around her little finger

Exercise questions


ResearchBlogging.org
If there is one finding that has remained pretty solid over the past 10 – 15 years, it’s the one that says being active is a good thing for managing chronic pain.  I’m not sure how many papers I’ve read where ‘exercise’ and some form of cognitive behavioural approach have been found to produce improvements in disability, mood and even pain – and the benefits are often maintained for 12 months or more.  But we have a problem, Houston.  The problem is this – many of these studies treat ‘exercise’ in much the same way as ‘interdisciplinary pain management’ – a black box that no-one really knows exactly what goes on in there, but hey it works.

This is a real problem when we come to put the research findings to work in the real world – exactly how did the clinicians in any of these studies go about their therapy?  Even when the various components are identified and labelled ‘light aerobic exercise’, ‘relaxation’, ‘problem solving’, ‘activity pacing’ – it’s not at all clear what those components actually look like.

I’ve included the Australasian study by Pengel, Refshauge, Maher, Nicholas, Herbert & McNair as a rare ‘good’ example of how a research paper can detail the individual components, but it’s no easy task to find similar rigour in so many other papers. But even in this paper, there are some unanswered questions for me, and I’ll come to them soon.

As I mentioned, engaging in exercise is good, what isn’t clear and hasn’t been for a long time, is what kind of exercise.  There have been oh so many fads in my time in pain management!  From ‘muscle imbalance’ from ‘incorrect’ posture through to core stability and Pilates, there have been waves of enthusiasm for a specific type of exercise that end up being challenged and found no more or less helpful than any other.  It looks like the specific type of exercise is immaterial – what is important is that the person does it regularly.  And to do exercise regularly, people have to enjoy it IMHO. So exercise can be walking the dog, going to a gym, dancing (many people know my penchant for bellydance!), and – wait for it – even housework!  I’ve often wondered whether it’s exercise per se – or more accurately, activity that involves whole body movement (which could include gardening, vacuuming, washing the car as well as many sporting activities).

What is much less clear, and the things I’m struggling to find in the literature right now, is where to start from (what intensity to start from and how to assess this), and how to progress.

One approach relates far more to graded exposure (from a psychological paradigm) in which the person develops a graded hierarchy of activities that are important to them and that they avoid, then starting from the least feared activity, progressively move up the hierarchy as confidence is increased and fear reduced.  This approach makes a lot of sense to me because it’s based on where the person wants to start, there’s a good theoretical model guiding the process, and the mechanisms of change have been well-established.  It also fits for me because many of the people I see are not unfit. In fact, it seems to be a fallacy that people with chronic pain are ‘deconditioned’ and unfit – they could be fit but engage in activity irregularly (in a saw-tooth pattern of boom and bust), or they could be fit but avoid applying this ‘fitness’ from one context to another, like the chap I saw who swam 50 lengths of a pool every morning, but couldn’t sit, couldn’t work, and wasn’t prepared to change this because ‘fitness’ was his rehabilitation.

Another approach is for the patient, usually with a physiotherapist, to ‘establish a baseline’ over a range of exercises, then progressively increase the demands of this programme by increasing the number of repetitions, increasing the resistance, or increasing the duration of the exercise programme.  The question I’m trying to puzzle through is – how do the patient and therapist go about determining this baseline? Is it based on the level of activity that can be carried out without the person experiencing a flare-up? Because if so, this could be one reason so many patients I see think that their goal is to avoid flare-ups at all cost – and ‘pacing’ to them is all about stopping activity ‘before I get a flare-up’.   In so many people with chronic pain, as soon as the person does something unfamiliar, their sensitive nervous system kicks in and they get a flare-up – whether the activity or exercise was especially demanding in cardiovascular terms or not!

Or is it based on ‘what the therapist thinks the person can do’ – in which case, how is that determined?

Given all the material I’ve been reading about clinician responses to patient behaviour, particularly things like distress, anxiety about health, duration of pain and so on, my suspicion is that even when a clinician ‘sets the baseline’ – it’s actually determined by what the patient is prepared to do. What that signifies to me is that whatever model is being used to justify the selection of exercise and the way in which it is progressed, it must include something about the interaction between the patient and the therapist, and it needs to involve an appreciation of the patient’s perspective – otherwise it’s not going to reflect the actual process that goes on.

