!

Pain is helps us to protect!

Sometimes it goes a bit wrong!

Someone will always ask why?

So we have to be able to explain how and why it might be amplified. The mechanisms underpinning the plastic changes that happen peripherally to terminal endings and previously silent receptors, changes at the dorsal horn with receptive fields and available synapses and supra spinally to with increased attention to incoming information, changes in the sensory cortex and strengthening of neural connections.

Stress can come from another conflicting piece of information making the situation uncertain again. Finding the right place on the continuum between simplicity and complexity for the individual maybe the key. This can be tough if the knowledge base lends itself to the simple end.

Another challenge is can you make it FUN. People probably switch off with any boring explanation. How we get things across is probably MORE important than actually what is said!

The use of visual representations and diagrams can help. We could show multiple layers of processing in the CNS or more open doors in the dorsal horn quickly with a basic picture. It is no different from the model of the knee or back used in clinics the world over.

These are some basic tips for the practical application of pain science HERE

Individualising

 

Rather than trotting out the same old patter each time it maybe good to use peoples experiences to individualize the interaction. Can we find part of someone’s history or story that lends itself to highlighting the unclear or trajectory nature of pain. This could be in contrast to scan results that can remain relatively unchanged over extended periods of time.

Does their pain correlate with periods of extreme stress or ease over the weekend or on holiday?

Have previous treatment methods aimed at the diagnosis helped over the longer term? Can we explain HOW they may have helped in the short term?

Why did picking up a biro cause their back pain to flare up but going to the gym did not?

Did their back pain flared up without any apparent stimulus or adverse event?

Key points

 

      • People WANT an explanation or diagnosis
      • Uncertainty is a stressor
      • Expectation of recovery is a big deal
      • Misinformation fills the gaps very nicely
      • Simple explanations can be good and bad
      • A Good grasp of the science is ALWAYS good
      • Individualising helps

 

 

There are a few muscles in the body that are often thought of as ‘magic’.

These ‘magic muscles’ seem to act differently from the other muscles in the body and we need to get them working at all cost by prodding and poking or performing bizarre exercises to ‘fire’ them up so that we can avoid ‘dysfunction’ and the inevitable contribution to pain from ‘sub optimal’ activation.

Witch doing her dirty tricks

Examples of these muscles and their related ‘dysfunctions’ are the TvA and back pain, the rotator cuff and shoulder pain and the glutes and well every pain going from the knee to the lower back and shoulder.

Sometimes (this means often) we just blame the muscle automatically without even bothering to perform ANY kind of test.

Simply stating “Your back pain is because your TvA is not firing”

We have some wonderful theories about how and when ‘magic’ muscles should activate and what role they perform at a joint such as are they movers or stabilizers.

It has been suggested some deep muscles should activate first and independently of the movement being performed to provide stability rather than help move the body such as the TvA and rotator cuff whilst the glutes should activate first before other more superficial muscles of the hip to be the ‘prime mover’.

It has also been hypothesized that muscles may have specific jobs because of their fibre type. Muscles with a predominance of slow twitch fibres mean that they are better suited to a postural or ‘stabilizer’ role rather than movers witch have been proposed to contain a greater proportion of type 2 fibres. Sometimes we call them local and global or even fancier…..tonic and phasic.

This influences a whole bunch of what people do, both therapeutically and in gym settings. Do we have much evidence beyond the theory to support these common practices?

This gives us three questions to answer in this blog in relation to this line of theory about muscles and if it contrasts with what has ACTUALLY been studied?

• Do ‘magic’ muscles have specific firing patterns or onset times?

• Do ‘magic’ muscles act independently to carry out specific roles such as stabilization?

• Do ‘magic’ muscles display a distinct dominance of fibre type that mean they have specific roles such as moving or stabilizing?

 

Muscle ‘firing’

 

Glutes

How many times have you heard someone say “They told me my glutes weren’t firing”. The glutes not firing or ‘activating’ first have been blamed for lower back pain, SI pain, knee pain and my personal favourite, opposite shoulder pain (its true……myofascial slings baby) amongst other things.

There are a few purported reasons for this lack of 'firing'.

• ‘Inhibition’ of the muscle after injury.

• Excessive sitting causing inhibition

To determine if there should be a specific firing order it is important to look objectively at how healthy people activate their muscles. We can then see if there is a specific pattern or level of activity we should to try to aim for to be healthy and if there is inhibition OR the theory is incorrect.

