Is exercise the new snake oil? or just a dirty word?

If you haven’t heard about the health benefits of exercise in the last 10 years or longer, then you’ve probably been a hermit! Exercise can do all these wonderful things – help you lose weight, reduce heart disease, moderate insulin and blood glucose levels, improve your mental health, and yes! reduce pain and disability when you’re sore. (check this list out)

The claims sound suspiciously similar to the claims made by old snake oil merchants – or the amazing White Cross Electric Vibrator!

Well perhaps there’s a little more research supporting claims for exercise… but are those claims being inflated just a little? When it comes to pain, particularly persistent pain, perhaps so…

But before I launch into some of the problems with exercise research, I have another problem with “exercise” – and that’s the word itself.

According to Wikipedia (and no, it’s not an academic reference!!) “Exercise is any bodily activity that enhances or maintains physical fitness and overall health and wellness.” Winter and Fowler (2009) in an interesting paper looking at definitions of exercise, found that “exercise” and “physical activity” are essentially the same and differ only in terms of motivation/intent, finally arriving at this definition: “A potential disruption to homeostasis by muscle activity that is either exclusively or in combination, concentric, isometric or eccentric.” Whew! Glad we’ve got this sorted.

But given the sticky nature of our minds, and that very few of us are inclined to spend hours debating the technical details, the word “exercise” has picked up quite a few other meanings. For me it conjures up images of sweaty, lycra-clad blokes grunting in front of enormous mirrors while they heave on lumps of metal to the pumping rhythm of loud music (and the eyes that follow my every move). It also raises the spectre of school sports where I was inevitably the last person chosen for any sports team, the last to come in after every run, the person who got hit in the face by the ball, who got her thumb smacked by the hockey stick the week before my piano exams…

I’m not alone in my distaste for “exercise”. Qualitative researchers have often investigated how people with pain view exercise: “I get the comments that “It is not dangerous” and that “you are not going to be worse.” I do not believe it is dangerous … but actually it happens that I become worse after .… I know that the pain will increase. And they … talk to me about pain that is not like my pain.” (Karlsson, Gerdle, Takala, Andersson & Larsson, 2018)

Boutevillain, Dupeyron, Rouch, Riuchard & Coudeyre (2017) in another qualitative study, found that people with low back pain firstly identified that pain intensity interfered “any minimal physical activity, standing still in one spot, is torture” (line 1683); “if my back hurts, I don’t do any activity that’s for sure, I am not going to the garden and do some digging, that is out of the question! I have two children, if I am in pain and they want to play, my back hurts and I can’t play with them. My back hurts I can’t do it. It’s not that I don’t want to it is just that I cannot. I am unable to” (line 29). In turn, motivation for exercise was reduced “I don’t have any desire to exercise. A lack of motivation, even apprehension” (line 390); “there needs to be this spark to get motivated, and I just don’t have it” (line 1335). Along with the lack of perceived benefits for some: “Sometimes I try to exercise and then I’m in pain, looking back had I known it would hurt I would probably not have done it” (line 2037) “It can be harmful, I give you an example: I have a colleague with low back problems, similar to mine, and she loves to take step classes, but each time she exercises too much, she is in pain but continues. I think she should stop, it is quite dangerous for her” (line 378).

A systematic review by Slade, Patel, Underwood and Keating (2014) found that “Individuals were more likely to engage within programs that were fun and had variety than ones that were boring, unchallenging, or onerous because they disrupted daily activities.” They added that “Difficulties with exercise adherence and not seeing benefits of exercise were frequently attributed to lack of time and fit into daily life.” Quotes drawn from the studies included in this review show that lack of confidence, negative experiences at the time, and poor “fit” between the exercises selected and individual preferences influence whether exercise was carried out consistently.

At the same time as these negative views, many participants in qualitative studies report that they use “movement” as a key strategy for their daily management. Whether movement looked like “exercise” as prescribed by PTs or trainers is a little less clear – people use the word “exercise” to mean many different things, hence Karlsson and colleagues (2018) combined the term “physical activity and exercise”.

Now one very important point about exercise, and one that’s rarely mentioned, is how little exercise actually reduces pain – and disability. A systematic review of systematic reviews from the Cochrane collaboration found that most studies included people with mild-to-moderate pain (less than 30/100 on a VAS) but the results showed pain reduction of around 10mm on a 0 – 100mm scale. In terms of physical function, significant improvements were identified but these were small to moderate in size.

And let’s not talk about the quality of those studies! Sadly, methodological problems plague studies into exercise, particularly sample size. Most studies are quite small, which can lead to over-estimating the benefits, while biases associated with randomisation, blinding and attrition rate/drop-outs, adherence and adverse effects.