If my hunch is correct, then I think a similar process might go on when deciding how to progress exercise.  Essentially, it’s a negotiation between the therapist and the patient – and it might be determined more by what the patient is prepared to do (in other words, their self efficacy), than on any other physiological principle.

Exercise is an excellent way to demonstrate to the person the ways they can increasingly engage in activities they haven’t been doing for a long time, if at all.  Whenever the demands are increased, the patient needs to draw on active coping strategies – possibly some they’re completely unaware of.  For example, many patients don’t realise how often they use positive self coping statements like ‘Yes I can do this’, ‘If I keep going, I’ll get this finished’.  Patients often don’t realise the influence of social learning – watching other people successfully achieve their new challenge – and clinicians can be oblivious to their role in reframing pain from something indicating harm or damage, to simply a response to doing a new movement.

I guess what I’m coming to as a conclusion is that even though physiotherapists and occupational therapists may not always want to be ‘cheap psychologists’ – actually a lot of the work in exercise therapy uses psychological principles rather more than physiological ones.

My unanswered questions are: where is the research on how baselines are established? What methods work well for this process? How are exercise goals negotiated?  How does a therapist decide how and when to progress exercise? Are the strategies used in developing an exercise progression directly translated by the patient into the rest of their activity, or do we assume generalisation in the same way that we often assume that coping strategies generalise into a work situation?  Are therapists aware that one of the reasons exercise may have a positive effect is that patients learn the process of coping with new demands through it?  If these coping strategies were developed more explicitly by clinicians involved in exercise and activity, would that enhance outcomes and help the person generalise their skills more readily?

Enough questions: anyone got some answers or is that someone’s PhD?

Pengel LH, Refshauge KM, Maher CG, Nicholas MK, Herbert RD, & McNair P (2007). Physiotherapist-directed exercise, advice, or both for subacute low back pain: a randomized trial. Annals of internal medicine, 146 (11), 787-96 PMID: 17548410

8 comments

  1. This is the *best* set of questions I’ve ever seen about exercise. Just asking them puts you way ahead of the pack🙂

    I somewhat dislike the word “exercise” because it implies ritualized, useless, repetitive, progressively more intense motion, which I think is the least effective kind (although of course the kind dearest to any measurer’s heart). Walking or bicycling (to actually get places), dancing, rolling around on the floor, swimming here and there, (up and down and all around), wiggling — those are the kinds of motion I like best, especially if they can just be folded into life, not as projects or chores you remember to do but just as how you live, or get from one place to another, or play.

    People so often “exercise” doggedly for a few weeks until they hurt themselves. Then it’s six months or a year till they start again (and do the same thing, like as not.)

    1. Thanks so much Dale! I’m not entirely an exercise-free zone, although there are times I say that! But I totally agree that ‘exercise’ can mean much more than going to a gym or doing ‘exercises’. And it makes the whole job of ‘exercising’ so much more if it ties in with personal values – but those darned questions still need answering, don’t they!!

  2. That is a great set of questions! There was a year in my life when I saw several musculoskeletal specialists/physical therapists, trying to find a way to manage my pain. Each made a physical exam, and then (usually without asking me – listening to patients is clearly a repeat topic here😉 they said “OK, we have to get you active. This will help your pain”. To which my response was “At the moment, I am doing a Pilates class, a Tai-Chi class, and a rock climbing gym session every week. If this is not the right level of activity, then I need a lot more specific help”. The outcomes were not happy – a typical reaction was “then you are doing everything right, just keep doing it, and you will get better”. To which I had to say “Sorry, this is not that simple, not after 3 years of doing this without improvement.”

    What I found for myself is that “formal” exercise does not necessarily match up with functional daily activity. I can walk into my climbing gym with a cane, resulting in some startled glances, climb several walls and walk away with increased, but tolerable pain. In a way, this is even an exercise of my acceptance skills – I know my pain will go up, at least for the rest of the day, possibly more. But it is a good way to spend time with friends, and a very enjoyable and stress-reducing activity, because being on a climbing wall requires a special sort of concentration which works like a movement meditation for me, and is a lot more effective than “traditional” meditation exercises. So I accept the increased pain as something that goes together with a really enjoyable activity.