The prone hip extension test has always been a favourite way of doing this. You know the one, get people to lie on their fronts and then the therapist or trainer pretends that their fingers are EMG machines and can tell which muscles activates first! This is known as the prone hip extension (PHT) test.

So, if pain was a consistent inhibitor of the glutes then we should see DECREASED EMG (with a proper machine) output from people who have had a previous injury during the PHT. This paper *HERE* actually found that the participants who had suffered a previous injury (in this case hamstring) had a GREATER EMG output. This was also the case here *HERE* where the chronic LBP group had a GREATER EMG signal in the PHT compared to those without. In fact any muscle ‘inhibition’ seems to resolve quite quickly *HERE* after injury.

As far back as 1990, so we really have ‘known’ this for a while, *HERE* they found that muscle firing was pretty variable in the PHT. Twenty healthy subjects each made 30 prone hip extensions with EMG used to measure the onset times of the right glute, biceps femoris, eractor spinae and left erector spinae. They found no significant difference in onset times between the muscles and variability in muscle activation within and between subjects. So the same person can perform the action differently and different people also perform it differently. This makes it really tough to have an objective firing order to base ‘dysfunction’ from.

This paper *HERE* DID find an objective order of muscle firing. They state very nicely their rationale for the need for the research.

“The development of low back pain is ascribed to changes of the muscle firing order in prone hip extension. There appeared to be no normative data on muscle firing order of the lumbar and hip musculature to provide a basis for recognizing variations”

They had healthy fifteen subjects and had a very similar testing procedure with a slightly different set of muscles around the hip but found the glute max actually activated LAST rather than first.

This was finding was supported *HERE* with a much greater sample size of fifty participants, 30 with back pain and 20 without. They looked at both onset time and amount of activation and found that glute activity was delayed significantly in both the symptomatic AND asymptomatic groups. Their conclusion being that the PHT was not able to discriminate between those with and without back pain.

They also made the great point that it is also tough to generalize what happens prone to standing or walking. This paper *HERE* found that changes in hip abduction altered the activation order and amount of activation (EMG amplitude) of the hip musculature. With 15 or 30 deg of hip abduction the glute max firing time was advanced with 0 deg delayed relative to the hamstring.

So slight alterations in hip position when prone changed firing order! What would happen with changes in body orientation (prone, supine, standing) or actually moving and at different speeds. Different terrains may influence hip width *HERE* and this would probably change firing order based on leg orientation.

In the Lieberman study looking at glutes during walking and running *HERE* we see alterations in timing and substantial activation changes between the two activities. This suggests that a single test is probably not transferable across multiple activities that may require different timings and activation levels.

As far as I am aware glute inhibition with prolonged sitting has not been studied. This is quite amazing considering how prevalent the theory is so it is tough to corroborate it. However WITHOUT evidence to support it and as we see delayed firing in those WITHOUT pain then we have to wait for more evidence before we can support this claim.

There is also the small point of can you really feel micro second differences in muscle activation with your fingers and if they are pretty minute do they matter anyway?

Although the 'glutes aren’t firing’ line sounds like an alluring and simple explanation for someone’s problems the actual SCIENCE really does not support such a simple answer.

TvA

The TvA is often a muscle that is blamed for not firing and inadequately stabilizing the spine leading to back pain. Although there certainly has been some early research showing delayed firing there is certainly not a well-defined causal link between delayed onset and lower back pain. Later work using both EMG and M mode ultrasound *HERE* have shown variable firing in healthy individuals and back pain sufferers with delayed onset not being a consistent finding for LBP patients.

Vasseljen et al state “Within and between subject variations need to be acknowledged in future studies” This paper found no association between changes in onset timing of the deep abdominal muscles and LBP.

This was finding was mirrored by Mannion et al *HERE*They found no association between the ability to activate the TvA both before or after training and a good clinical outcome.

Much like the glutes, the onset of TvA muscular activity has been shown to be variable between tasks so generalizing what happens with a muscle in one research piece using a specific movement such as rapid arm movement cannot be used to create a generalized muscular model for human function.

Morris et al *HERE* found the role of the TvA to be more function specific with muscular activation to being dependent on direction and magnitude of an action being performed. It has previously been hypothesized that the TvA acts independently (not function dependent) like a corset to stabalize the spine and it does this bilaterally. The original research only looked at the contralateral (to the arm motion) TvA but extrapolated this to bilateral activity.

Morris et al reported that no one (in the admittedly small sample size of seven) used a bilateral activation strategy in response to unilateral arm movements, the TvA acted both reciprocally and asymmetrically and the authors suggested that training the TvA to act bilaterally may actually INHIBIT normal movement.