Before anyone starts getting crabby about this blog post, here are my key points (and why I’ve taken this topic on!):

1. Over-stating the effects of exercise won’t win you friends. It creates an atmosphere where those who don’t obtain pain reduction can feel pretty badly about it. Let’s be honest that effects on pain reduction and disability are not all that wonderful. There are other reasons to move!
2. Exercise and physical activity can be done in a myriad of wonderful ways, research studies use what’s measurable and controllable – but chasing a puppy at the beach, dancing the salsa, cycling to work, vacuuming the house, three hours of gardening and walking around the shopping mall are all movement opportunities up for grabs. Don’t resort to boring stuff! Get creative (need help with that? Talk to your occupational therapists!).
3. The reasons for doing exercise are enormously variable. I move because I love the feeling of my body in rhythm with the music, the wrench of those weeds as they get ripped from my garden, the stretch of my stride as I walk across the park, the ridiculousness of my dog hurtling after a ball… And because I am a total fidget and always have been. Exercise might be “corrective”, to increase cardiovascular fitness, because it’s part of someone’s self-concept, to gain confidence for everyday activities, to beat a record or as part of being a good role model. Whatever the reason, tapping into that is more important than the form of the exercise.
4. Without some carryover into daily life (unless the exercise is intrinsically pleasurable), exercise is a waste of time. So if you’re not enjoying the 3 sets of 10 you’ve been given (or you’ve prescribed to someone), think about how it might translate into everyday life. It might be time to change the narrative about movement away from repetitive, boring exercises “for the good of your heart/diabetes/back” and towards whatever larger, values-based orientation switches the “on” switch for this person. And if you’re the person – find some movement options that you like. Exercise snacks through the day. Jiggles to the music (boogie down). Gardening. Swimming. Flying a kite. Don’t be limited by what is the current fashion for lycra and sweaty people lifting heavy things with that loud music pumping in the background.

Boutevillain, L., Dupeyron, A., Rouch, C., Richard, E., & Coudeyre, E. (2017). Facilitators and barriers to physical activity in people with chronic low back pain: A qualitative study. PLoS One, 12(7), e0179826. doi: 10.1371/journal.pone.0179826

Edward M. Winter & Neil Fowler (2009) Exercise defined and quantified
according to the Système International d’Unités, Journal of Sports Sciences, 27:5, 447-460, DOI: 10.1080/02640410802658461

Geneen, L. J., Moore, R. A., Clarke, C., Martin, D., Colvin, L. A., & Smith, B. H. (2017). Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database Syst Rev, 4, CD011279. doi: 10.1002/14651858.CD011279.pub3

Karlsson, L., Gerdle, B., Takala, E. P., Andersson, G., & Larsson, B. (2018). Experiences and attitudes about physical activity and exercise in patients with chronic pain: a qualitative interview study. J Pain Res, 11, 133-144. doi: 10.2147/JPR.S149826

The OOV – Fabulous or familiar?

I love gadgets! New, innovative, groovy – I feel special when I have a new toy to play with. I justify my pleasure by saying “Oh it saves me SO much time”, or “I can do SO much more” – but really, it’s the wow factor that gets me every time. So it is with new and groovy treatments for pain. It used to be all “leg length discrepancy” and “muscle imbalance”, now it’s “neuroplasticity” and “educational neurophysiology”. So I think I’ve stumbled upon the Next New Thing. The OOV.  I attended a one day fundamentals workshop – incidentally, paid for by the University Department in which I work, so this is an unbiased review.

The OOV is a neat foam device shaped somewhat like a goose (if you use your imagination), or perhaps like an insect thorax. It’s curved side to side and from front to back on the bottom, while the top has two concave and one convex curve roughly approximating the curves of the spine.Designed by an osteopath, there are several principles the inventor and educators indicate underpin the rationale for the OOV. These are:

• Functional movement training
• Developing stability via the pelvis and deep “core” muscles, with joint mobility where this is needed (shoulders and hips)
• Developing motor control
• Establish endurance
• Refine balance
• Relaxed performance

The exercises performed on an OOV are therefore carried out slowly (almost meditatively), in time with breathing (deep diaphragmatic breathing), and with control.

Training also requires attending to feedback from using the device itself – use it with inefficient motor control and you fall off. Use it with fluid control and, over time, develop strength. The materials included in the training manual state that motor control learning requires a “closed loop feedback” process of attending to sensory information as new movements are learned. After the movements are mastered, then and only then is speed acquired. Exercises focuses on using eccentric contractions to keep movements slow and smooth – and “allows for kinetic chain sequencing to improve”, “increases cross bridge connection between muscle fibres thereby increasing strength, activates the deep muscles, stimulates the low threshold slow twitch fibres building stamina, lengthens the fascia due to long, slow and sustained load”.