    And yet my ability to do this very physical activity does not easily translate into my ability to cope in the real world. By definition, a gym or an exercise class is a restricted environment, because one can choose which moves to make and when. In comparison, my daily environment is not controlled. For example, I don’t get to choose the chairs in restaurants or on buses, and the wrong type of seat can leave me limping for a long time. So for me, exercise is great as a way to get some stress relief, and to “keep in touch” with my body – I really enjoy keeping my muscles working and engaged. I think if someone is not exercising at all, then introducing exercise would be very beneficial as a way to get someone’s muscles moving and re-conditioned. But if someone is already fit, the highly structured movement does not necessarily help with figuring out the right ways to cope with unstructured world outside the gym, and other things are needed to make this work.

    In fact, I think it is important that any research about exercise reports characteristics of the group being tested. I think the results would be very different for people who are indeed de-conditioned and not moving, and for people who are more or less fit, like me, or like your client who was swimming every day.

    1. You make some excellent points Mary, especially about the predictability of different environments and the need to individualise exercise. One thing I’d note is that exercise is not always going to reduce pain, even over time. What exercise does provide is a good opportunity to get used to fluctuations in pain and to develop ways to cope with this and feel less bothered by the fluctuations. I think the other point I’d like to make to clinicians is that it’s vital to help people generalise what they learn during exercise sessions into the rest of life – even to the point of recognising that exercise occurs during ‘other’ normal activities!

  3. First of all a thank-you – this blog provided a helpful structure to a training session I was doing today on graduated reactivation!

    And now to answer all your questions! OK, none of of them – they were rhetorical right? – put perhaps help to balance up things from a physiotherapist’s perspective.

    First of all the bit we can agree on – research shows you ‘need’ a physiotherapist as part of your pain management programme (ie all the published models have one), and most use a strengthening / tolerance approach to the exercise component (eg gym-based), but we can’t be any more specific than that.

    I’d also like to be pedantic and raise the issue of exactly what people expect from their exercise (we are talking self-management aren’t we?). Why fun? Why enjoyable? I’d be much happier to discuss it’s importance. By definition, exercise refers to practise, rehearsal, training, exertion etc. Not sounding so much fun now, eh? But many people do this in different aspects of their lives for a number of reasons. How many musicians are counting down the hours till the next time they can play some scales or other fingering drill? Not many I imagine, but a ‘necessary evil’ in order to get to the really good stuff, like performing in public, or nailing a tough piece of music.

    Even ‘professional’ exercisers (eg sportsmen, dancers, acrobats) will distinguish between the joy of everything coming together and the sheer mundanity of certain aspects of their profession / hobby. Recovery from injury / preseason training / out of season conditioning – these are ‘the hard yards’, exercise for the sake of exercise with no immediate reward. But the bigger goals – the last minute try-saving tackle, landing a technically demanding jump, that’s important enough to them to persevere when most of us gave up (or changed focus!) on such single-mindedness when we found out about the opposite sex and/or alcohol.

    So when a patient asks me (the evil physio-terrorist) ‘why would anyone do something that makes them have more pain?’ I can only agree, and acknoweldge that if it was me if would have to be pretty important. In fact I used to spend a whole hour (!) in our services intensive pain management programme asking that very question – ‘Why bother to exercise?’. And after three weeks of being pushed and pulled, and supported in doing some regular (daily) exercise, they are not shy in telling me. It helps. It gives confidence about their physical abilities, it helps to take them closer to their own functional goals, improves their sleep, has given them new skills to approach new challenges (pacing / prioritising / managing flare-ups), reduces anxiety – they fill up reams of paper about the merits of doing something intrinsically unpleasant!

    Interestingly, physiotherapy has for several decades desperately tried to define/associate itself within the medical sciences (with some success). The merits of exercise within managing chronic pain are therefore often cited within this biomedical context – CV fitness = reduced pain and increased energy to combat fatigue; stretching = stimulating autonomic muscle activity inhibition and stimulation of synovial fluid within joint capsules; strengh and conditioning = address soft tissue adaptations from guarding / reduced activity.

    Now clearly this isn’t the only thing happening, if indeed it’s happening at all – we often see improvements in the patient WAY before any physiological changes could occur; research seems to consistently repeat the message of ‘it doesn’t matter WHAT the exercise is, but make sure you do something’. But isn’t this the nature of the biopsychosocial framework (and for some, it’s appeal)? Give 10people the same exercise, and you’ll find 10 different ways in which it has helped.