Again we see that it is just not that simple and giving a muscle a specific job with a timing strategy is a potentially problematic line of reasoning when we dig a bit deeper than the theory.

Rotator cuff

The rotator cuff (RC) has also be given the job of stabilizing the gleno-humeral joint with a hypothesized earlier onset time and co contraction to provide joint stability. This systematic review of the stabilizing characteristics of the rotator cuff *HERE* found only in 4 out of 10 of the tested movements that the RC onset time was earlier than more ‘global’ muscles around the shoulder joint. Co-activation was also not consistent across different movements.

The authors concluded here that there is no clear evidence for seeing the RC muscles as simply stabilizers but instead acting in a direction specific manner. This was supported by more co contraction between the supraspinatus and infraspinatus than between either muscle and the subscapularis. The stabilizing role of the RC maybe the limiting of translation within the joint in a direction specific manner.

This is supported by this paper *HERE* that found that the subscapularis being more active in shoulder extension and the supraspinatus and infraspinatus more active in shoulder flexion. Interestingly the level of external load did not alter muscular activation level! It was also supported *HERE* with different variations of shoulder exercises influencing the muscles role.

Boettcher et al *HERE* helpfully put their conclusion in the title of their paper “The role of shoulder muscles is task specific”. They wanted to see if the RC muscles displayed distinct rotator or stabilizer function and although the title somewhat suggested this was not the case this was confirmed in the paper with a task specific activation being apparent.

Muscle fibre type

 

The predominant fibre type of muscles has been cited as a reason behind why a muscle should be classified as a ‘stabilizer’ or a ‘prime mover’. A stabilizer would have a much greater amount of type 1 fibres whilst a prime mover a greater amount of type 2 and type 2A.

But do we see a predominance of fibre types within muscles?

Trunk muscles are often theoretically split into ‘inner’ and ‘outer’, the inner unit involving the deeper muscles that should have a much greater concentration of type 1 fibres. As we have looked at previously the inner unit muscles don’t appear to have a reflexive and independent activation or movement strategy. So what about their fibre type, is this more suited to stabilization?

This study *HERE* used bioposy to study the rectus abdominis, TvA and Obliques. They found large variation BETWEEN people but little difference between the individual muscles, in fact their words were “minor or non-existant”. They concluded that the muscles actually have a SIMILAR functional capacity.

This paper *HERE* looked at 36 muscles in a relatively young sample size. They found that “Most of the muscles studied were known to fulfil both tonic and phasic functions, however, and showed no striking preponderance of either fibre type.”

In an older population in the rotator cuff, this paper *HERE* also showed a mixed fibre with a maximum of a 60/40 split between type 1 and 2. This was also apparent in an older paper *HERE* looking at back muscles with around a similar split between type 1 and 2. Certainly not enough to warrant classifying muscles into specific roles.

A more recent systematic review paper *HERE* also suggests that there is little inter (between) or intra (within) differentiation of fibre types in either healthy people or LBP patients in the multifidus and erector spinae muscles.

Two muscles *HERE* that DO APPEAR to have a much greater predominance of type 1 fibres are the soleus and tibialis anterior that have around 80% of fibres being more ‘postural’ although we don’t seem to talk about these muscles in the same way but obviously they do a lot of endurance type work!

Conclusion

 

What does the research tell us?

• Muscle firing patterns do not appear to fit theories that are often discussed and that influence exercise prescription.

• Muscle firing, when looked at over repeat trials, seems to be variable within and between individuals and does not support a specific muscular strategy to base ‘dysfunction’ from.

• Muscles appear not to simply have ‘roles’ that are independent of the action being performed and can be consistently defined.

• Co contraction levels appear not to be consistent enough to support a singular role of stabalistation to a joint.

• Generalising activation patterns in one task to beyond that task appear unfounded.

• Fibre types although not a perfect 50/50 split do not really show a dominance of fibres that allow us to categorise muscles into postural or movers. Movement data also does not support this.

Knowledge about pain science is rapidly growing with articles and blogs aimed at everybody from personal trainers to doctors and surgeons springing up on the topic. It could be argued that anyone who deals with the body should have a basic understanding of how pain works.

We have criticism that we still have not gone far enough in this field and others seeing the pendulum as having swung far to far already!

Whilst it is important to digest this barrage of information, we also need to think about the real world application of the academia to the end user, e.g. the person you are trying to help understand all this information, and often this is the bit people find hard.