The training manual also discusses myofascial slings and suggests that by training the deep core muscles (transverse abdominis, multifidus and the pelvic floor – and don’t forget the diaphragm), and the superficial units (posterior oblique, deep longitudinal, anterior oblique and the lateral muscular slings) coordination and recruitment patterns will allow for stability, strength and speed as forces generated by limbs are transmitted through the body.

Next, the manual describes several postural types. There is the so-called “ideal posture”, kyphotic-lordotic posture, flat back posture, and sway back posture – and of course, we must correct the variants so we can achieve the ideal. I’ll leave you to draw your conclusions as to the rationale for this.

Finally, there are the four pillars of movement:

1. Axial elongation – for efficient spine articulation, the “safest” environment for movement, preventing compression and shearing forces, and providing the optimal position for the core muscles to work. Just by lying on the OOV, the spine is placed in this wonderful position, provided of course that you lie with your lumbar region in the right spot, which can be just an inch or so from where you may really want to lie.  Efficient breathing – Axial elongation allows for diaphragmatic breathing, with the head lower than the hips which apparently inhibits the secondary respiratory muscles.
2. Hip mobilisations – to develop correct posture and proper alignment begins with the feet, by dissociating the lower half of the body from the upper half, the stationary half provides stability and support so that forces are directed towards the moving half.
3. Shoulder and thoracic spine mobilisation – to enhance, strengthen and extend the fluid range of movement at the shoulder which, because of our terrible working environments, seems to produce faulty movement patterns.
4. Core control – as the manual says “not enough can be said about the importance of a strong core. But strength means nothing if all the muscles that make up the core are not working efficiently during movement”.

OK, so far so good. Training is based on the principles above, with the addition of balance and proper alignment, interspersing new exercises with a balance position, adding new movement patterns to increase the challenge to the nervous system (yes! neuroplasticity!), practice to develop complex movement patterns, and finally repeated practice using weights, increased repetition etc. And if you perform a new set poorly, step back a bit, reduce the demands until motor control develops.

I spent a day using the OOV. With my sensitive nervous system letting me know three days later that I’ve been using muscles I don’t usually demand so much from, I think it does what it says it does – you definitely work a range of muscles more intensely than in everyday life. It’s fun, and because of the slow pace where control is the aim, it’s achievable even for people who wouldn’t ordinarily want to “do exercise”.

What do I think of it? Well, I predict there will be classes for OOV training in many gyms in New Zealand and the world. During the workshop I heard that performance athletes (yes! the Australian swim team!) are using it, that you can rehabilitate sore backs, shoulders, hips, whatever; I learned that you must be SO careful with your back because the discs can be smashed; that posture patterns are dysfunctional; that the reason we have back pain is because of poor core stability, that we can have an unstable pelvis; that this is the way of the future. Even 70 year old women with osteoarthritis can now manage things she couldn’t do before.

Warning: I am skeptical of any new thing. After seeing so many variations over the years I’ve worked in pain management, particularly within the musculoskeletal world, I guess I’m a bit wary of fads. Here’s the thing: While I think the OOV functions well as an option for exercise, and novelty can be a good thing to maintain motivation, let’s not inflate the potential. Buzz words like “motor control”, “neuroplasticity”, “core strength” are going to have grab. The exercises, many based on Pilates, will be familiar and yet challenging on the unstable platform of the OOV. BUT the basic assumptions that:

• there is one ideal posture and lordosis is associated with back pain and disc degeneration (Been & Kalichman, 2014; Murray, Dixon, Hollingworth, Wilson & Doyle, 2003; Nourbakhsh & Arab, 2002)
• backs are fragile and must be coddled, particularly the discs  (Bakker, Verhagen, van Trijffel, Lucas & Koes, 2009; Claus, Hides, Moseley & Hodges, 2008; O’Sullivan, O’Keefe, O’Sullivan, O’Sullivan & Dankaerts, 2012);
• core stability and motor recruitment are at fault in back pain, therefore they need to be retrained ( Laird, Kent, & Keating, 2012)
• that myofascia can be effectively stretched (Scleip, Dureselen, Vleeming, Naylor, Lehmann-Horn, Zorn et al, 2012; Turrina, Martinez-Gonzalez & Stecco, 2013)

are, I think, arguable. I particularly dislike the language associated with the reasons for developing core stability – that backs are easily damaged, that great care must be taken to avoid damage, and that a critical reason for back pain is either lack of core stability or pelvic instability. While these notions are logical from a biomechanical viewpoint, they don’t accommodate natural bony, ligamentous and muscular variations (how many clavicle variations have been identified?), they omit the nervous system, and they fail to include the active, dynamic and ever-changing, self-regulating, homeostatic human systems involved.