    The skill for me is in recognising that exercise has all these different attributes, rather than simply it’s pain reducing, golgi body stimulating elements alone. And perhaps that is where the ‘bad press’ arises from – a clinician too entrenched in a biomedical culture (most Out-patient settings) to step back and discuss with their patient what they want to gain from their exercise programme, and have the confidence to measure those outcomes rather than pain and range of movement.

    Clearly a topic close to my heart (and perhaps I’m a little defensive about too!) but kudos to you, yet again, for a stimulating discussion point.

    Andrew

    1. Whew! That took a while to wade through! Great points, especially about the way in which exercise has been framed within a biophysical model – when it looks like so many of the benefits are psychosocial! Which I guess was one of the points I wanted to make – and if exercise can achieve those benefits, is there any reason why activity can’t be considered in the same breath? Why the distinction? Because activity is so much broader, easier to integrate into life, and directly relevant to goals. The problem is, I think, that activities are less readily carried out in a clinic environment without being artificial and thus having precisely the same lack of relevance as exercise. So perhaps the area that needs far more work is that transition from engaging in exercise-in-the-clinic-under-supervision to activity-in-the-real-world-alone. For me this is the REAL work of pain management – generalising skills so the person can function equally well no matter the environment. What I see so often is that this transition is assumed to happen all by itself, and that one environment is as easy to exist in as another.
      Your point about exercise consisting of sub-skills that need motor rehearsal to become automatic is well made – and the same thing happens in ballet (hours of plies and releves as a kid!) and bellydance (figure eights and shimmies). The point though, is that these exercises are KNOWN by the participant TO BE RELEVANT! So your point about therapists needing to take the time to discuss the purpose of exercising, or what the individual wants from exercise is also well taken. But there are options in how these repetitive exercises can be undertaken – in dance it’s easy to put music on and do the repetitions and that works really well for me. Other people might like the competition of being with other people and trying to outdo each other. Still others might get into a meditative state while doing the hard yards. How often are these elements brought into ‘exercise’ programmes?
      And I am sad that those questions of ‘where to start’, ‘what is a baseline’, ‘how to progress’ are not yet answered – they’re the ones I think we really need to know about because they can then give us confidence as therapists in our approach – at the moment it’s a bit of myth-making and mystery.

  4. From a patient’s perspective, I think Adele is very right – the exercises have to be known to be relevant. I can totally relate to the general need for training. For example, I don’t really like doing Pilates. It’s not fun, or exciting, or relaxing. But it does help core stability, and, as it happens, core stability is a key component of climbing (my enjoyable exercise😉 It is also supposed to be very good for my back etc., though the benefits are not particularly obvious for me, even after years of training (other than physical therapists telling me that I have good control, but, well, that is not a functional benefit). Still, in between those two things, I have kept at it for years, on the understanding that it supports doing climbing, which is my fun activity.

    In general, I went along with whatever my physical therapists prescribed as daily exercise. But there was one thing to which I said definite “no”. Swimming is supposed to be very good for back and joint pain. For me, just 10 minutes of swimming or hydrotherapy brings up a 2-day pain flare-up, bad enough that it becomes difficult to go about my daily activities. After trying several times, I finally said to my physio: I am currently able to do 70 minutes of tai-chi with much less pain than this, or spend 30 minutes doing a variety of exercises in a gym. These activities don’t require much preparation. In comparison, by the time I factor time to travel to the pool, change in and out of swim suit, and take care of my wet things afterwards, I will be spending 2.5 hours of preparation time for sake of 10 minutes in the water, which will not even exercise me enough to tire me out, but then leave me struggling with pain for the next 2 days. I am willing to stick it out for some time at least, and see if I can build it up, but only on condition that you explain to me what benefit it is giving me functionally that I am not receiving from my other activities, and how we are going to assess its effectiveness”. His reaction was “OK, then, do something else”. I do wonder sometimes if I would be better off if I persevered, but I still stand by the idea. I would do something like this only if someone would explain to me, sensibly, why this is important and giving me benefits in connection with real-life activities. Which, I think, fits well with what Adele is saying about the importance of exercise being relevant.

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