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