Consider the OOV as an adjunct, a toy, a nice way to introduce movement to people who are fearful of movement. Use it to vary an exercise routine. Have fun with it. But please don’t base your back pain rehabilitation on the idea that this device is the bees knees.

Quick addendum: GREAT critical questions about a ten-year follow-up of strengthening vs flexbility exercises with or without abdominal bracing – http://www.ncbi.nlm.nih.gov/pubmed/25271520; the original article is http://journals.lww.com/spinejournal/Abstract/2014/06010/Ten_Year_Follow_up_of_Strengthening_Versus.2.aspx

 

Bakker, E. W., Verhagen, A. P., van Trijffel, E., Lucas, C., & Koes, B. W. (2009). Spinal mechanical load as a risk factor for low back pain: a systematic review of prospective cohort studies. Spine, 34(8), E281-293.

Been, E., & Kalichman, L. (2014). Lumbar lordosis. Spine Journal: Official Journal of the North American Spine Society, 14(1), 87-97.

Claus, A., Hides, J., Moseley, G. L., & Hodges, P. (2008). Sitting versus standing: does the intradiscal pressure cause disc degeneration or low back pain? Journal of Electromyography & Kinesiology, 18(4), 550-558.

Kirilova, M., Stoytchev, S., Pashkouleva, D., & Kavardzhikov, V. (2011). Experimental study of the mechanical properties of human abdominal fascia. Medical Engineering & Physics, 33(1), 1-6.

Laird, R. A., Kent, P., & Keating, J. L. (2012). Modifying patterns of movement in people with low back pain -does it help? A systematic review. BMC Musculoskeletal Disorders, 13, 169.

Murrie, V. L., Dixon, A. K., Hollingworth, W., Wilson, H., & Doyle, T. A. (2003). Lumbar lordosis: study of patients with and without low back pain. Clinical Anatomy, 16(2), 144-147.

Nourbakhsh, M. R., & Arab, A. M. (2002). Relationship between mechanical factors and incidence of low back pain. Journal of Orthopaedic & Sports Physical Therapy, 32(9), 447-460.

O’Sullivan, K., O’Keeffe, M., O’Sullivan, L., O’Sullivan, P., & Dankaerts, W. (2012). The effect of dynamic sitting on the prevention and management of low back pain and low back discomfort: a systematic review. Ergonomics, 55(8), 898-908.

Schleip, R., Duerselen, L., Vleeming, A., Naylor, I. L., Lehmann-Horn, F., Zorn, A., . . . Klingler, W. (2012). Strain hardening of fascia: static stretching of dense fibrous connective tissues can induce a temporary stiffness increase accompanied by enhanced matrix hydration. Journal of Bodywork & Movement Therapies, 16(1), 94-100.

Turrina, A., Martinez-Gonzalez, M. A., & Stecco, C. (2013). The muscular force transmission system: role of the intramuscular connective tissue. Journal of Bodywork & Movement Therapies, 17(1), 95-102.

Exercise and chronic pain

One of the most consistent recommendations in cognitive behavioural therapy approaches for chronic pain is for people to exercise. Exercise is thought to help reduce pain, improve physical fitness and support participating in social, professional and domestic activities. By being fit people can manage their daily activities at a lower percentage of their maximum aerobic capacity and, hopefully, minimise the risk of flare-up.

While the overall premise of exercise is clear, the details of how often, what kind and the best approach for recovery after exercising are rather less. The problem for people with chronic pain is that moving HURTS.  Some people have even argued that chronic pain is, in essence, an activity intolerance disorder.

Daenen, Varkey, Kellmann & Nijs (2014) have attempted to clarify the state of play in exercise for chronic pain, and propose some interesting guidelines for clinicians. You see, one type of chronic pain is not the same as another – and neither is one form of exercise exactly like another.

How does exercise “work”?

Exercise is “planned, structured and repetitive bodily movements that are performed to improve or maintain one or more components of physical fitness” (Howley, 2001).  Aerobic exercise at approximately 70% or more of maximum aerobic capacity sparks production of endorphins and descending inhibitory mechanisms (serotonergic, opioidergic, adenosinergic systems); it also reduces weight, strengthens muscles and increases bone density. People without chronic pain experience pain inhibition for up to 30 minutes after aerobic exercise, but this period is much shorter for those involved in resistance training (just a couple of minutes). Researchers think that endogenous opioids and growth factors are released, supraspinal nociceptive inhibition occurs, releasing beta-endorphins from the pituatary and hypothalamus and these enable analgesia by activating mu-opioid receptors in both the periphery and central nervous systems.

