softness

Why does “doing exercise” work?


Bless all the physiotherapists in the world, they keep us doing exercises. And exercises are good because they get us doing the things we want to do in our daily lives. But how does it work?  This is not an exposition on exercise physiology – I’m not au fait enough with physiology to do that and there are many other people out there with vast amounts of knowledge giving us the benefit of their wisdom who have written at length about exercise and why it’s important. Instead I want to talk about some observations – and maybe pose some critical questions too.

For many years I’ve worked in a chronic pain management centre where people with chronic pain attend a three week intensive pain management programme. Staff members from outside the Pain Management Centre (we were located as an outpatient facility on the grounds of a rehabilitation hospital) always told us they could spot a person with pain the moment they saw them wandering from our building to the main cafeteria: people walking slowly, sometimes limping, but often just walking very slowly towards the cafe.

Over the course of the three weeks, this group of people would go from this slow amble to walking briskly and attending the hydrotherapy sessions, doing a daily exercise session (circuit-style); and in the final week of the programme, catching a bus to the shopping centre, purchasing food, coming back and preparing a shared barbecue for friends and family. What a turn-around!

Now, I said I wasn’t going to talk about physiology and I won’t, but I WILL point out that three weeks is not a long time. It’s so little time that it’s impossible for muscle length and strength to change significantly. And yet movements (measured using the six minute walking test and timed up and go) were quicker. Postures changed. People looked more alert and took more notice of the world around them. The question of how it is that this group of people could go from being recognisably “pain patients” to people who could do everyday activities has to be asked.

There are a couple of points to make before I do my thing. Firstly, while the people attending the programme were undeniably uncomfortable, clearly slow in their movements, and most definitely disabled, they weren’t, by usual measures “deconditioned”. In other words, they were of pretty average fitness – and indeed, many had been attending daily gym sessions at the behest of a case manager and under the supervision of a physiotherapist for months! At the same time they were not DOING much and felt extremely limited in their capabilities.

The second point is that although the programme had two “exercise” sessions each day, these were not high intensity sessions! The aim in most cases was to help people establish a baseline – or a reliable, consistent quota of exercise that they could do irrespective of their pain intensity. Most of the work within the exercise sessions was to help people become aware of their approach to activity, to modify this approach, and to then maintain it. Movement quality rather than quantity was the aim.

Here’s where I want to propose some of the mechanisms that might be involved.

  1. Humans like to, and almost need to, compare their performance with other people. It’s not something we choose to do, it’s an innate social bonding mechanism and whether we then modify what we do to match others – or deliberately try to do the opposite to mark out our own stance – we’ve based our behaviour on having observed what’s “normal” around us. And this applies even when people develop disability (Dunn, 2010), but perhaps more importantly, may well be fundamental to how we experience our world – and ourselves (Santiago Delefosse, 2011). When a group of people meet, their behaviour rapidly becomes more similar – similar gestures, similar body positions, and similar facial expressions. I wonder if one of the mechanisms involved in change within a group of people who live with chronic pain is this tendency to mirror one another’s behaviour.
  2. Having proposed that mirroring is one mechanism of change, why don’t groups of people with chronic pain ALL remain slowed and showing pain behaviour? Well, another mechanism involved in behaviour change is operant conditioning. When a group is performing exercise under the supervision of a “wise and caring authority” (ie a physiotherapist), many reinforcements are present. There’s the “no, that’s not quite the right movement” response, and the “oh you did it!” response. The “you can do it, just push a bit more” response, and the “if you can do that, how about another?” At the same time people are set quota or “the number of repetitions” to complete within a timeframe. Simply recording what is happening is sufficient to change behaviour – just ask someone who is on a diet to record their food intake for a week and you’ll likely see some changes! But add to this a very potent response from the wise and caring physiotherapist, and you’ll get warm fuzzies for doing more, and possibly cold pricklies if you don’t try.
  3. And finally, and possibly the most powerful of all, is the process of confronting feared movements – and doing them. Doing them without “safety behaviour” and doing them to specifically confront the thing that makes them scary. And doing them in many, many different settings, so as to alter the tendency to avoid them because they’re scary. A recently published systematic review and meta-analysis of graded activity (usually based on operant conditioning principles, and perhaps on cardiovascular fitness training principles) compared with graded exposure (deliberately confronting feared and avoided movements in a whole range of different contexts) found that graded exposure more effectively reduces catastrophising than just doing graded activation. This shouldn’t surprise us – one of the mechanisms involved in disability associated with nonspecific low back pain is avoiding doing things because people are fearful either of further injury, or of being unable to handle the effects of pain.