1. Pain science can help us to understand what NOT to say, but not what TO say.

 

At the very LEAST a better understanding of pain science should influence us to know that what we say can have a profound affect on the way someone perceives themselves and their current state. Unfortunately words that hinder rather than help can often easily trip off the tongue as they have been used so many times before!

Just staying away from certain words may help to not create detrimental nocibo effects.

• Rip
• Tear
• Instability
• Damage
• Degeneration
• Chronic
• Out of place

These words have the potential to alter people’s perceptions of their capabilities, beliefs and expectations for recovery. ‘Thought viruses’ is a catchy term regarding negative beliefs and how they can be generated and passed between people.

What should we say? Well that is an infinitely harder question to answer and will vary between individuals, there are certainly are no recipes here.

Hence why learning what NOT to say is often a great start!

2. Learn more about the subject!

 

A criticism of our current educational processes is that they do not teach much about the mechanisms behind the experience of pain at undergraduate level or in many courses that deal with injury.

While it is a start to watch a few videos or read a few blogs, using the concepts of modern pain science should be underpinned by a good working knowledge of how pain works. A few buzz words or analogies probably aren’t quite enough to get it across to the target audience, especially when they have a habit of asking tricky questions.

Here are some questions it may just be worth knowing the answer to or how to explain:

What is pain?
How does nociception work?
What is central sensitisation?
What is peripheral sensitisation?
What are the supra spinal mechanisms involved in the pain experience?
What are descending inhibition & facilitation?
Why do stress, context & emotion have an effect on the pain experience?

3. Explanation of a complex subject like pain takes practice.

 

Everything is hard before it is easy - motivational slogan on a clipboard with a cup of coffee

People can feel under pressure to be able to ‘explain pain’ like an expert. Firstly you need the basic science then you need to learn how to articulate it and this does not happen over night.

As Einstein says, “If you can’t explain it simply you don’t know it well enough”.

Complexity and confusion during an explanation may lead to confusion and uncertainty in someone’s understanding and actually increase rather than dampen down someone’s pain experience.

Perhaps it is something than should be practiced away from a ‘live’ environment to build your own confidence and communication skills? Fuck it up a few times, learn from this and be ready to roll it out when you need it.

All the best presenters practice after all!

4. You may need more than one analogy.

 

Analogies have been promoted as a great way to get across complex subjects such as pain. As we use analogy so much in everyday life this makes a lot of sense but it is good to keep in mind always that these things depend on the person receiving the analogies previous experiences, cultural factors and education level.

SO if it aint working then switch it up.

5. Challenge concepts and not people.

 

A great way to ruin rapport, which can be vital to the success of what you are trying to achieve, is to tell people they are wrong or make them feel stupid. Beliefs can be like superglue and adding confrontation into the mix can make things go downhill quickly. If it is not working STOP, maybe you can come back to it later or drip feed in over time.

6. Always find out how someone has perceived what you have told them.

 

This is vital, it maybe the information you have presented is perceived in precisely the way that you did not mean it to be! Prof Kieran O’Sullivan promotes a most sensible course of action by asking “What would you tell your friends and family about what I have told you”.

This means any miscommunications can be (hopefully) remedied before they turn into ‘thought viruses’ such as “they told me the pain was all in my head”.

7. There are no recipes or protocols - It is about the individual.

 

What works for one person may not work for another. Perhaps a plus for pain science is it points towards being person centered rather than having a specific protocol across humans such as more protocol based approaches do.

Strategies that have been promoted from the fields of psychology involve techniques such as exposure therapy and expectancy violation. We have to be careful that the patient/client identifies the specific fears and beliefs to be addressed, and hopefully inhibited, and this is not seen as a general concept.

8. Changing beliefs is not an instantaneous process, an exact science or even always possible.

 

As discussed in point 5, beliefs can be sticky and contagious between friends, family and work colleagues (even more so with Dr Google!). Rarely do people walk out from chatting with their therapist or trainer and suddenly change their outlook and opinion on themselves or beliefs they hold.

It could be a slow and laborious process (likely!) or in fact never happen at all!

9. People often have their OWN epiphanies away from you.

 

Reconceptualising can happen in mysterious ways with mysterious triggers, a bit like an apple falling on your head! You may have to wait for someone to come to their own realisations about the information you are giving them rather than expecting an epiphany in front of your eyes.