…And if you have fibromyalgia?

People with sensitised nervous systems, and in particular those people with dysfunctional descending inhibitory mechanisms, such as those with fibromyalgia, do not experience this endogenous analgesia. Instead, they can have increased pain possibly through a reduced pain threshold after exercise – myofibre (muscle fibre) damage is a normal part of exercise, but is associated with lactates and oxidative stress, and these can be potent contributions to nociception. In an individual with poor descending inhibition, this nociceptive input can trigger a flare-up of symptoms.

Stress responses

Daenen, Varkey, Kellman & Nijs (2014) also point out that people with chronic pain can have abnormal stress responses, with increased activity of the sympathetic nervous system, and problems associated with the HPA axis. What this means is that people with some forms of chronic pain are chronically “stressed”, that is, they’re exposed to stressors simply from having chronic pain, and this changes the homeostatic response of the HPA axis and sympathetic nervous system. This can lead to excessive fatigue and difficulty recovering from exercise, because exercise is also a stressor in which growth hormone, testosterone, cortisol, epinephrine, and norepinephrine are released. Normally this enables the body to gradually adjust to a stressor and maintain homestasis – by exercising in small but regular amounts, and allowing enough time to recover in between, the body becomes more able to respond to stressors.

In people who are chronically stress, failing to provide adequate recovery periods can lead to ongoing sensitisation of nociceptors and increased experience of pain. Daenen, Varkey, Kellman & Nijs (2014) consider that dysfunctional reactivity of the HPA axis contributes to exercise intolerance in people with fibromyalgia.

What does this mean for exercise for people with chronic pain?

I think this means we need to be careful about how we go about prescribing exercise. The purpose of exercising is generally to ensure people can manage their everyday activities with a little room to spare in terms of activity tolerance. My study suggests that people who cope well with pain use exercise more for their mental health than to improve fitness or muscle strength. And this group of people used low-level cardiovascular exercise such as walking, cycling, dancing and tai chi as their preferred form. Some people used their daily activities as their form of exercise – things like gardening, vacuuming the floor, washing windows, hanging out washing, cleaning the car.

I think we need to ensure we are very clear as to the goals of exercise. Why this particular set of exercises?

We also need to be clear that one size does not fit all. If a person doesn’t enjoy going to a gym, this shouldn’t be the ONLY form of exercise they’re exposed to. If the person doesn’t have an activity intolerance, maybe they need to develop recovery strategies rather than changing their exercise form.

We need to be aware that increases in pain intensity are likely for some people who have pain such as fibromyalgia. People with this type of pain problem may benefit from developing both an exercise form they enjoy and therefore can do consistently (I like to bellydance and garden!), AND to develop effective recovery strategies. Perhaps helping people use strategies such as mindfulness and diaphragmatic breathing as part of a cool-down could be a good option.

Finally, I think it’s important to avoid implying that people who have dysfunctional endogenous analgesic systems are simply “noncompliant”, need “psychological” input, or just need more encouragement. Maybe it’s time to reconsider the kind of exercise and recovery we’re prescribing, and titrate it according to the individual’s response to exercise.

 

Daenen, L., Varkey, E., Kellmann, M., & Nijs, J. (2014). Exercise, not to Exercise or how to Exercise in Patients with Chronic Pain? Applying Science to Practice The Clinical Journal of Pain DOI: 10.1097/AJP.0000000000000099

Howley ET. Type of activity: resistance, aerobic and leisure versus occupational physical activity. Med Sci Sports Exerc 2001;33:S364-9; discussion S419-20.

Exercise questions

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

Low back pain: unfit? just not doing much? or something else

For as long as I’ve been working in pain management (and probably well before), I’ve heard patients being described as ‘deconditioned’. From what we know about the effects of staying in bed because of illness or injury, it makes sense to think that if a person does very little they will become unfit. Common sense really. And from this assumption an industry of gym programmes and fitness initiatives have been instituted as an integral part of back pain rehabilitation.

Now before my physiotherapy colleagues start to lynch me, I’m not saying that these programmes should be banished into outer darkness because ‘reactivation’ has been shown to be effective in the recovery from back pain – but maybe it’s effective for quite a different reason from the one usually given.

Verbunt, Smeets & Wittink, in this editorial from Pain conduct a review of the relationship between physical inactivity and deconditioning in people with non-specific chronic low back pain, and find scant evidence for the strength of this belief.  Ooops.