Where am I going with this post? Well, despite the face validity of exercise for reducing pain and disability, it’s not the physiological effects that first produce results. It can’t be because tissues do not adapt that quickly. What does appear to happen are a range of social-psychological processes that influence whether a person will (or won’t) do something. What this means is two things:

  • Physiotherapists, and indeed anyone who helps people do movements to reduce disability, really need to know their psychological processes because they’re inherent in the work done.
  • Becoming expert at analysing what a person wants and needs to do, and in being able to analyse then carefully titrate exposure to the contexts in which things need to be done is vital. That’s fundamental to occupational therapy theory, training and expertise.

 

 

Dunn, D. S. (2010). The social psychology of disability. In R. G. Frank, M. Rosenthal, & B. Caplan (Eds.), Handbook of rehabilitation psychology, (2 ed., pp. 379-390). Washington , DC: American Psychological Association

Lopez-de-Uralde-Villanueva, I., Munoz-Garcia, D., Gil-Martinez, A., Pardo-Montero, J., Munoz-Plata, R., Angulo-Diaz-Parreno, S., . . . La Touche, R. (2015). A systematic review and meta-analysis on the effectiveness of graded activity and graded exposure for chronic nonspecific low back pain. Pain Med. doi:10.1111/pme.12882

Santiago Delefosse, M. (2011). An embodied-socio-psychological perspective in health psychology? Social and Personality Psychology Compass, 5(5), 220-230.

4 comments

  1. Ihreard and saw you speak at a fibro meeting and was inspired by your real understanding of pain problems etc.So far I have been uninspired with groups of people with fibro ‘partly because the energy level is usually so low reguardless of peoples outward” healthish
    appearence and talks given dull,repetative etc.That makes me sound very harsh but having fibro and pain issues I am sympatetic and do understand.I have found most of my help from “Patients Like Me” website,

    I think that you are “Bronnie”””silly if Im talking to the wrong person.!

    Anyway I am very heartened by your writing,your research and the way you bridge between research terminology and lay persons understanding.And that, from N.Z,comes serious study.

    I was a nurse over 35yrs and used exercise to deal with backpain.Only after lumber surgery and life stresses did I begin getting sore as if my body was in a rage about constant pain:like being on fire.

    15 years now: I am quite well informed and can manage myself but find even the best Drs,here dont “get” the pain bit.

    I dont know if anyone really does:each sufferer figures out some way of managing even if it takes ages of self observation and susing out who can really speak about fibro.

    Mostly I just want to say again how much I appreciate your words and help thus derived.

    1. Hi Philippa, yes it’s Bronnie! and thank you so much for your kind words about the blog. It’s a labour of love. I’m so pleased to hear that the “Patients like me” site has been good. Wouldn’t it be awesome to do something like that in NZ? And for all healthcare practitioners to go through it to understand more about “what it’s like” to live with pain rather than constantly trying to get rid of pain. So many people, let alone health professionals, don’t understand pain, it’s really sad. I am glad that my work is doing a tiny bit to bridge that gap. I agree, each person will eventually find a way to live alongside their pain, what differs is how long it takes, and how much struggling to beat the pain when it can’t be beaten! If there’s anything that you’d like me to write about, please do let me know. And another blog you may enjoy reading is “My Cuppa Jo” which is written by my friend and fellow person living with pain, Joletta Bolton. She’s an amazing woman who lives with chronic pain and is bringing her “insider’s view” out to the world so we can all share in how she’s learned to live with her pain. I hope you enjoy it. Keep in touch!

  2. I usually would use graded exposure for high fear of pain and graded activity for catastrophizers with thought monitoring but apart from that great post. I would however like to see my clientelle improve that much that fast. Always a good read Bronnie

  3. I think once you get past the stigma of physical activity with arthritis. I was in that boat and was headed to a knee replacement. I read Eugene Sims book How To Achieve Freedom From Arthritis and his methods were the catalyst for me. Now I can say I am on the road away from knee replacement. freedomfromarthritis.com is his site. It’s a fantastic resource!

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