10. You can’t talk tolerance into a tissue.

 

One of the major parts of the BPS model is the B for biological. Just because you can help someone understand they are not fragile does not mean they suddenly develop an enhanced capacity for moving. The less you move the less likely you are to be robust at moving, that’s the SAID principle in action.

Someone once said “you can’t talk tolerance into a tissue” a very true statement. But you may have to talk to someone first to get them to do that work and get the tolerance!

11. BPS model is still in the minority away from social media.

 

For the eagle eyed yes it did say 10 and this is number 11!

It may feel like social media is awash with pain science from every angle to the delight of some and not to others! Go out into the wider world of the internet and shock, horror the actual real world and it feels like the information being delivered in the medical and training world regarding pain is still pretty traditional with structural and biomechanical factors being promoted.

Lower back pain is a real BIG DEAL for a lot of people and with all the opinion and dogma that gets attached to various exercise types surrounding it I thought I would take a little look at the EVIDENCE base to try and get some clarity on what really is the BEST exercise for low back pain (LBP).

We are in luck here too. The good folks of academia have blessed us with a plethora of studies to choose from, not just looking at if a certain type of exercise is effective for LBP but also comparison studies to find out if they are MORE effective than something else!

The evidence

 

Lets start off looking at one of the most popular methods touted to resolve chronic back pain…..Pilates. This study *HERE* looked at Pilates in comparison to a stationary bike program over 8 weeks. The results indicated that at a 6 month follow up, an important time measure for CHRONIC pain, there was no between group differences, both were effective for reducing pain, disability and catastrophising.

Interestingly at 8 weeks the Pilates group was performing significantly better than the stationary bike group but NOT at the six month follow up. Could this be due to receiving an exercise method PERCEIVED to be the most clinically relevant treatment and influencing the short term measure?

This result was also replicated with a larger look at the data in a meta analysis of core stability exercises versus general exercises for chronic back pain *HERE*. The authors concluding that core stability training out performed general exercise in the short term but not in the longer term.

This paper found that a successful outcome for lower back pain using core based exercises was not associated with improved abdominal muscle function *HERE*. A positive effect of stability exercises has been postulated to be due to central mechanisms unrelated to abdominal muscle function. One reason could be the expectation being met of receiving the most PERCEIVED relevant treatment hence the shorter term success in the outcome measures. An expectation being met may activate mechanism’s such as the reward analgesia system.

Another systematic review with meta analysis provides the ‘coup de grace’ *HERE* concluding unequivocally:

 "There is strong evidence stabilisation exercises are not more effective than any other form of active exercise in the long term. The low levels of heterogeneity and large number of high methodological quality of available studies, at long term follow-up, strengthen our current findings, and further research is unlikely to considerably alter this conclusion”

Next up we have a walking program compared to specific back strengthening exercises *HERE*Both were performed twice a week for six weeks and a number of measures were taken. Again both groups improved but without much difference between them. It is important to note here that the participants were all sedentary to begin with so a take away maybe that the ACTIVITY here was the most important factor for those who do not do very much of it rather than the SPECIFICS of the activity.

Athletic woman warming up doing weighted lunges with dumbbells workout exercise for butt legs at home healthy lifestyle sport bodybuilding concept.

Conventional wisdom may have us believe that a specific intervention, due to its targeted nature, should out perform the more general one and not just a bit but significantly. That does not seem to be the case however. Much more general exercise WITHOUT the need for specific instructions or exercise experience and expertise seems to be just as effective.

A classic ‘moan’ from the sycophantic supporters of failed treatments is “they did not do it right” shifting the blame over to the person. The good thing with a more general program is that we can say with a degree of certainty they are just as effective but without so much that can be done in the ‘wrong’ way.

This randomised control trial *HERE* looked at a higher loading exercise program versus a lower loading ‘motor control’ program for patients with ‘mechanical’ lower back pain. Here the lower load group outperformed the high load group in some measures but at the 12 & 24 month follow up *HERE* there was no significant difference in the outcome measures. So again we see no real differences between two quite distinct exercise programs with both making improvements.

There are some caveats here. Both groups received education about pain mechanisms and, gulp, non alignment and optimal movement (whatever that is). As both groups shared this, it could have been an influence on the outcome. The low load group also did a greater variety of movements rather than just the deadlift performed by the higher load group. There is data, that we will get to later, that suggests reduced variability could be a factor in cLBP hence a healthy dollop of variation of movements performed could have had a positive effect.