There are several theoretical models that integrate the hypothesis that deconditioning is part of, and complicates, the recovery of people with chronic low back pain. The most popular in recent years is the pain-related anxiety and avoidance model (Vlaeyen and colleagues), in which people misinterpret their pain as threatening or something to be avoided at all cost, consequently fear moving, stop doing normal activities of daily living, and become deconditioned.  The model has been incredibly helpful for initiating a graded exposure approach to feared movements, and for shifting the psychological focus from low mood and into anxiety about pain and consequent behaviours.  BUT, as this review points out, it’s unclear whether being inactive and deconditioned maintain the ongoing disability.  And there is little evidence that being fit protects against experiencing low back pain in the first place.

As I said before, I’m definitely not arguing against the use of exercise as a component of rehabilitation for chronic low back pain – but at the same time, it’s really important to make sure the rationale for this is based on reality, not a myth.

Back to the findings of this review.  Firstly, is there evidence that people with chronic low back pain are actually doing less than people without? Basically, no.  But the pattern of activity can be quite different – people with ongoing tend to be just as active overall in a day, but their activity has peaks and troughs, what can be called ‘boom and bust’, or ‘saw-tooth’ pattern of activity.   Studies also show that people’s disability level is associated with their perception of how little they did – and this didn’t relate to their actual activity level.  Now that’s interesting – feeling like activities are obstructed by pain seems more salient to disability than the actual amount of activity carried out.  Perception is reality.

Are people with chronic low back pain less fit?

Several parameters are explored in this paper – deconditioning should be linked to changes in body composition (fat vs muscle), bone strength, muscle control and cardiovascular changes.

• Body fat percentages are higher in people with chronic low back pain – but bone strength is equivocal.

Muscle strength and endurance should be affected if a person is deconditioned: ‘adaptive remodelling in muscles’.   This should be reflected in atrophic changes to the muscle as well as changes to the type of fibre found in muscles.

• While some studies seem to show changes in paraspinal muscles, generalised atrophy isn’t found.  Biopsy of muscle fibres show atrophy of type II fibres, and this appears to be related to the duration of the low back pain. But the authors in this paper point out that these changes could be atrophy due to aging rather than back pain, and there were no studies to show the ratio between type I and IIX fibres in people with or without low back pain.
• Postural control studies haven’t controlled for the level of physical activities of daily living, so it’s unclear whether any differences found are due to overall low activity level (which could have existed prior to the onset of back pain), or whether any changes were as a result of doing less because of low back pain.
• Cardio fitness – well, here’s a kettle of fish.  There are loads of confounds – the type of exercise protocol used, work status comparisons, diagnostic comparisons, age and gender matching – it’s just not pretty.  This paper points out that there is conflicting evidence regarding cardiovascular deconditioning, or whether those who are working despite chronic low back pain are ‘fitter’ than those who are not, although there does appear to be a gender difference – males who are working appear to have better aerobic fitness than either women who worked outside the home, or males who did not work outside the home.  Maybe returning to work prevents cardiovascular deconditioning – but it’s unclear whether the types of work between women and men (both work in the home, and outside of the home) were controlled for.  Almost all the studies have used a cross-sectional design, so it’s really difficult to know whether deconditioning occurs after onset of pain, or prior to the onset of pain.  Low aerobic fitness and low activity levels do not appear to be risk factors for developing chronic low back pain.
• Metabolic factors – insulin insensitivity is associated with low activity levels like lots of bed rest.  Unfortunately there were not studies examining this in people with chronic low back pain, and the level of inactivity required to develop insulin insensitivity hasn’t been determined.

Now it really does get interesting for me here.  I’ve griped about the lack of validity (and reliability) of functional capacity evaluations.  They rely on people being prepared to ‘give it their best’ and for many reasons people with chronic pain may not do so.  It could their concerns about pain immediately, pain the next day, or the implications of ‘good’ performance on things like compensation.  On the other hand, a one-shot assessment isn’t able to predict performance over a day or a week – and some patients ‘over-do’, others ‘under-do’, and even the influence of the person doing the assessment can change how well the individual performs a functional test.

The authors in this paper plead for researchers to:

(1) objectively monitor general physical activity level and control for this in statistical analyses of physical fitness

(2) consider studying the factors that influence performance during performance testing in order to improve validity

(3) use longitudinal designs rather than cross-section designs to ensure correlation isn’t confused with causation – and outcome measures should monitor the impact of functional activity gains

(4) confounds known to influence physical performance usch as gender, age, recreational activities, job type, diagnosis, etc should be monitored so multiple regressions can be carried out with some confidence

The summary?