A comprehensive paper “Exercise interventions for the treatment of chronic low back pain: a systematic review and meta-analysis of randomised controlled trials” found beneficial effects for exercise over thirty nine RCTs with a small but SIGNIFICANT effects on lower back pain for both strength/resistance AND coordination/stabalisation programs. The largest effect size was seen with exercise programs that focused on the WHOLE body which tended to be strength/resistance based. The important take home here is that exercise interventions were deemed more beneficial than other treatments.

The EVIDENCE of ANY real superiority of one type of exercise over another seems to be lacking here. Anyone who tells you they have a SUPERIOR ‘method’ maybe over egging the pudding!

What does that mean? Well exercise that gets DONE will probably be the most effective. Some questions worth considering are:

  • What activities do people ENJOY?
  • How easy is it for them to do?
  • How relevant is it to their functional outcome measures?
  • Are they easily able to access the necessary equipment or need specialist instruction?

I discuss the effect of environment and access *HERE*.

A focus on the HUMAN BEING doing the exercise rather than just their back might be just the ticket!

A good rehab program should be well rounded and encompass lots of factors associated with human function rather than trying to find the magic bullet of one type of exercise. Imagine if athletes only ever practiced one type of exercise! A combined approach to physical rehab could be beneficial incorporating variation in movements, high and low loads and specific and more general components.

An approach to lower back pain that considers lots of different aspects around movement is by Nijs et al *HERE*. It fits all my biases of people’s individual relationships with movement/exercise therapy for their back pain and the multiple factors to be considered across both the cognitive and physical realms.

It is also important to think about other factors associated with LBP and not just get hung up on exercise *HERE* and *HERE* 

Deconditioning

 

So it makes sense that if exercise works for lower back pain then it maybe due to the fact that people need to get a bit stronger or some more endurance and that performing exercise helps with this.

Like lots of things that seem to make sense in regards to the body it is not so clear cut when we delve in a bit deeper. This systematic review *HERE* concluded that the positive effects from exercise for LBP were NOT directly attributable to things such as strength, mobility or endurance.

Deconditioning has often been linked to lower back pain and hence the idea of reconditioning as a cure for lower back pain. This did not seem to be the case in this study *HERE* that looked at physical deconditioning in the first year following the onset of back pain.

Perhaps this adds to the argument that the DOING of exercise in more important than the type or the targeted physical aspects e.g. strength. The potential for the PSYCHOLOGICAL effects to be as important, or even more so, than the physical seems highly plausible and is certainly food for thought.

Being physically active is often touted as both prevention AND cure for LBP. This paper *HERE* suggests that it is not that clear cut, surprise surprise, looking at it as being more of a U shaped relationship. They found a moderate increase in cLBP risk with both a sedentary lifestyle OR excessive activities so more does not simply equal better when it comes to exercise.

This systematic review with meta analysis *HERE* DID find, although no discussion of the bottom and top ends, low to very low evidence that exercise alone reduces incidences of LBP and moderate evidence that combing education with exercise also helps.

As usual the deeper we delve the less clear it becomes and why we should be wary of simplistic answers and cures that are usually based around doing the one BEST thing such as activating a muscle or correcting a pelvic tilt.

Are there any physical ‘deficits’ or characteristics we see with LBP?

 

Laird et al looked at lumbo pelvic MOVEMENT in people with AND without back pain *HERE*. Their systematic review found, in comparison to those NOT in pain, reduced proprioception (15 studies), slower movement (8 studies) and reduced range of movement in all directions (26 studies)

Nourbakhsh and Arab *HERE* DID find that muscle endurance and weakness WERE associated in their sample size of 600. This however does not imply that these factors were a cause of LBP especially with the type of the study performed.

Both papers also looked at some structural factors and their association with LBP. NEITHER paper could find an association between lumbar lordosis angle or pelvic tilt angle. Nourbakhsh and Arab also investigated the association of leg length discrepancy and abdominal, hamstring and hip flexor length with LBP and found none.

This paper *HERE* looked at the spine loading characteristics of those with and without back pain. They found INCREASED spine loading for those with LBP and significant increases in all of the 10 muscles studied using EMG data. They also found the LBP group had severely restricted motion in a free lifting task. They concluded that the increase in spinal loading was due to INCREASED muscular co-activation.

Trunk stiffness in this study *HERE* was related to fear of movement in those suffering from LBP. Greater kinesaphobia fear of movement) resulted in greater trunk stiffness.

So we have kinematic and muscular data suggesting that those suffering from LBP have GREATER muscle activation and co activation and REDUCED movement around the lumbopelvic area. This makes sense if we see muscular responses to pain as being PROTECTIVE in nature and aiming to minimise movement in this area due to pain or the perceived THREAT of pain.