There is little research evidence that people with chronic low back pain are deconditioned either before they developed their problem, or after.  Despite this, it’s thought that being fit in a generally active way is good for overall health and especially as we age.  Engaging in more exericse does have an effect on recovery from low back pain (well, reducing the disability associated with low back pain), but we don’t know why.  Just don’t assume that because someone perceives they’re disabled, they are actually unfit.

Verbunt JA, Smeets RJ, & Wittink HM (2010). Cause or effect? Deconditioning and chronic low back pain. Pain PMID: 20153582

Fibromyalgia: an overview

I didn’t intend to get into a theme this week, but this paper arrived in my inbox this morning, and given both the prevalence of fibromyalgia, and the often ‘fuzzy’ management that can be provided, I thought it might be worthwhile taking a look at it.  The paper itself is a pre-print, but has been revised earlier this year and is probably the final version.

The outline of the paper covers diagnostic criteria, and briefly discusses the place of neuroimaging (if only we could get that done readily here!), but notes that many other conditions overlap or mimic FM such as hypothyroidism, tendonitis, ankylosing spondylitis, as well as chronic fatigue, suggesting some sort of common pathway in either the peripheral or central nervous system, raising the possibility of some common treatment approach.  So far though, it’s not clear – and it’s important to rule out these other conditions that all have their own management approach before deciding that FM is what the problem is.

The next section of the paper reviews the current state of knowledge around pathophysiology as a basis for treatment and rehabilitation.  Both peripheral and central sensitisation seem implicated in FM, leading to amplification of sensory impulses that alter pain perception.  Increased excitation of various peripheral structures can in turn lead to neuroplastic changes in the central nervous system – winding up the whole experience for the person in the middle of it!

Imamura, Cassius & Freni, the authors of this paper, briefly review some of the factors thought to play a role in the reduced threshold for neuronal firing, including elevated levels of substance P, calcitonin gene-related peptide, bradykinin, and so on.  Included in their review are CNS factors such as the altered non-REM sleep of people with FM – and that this is associated with the severity of symptoms; the association between depression and FM; and neuroimaging studies showing a change in regional cerebral blood flow to pain-related structures in people with FM.

If these aspects of FM can be explained to people with the pain problem it could make a significant difference to their own attitude toward their pain.  For many people, it can take several years before a diagnosis of FM is made: during this time the beliefs and approaches of many practitioners can influence their understanding of their pain – and sadly, some practitioners are not empathic and can take a somewhat pejorative approach to people with the disorder.  Knowledge can lead to understanding – and understanding can lead to a sense of empowerment.

Moving through the paper, the authors indicate that treatment needs to be based on the proposed model of fibromyalgia.  That is, it needs to address central mechanisms rather than peripheral ones (so, no more NSAIDs, opioids or corticosteroids!), and the overall approach needs to be ‘rehabilitative’ – I’d suggest biopsychosocial as the model!  The shift is from curing the problem to improving health status and health -related quality of life.

There are two arms of management for fibromyalgia:

(1)  pain relief through medication and ‘physical’ strategies to reduce peripheral and central sensitisation

(2)  cognitive behavioural approaches to manage sleep, fatigue, mood, cognitive problems, headache, migraine and other problems associated with FM.

Although the authors suggest ‘education’ as a cornerstone – I’d rather suggest helping the person to reconceptualise their problem as one of pain processing.  Education can be seen as simply providing information – reconceptualising is about helping the person see themselves and their pain problem as something they can manage, something only they can do – and something they can do.

The remainder of the paper looks at pharmacological approaches and the rationale for using tricyclic antidepressants and/or serotonin/norepinephrine-reuptake inhibitors, and tramadol because of their effect on reducing afferent transmission at the dorsal horn or increasing the activity of the descending inhibitory pain systems.

It should be noted that even these drugs don’t always reduce the pain and all have their own array of side-effects – so they need to combined with self management.

Nonpharmacological approaches are then reviewed.  This is where the interdisciplinary team can take the lead because these approaches are both effective – and once learned, don’t consume health resources in quite the same way as medications can.

Exercise gets the nod – remembering that exercise can include enjoyable daily activities such as walking, gardening, dancing and playing with the dog, not just going to a gym!

Electrical stimulation – this is suggested, although as far as I know, it’s not readily available – Imamura et al. indicate transcranial direct current stimulation as an effective approach, but I haven’t heard much of this as a strategy available in New Zealand.  (If anyone has, let me know).  I’m also not entirely comfortable with this as a self management strategy – it sounds pretty invasive and requires health care input, at least initially.