Here is a bit of opinion based on the data.

How do exercise strategies that promote core stiffness such as many popular approaches for LBP affect this? Could they perpetuate the problem rather than solve it? High loading strategies may also promote increased stiffness, could this have the same negative effect?

Could a key be being able to ‘turn off’ muscles as much as we are trying to ‘turn them on’? Potentially choosing the right amount of muscular activation and stiffness for the task is the sign of ‘healthy’ movement rather than just increased ‘activating’, ‘firing’ or whatever you choose to call it. Reduced movement may not be under activation of a muscle but increased activation of another to stiffen the joint.

Freedom of movement, both physically and psychologically, should be an aim for those working with people suffering from lower back pain.

 

Variability

 

As it’s my blog I get to indulge in some my biases! One of those is movement variability. There is a reasonable amount of data in my opinion that suggests decreased movement variability is associated with LBP.

This first paper supports some of the kinematic changes we see around the trunk discussed in the section above. The authors *HERE* looked at the coordination patterns between the trunk and the pelvis during running and walking comparing different groups. As loads increased during running, variability in pelvis and thorax rotation decreased on a continuum between the no LBP group, one bout of LBP and then the chronic LBP group. The decrease in variability could be due to the increased trunk STIFFNESS noted in other papers.

Lamoth et al *HERE* found a more rigid, less flexible pelvis-thorax coordination variability (counter rotation) as walking velocity, and therefore demand, increased. This decrease in thorax to pelvis motion was also present in a study by Van Den Hoorn *HERE* and also attributed to increases in trunk stiffness.

Falla et al found reduced ranges of motion in a free lifting task with the LBP group in their study *HERE*

As well as looking at the kinematics they also explored INTRA (within) muscular activity using EMG. They found significant higher values for EMG activity for the LBP group, consistent with other studies, to accompany the reduced kinematics of the spine indicating a stiffer strategy.

The LBP group also displayed decreased variability in muscular strategy, not displaying the shift in activity to different muscular regions that the pain free group did. This repetitive muscular strategy was accompanied by an increase in LBP, reduced lumbar movement and increased pressure pain sensitivity.

Decreases in variability have also been linked to chronicity in back pain *HERE*

 

What does this variability stuff all mean?

 

Well it could be that simply decreasing trunk stiffness may automatically increase variability. It may also be that focusing on decreasing stiffness through more relaxed movement across a variety of tasks, such as gait, could be a treatment strategy for LBP sufferers.

Could this increase in stiffness and decrease in variation also play into intra muscular metabolism? This could potentially increase ongoing sensitivity via mechanisms such as changes in local tissue PH and excitation of acid sensing ion channels in afferent neurons.

Whilst looking at variability is a promising avenue, and worthy of exploration in my opinion, I do discuss some of the limitations currently present here in this line of research *HERE*

Conclusion

 

  • Lots of different types of exercise have a positive effect on LBP.
  • No one type seems to be superior.
  • Focus on the HUMAN BEING not just the back.
  • Exercise that people enjoy and is easy for them to do will probably get done and hence have a positive effect.
  • Consider a rehab program combining different exercise variables e.g. high and low load and types rather than one singular type or exercise method.
  • Deconditioning is not clearly associated with LBP.
  • Positive effects from exercise for LBP may NOT be directly attributable to things such as strength, mobility or endurance.
  • Increased trunk stiffness and decreased ROM and speed of lumbar movement ARE associated with LBP.
  • Structural factors such as lumbar lordosis, pelvic tilt, leg length discrepancy and muscle length are NOT likely to be associated with LBP.
  • Kinematic AND intramuscular reduction in variability is associated with LBP.
  • Decreasing stiffness and promoting freedom and variability of movement maybe a good goal in rehab, especially with those displaying kinesiophobia.

 

I have to give a hat tip to my mate Todd Hargrove for getting me thinking about the subject of environment and the effect it can have on movement behaviours. Here is a link to his recent blog piece "The environment for movement"

It is really important that we think about the environment that people will be using for increased activity or the exercises we have asked them to perform. The environment around them will affect the outcome of the activity or the exercises and we can help shape this environment for them to be successful in the tasks we want them to perform.

A question I ponder more and more is how many failed rehab or fitness programs are because of a lack of consideration of ENVIRONMENT and NOT the person or the program?

We have to consider the HUMAN BEING doing the exercise. You can discuss the relative evidence base or sets, reps and % of MVC of whatever exercise bias you hold. It really does not matter IF IT AINT GETTING DONE and the environment can directly affect that.

Our ENVIRONMENT can act as a constraint to either INCREASE exercise & exercise compliance or DECREASE it. Movements and actions will emerge based on the constraints placed upon them. When we are dishing out exercises this should be at the forefront of our minds, as these constraints will dictate how much of the exercises are performed and the way in which they will get done.

Child hand sticking out from plastic bottles garbage - environmental disaster concept, copyspace

The environment could affect the AMOUNT of movement such as EVEN doing an exercise in the first place to manipulating the environment OF an exercise and the specific outcome.

My son and swimming

 

A personal example of the emergence of movement happened shortly after reading Todd’s blog. I went on holiday and fortunately we had a very shallow and warm swimming pool right outside our room. My son, who is 4, with a bit of cajoling managed to teach himself to swim! Cue proud dad moment.

The fact we had a shallow and warm (important when you are 4) pool meant my son was able with great confidence to get in the water without his arm bands. He was also able to push off the pool floor and touch down if needed. This aided his practice enormously.

The environment of having a shallow pool with no deep parts enabled AND contributed to his learning process. The location meant he could go any time he wanted and hence increased his practice time. The depth improved his confidence at not having an external aid and also acted as a safety net to make mistakes in learning non lethal : )

The ENVIRONMENT acted as a direct catalyst to confidence, compliance and outcome. A question we should all ask ourselves is “Does my treatment or fitness program do this?”

Are you self limiting?

 

It could also affect someone’s whole treatment or training approach!

How many therapists work out of rooms that you could not swing a cat in? If a treatment couch dominates the room then it will probably dominate the therapeutic approach too! This environment does not lend itself to the performance of exercise and coaching cues etc.

A trainer in a busy commercial gym may be affected via the amount of space or the equipment available to them. Hence their exercise programming may be limited to using small spaces and fixed resistance machines.

External & internal constraints

 

We have a number of different EXTERNAL constraints acting on us such as the environment someone is operating in, the task being performed, the instructions they are given and the equipment they use.

We also have INTERNAL constraints. These would be things like confidence, fear (of movement, reinjury etc) and movement skill (ability to perform a task). If your task is beyond any of these internal constraints there is more likely hood of it not getting done! A complicated lift, in a rehab or training context, for someone with low confidence, body awareness and movement skill may prove far to challenging and hence affect the outcome.

Then we may have Internal constraints such as confidence in using the equipment, body image and fear of getting it wrong and making things worse. A focus on fitting exercise/exercises in with the person and involving them rather than just dictating to them may have a profound impact on if they actually get done or not! In fact it could be more important than the exercise itself in many cases.

The concept of exercise itself may need to be reframed for someone with poor associations with exercises, we could regard this as an internal constraint, and many failed attempts to integrate exercise into their lives. Can we create fun movement tasks or activities to help movement emerge? Can we tie these in with physical activities they do enjoy and are more likely to perform?

Environment & an LBP example

 

An example could be getting someone with lower back pain that is sedentary more active as part of a rehab plan. If you say you have to do a specific type of exercise program in a gym then that may present external environmental problems. Someone has to be a member of a gym, get to the gym, the gym they are able to get to also has to have whatever equipment you have suggested they use. All of these factors may present barriers and hence must be considered and addressed. In contrast a walking program in a local park may yield better results for some with a much lower barrier to getting it done based on their location, preference and confidence.

Rather than just shoving an exercise down someone’s throat…..

Find out what activities they enjoy and feel capable of. Are they a regular exerciser or gym goer to begin with?

  •  Explain the exercise/movement or activity, why they are doing it and the importance of it to their problem or goal.
  •  Ask what is their opinion/perception of what you have asked them to do and their confidence in doing it.
  •  Help set out when in their schedule would be best for them to realistically do it.
  •  Making sure they have good instructions of what to do. A short video clip using a video phone can help.

At a recent course I ran the class brainstormed ways of creating loaded training without having to attend a gym. This can be a barrier for many people with this aspect of rehab or training.

Ideas included:

  •  Sand bags
  •  Bags filled with books
  •  Bags of compost (they come in 20kg bags!)

Much as we aim to ‘meet the person where they are at’ with an educational approach to reduce barriers we should also do this with exercise to increase compliance.

In part two of this blog we will look at how factors such as environment and the other constraints that we have lightly discussed here will affect movement outcomes such as variability and skill development.