Acupuncture – this is less well-documented, and results are, as these authors say, ‘controversial’.  They suggest that ‘clinical benefits seem to be of small magnitude and of short duration’ – my main concern would be that unless the person can ‘do it themselves’, it will involve more appointments, so I’d not be comfortable with it as a self management approach.  I hold a similar view of injections – Imamura et al suggest that ‘concomitant myofascial pain, along with instruction in relaxation techniques, may benefit some patients with an associated mysfascial pain component.’ 

The final area reviews, very, very briefly, cognitive behavioural therapy.  The authors indicate its use for ‘associated psychological and psychiatric comorbidity’, but I’d be inclined to challenge this.  The perception of pain involves thoughts and beliefs about the meaning of pain – and the effect of reconceptualising fibromyalgia as not being a ‘life sentence’ or a ‘constant struggle’, and understanding what some of the mechanism are, will bring about changed perception.  Distress reduction, increased sense of self efficacy and more effective approaches to activity, relaxation, cognitions, as well as effective communication skills and working on relationships – these are all integral to living a good life despite pain.

Overall – this is a nice, brief review especially of some of the pathophysiology of fibromyalgia and the rationale for the treatment approaches suggested.  There are plenty of good references, and while it’s not an ‘easy’ read, it’s quite brief and contains the essentials.

 

From Imamura, M., Cassius, D., & Fregni, F. (2009). Fibromyalgia: From treatment to rehabilitation European Journal of Pain Supplements DOI: 10.1016/j.eujps.2009.08.011

Graded exercise or walks for recurrent low back pain

As a confirmed exercise-free zone, I am always interested in studies that look at whether specific exercise makes a difference in recovery for people with chronic pain.  My preference is to dance (yes, belly dance is good!), and I enjoy walking and cycling, but gyms? no way!

This study caught my eye because it is a head-to-head comparison of two popular approaches to reactivation for people with recurrent low back pain – graded exercises for eight weeks, or a walking programme for eight weeks.  While I could argue that the small sample size (71 participants), and the lack of double-blinding and a couple of other methodological issues make this study somewhat weak, there are some interesting things to note from it.

The basic study consecutively recruited participants into two groups – one received a graded exercise programme supervised by a physiotherapist in which stabilising exercises (Richardson’s protocol was followed) were prescribed, and ‘the progression of the exercises was based on the patients’ pain level and observed movement control and quality.’ The programme was for 8 weeks.  Specifics of the approach are reasonably well-described in the paper.

The other group was instructed to take one 30-minute or two 15-minute walks each day ‘at the fastest pace that was convenient and did not set off pain. If their pain persisted or increased they should slow down. They should continue with other usual activities. They were also given general home exercises but with no follow-up instructions.’This group was also asked to record their progress over the 8 weeks.

The measures used were the Oswestry, visual analogue scale for pain, and the physical health subscale of the SF-36. A self-efficacy scale was used, and the Fear Avoidance Behaviour Questionnaire.

What happened?

Well, both groups demonstrated a reduction in pain intensity over the 36 months, with the difference between the groups only evident in the exercise group at the first measurement point immediately after the programme.  Both groups also demonstrated improvement in function (reduction in disability) with the exercise group showing slightly more improvement than the walking group.  Physical health and self efficacy also improved for the exercise group but not as much for the walking group.

Neither group showed any changes in fear-avoidance scores.

Conclusions…

The authors suggest that their original intention was to identify, in a real clinical setting, whether stabilising exercises made a difference to pain and/or function.  They state ‘it is … not clear that reduced pain and disability after stabilizing exercises is associated with changes in the muscle activity pattern: other underlying explanations are possible.’

What is known, is that in this group of reasonably nondisabled participants, exercises helped them feel slightly more confident about their ability to manage (improved self efficacy).  The authors admit that perhaps the changes were because of what they describe as ‘a behavioural change’, and they cite Wessel, van Tulder et al who reviewed the factors that are known to predict positive outcome in nonsurgical management of low back pain.  So, these two groups may have improved simply because they were both given a structured programme of activity to follow.

There are some real differences between the two groups that weren’t controlled for – one group had 8 weeks of clinical input with a therapist, with a set of special exercises that were monitored.  Their progress was recorded, and undoubtedly they were given praise and felt a sense of achievement when they became competent enough to progress to the next set of exercises.

The comparison group simply recorded their walking over the 8 weeks, and had little or no therapist contact.  Their programme didn’t change or progress, so some of those really exciting positive vibes that come from achievement (and are known to directly influence self efficacy) were missing.  So I’m not surprised they reported a better sense of self efficacy at the follow-up sessions.  I’m a bit surprised there was so little difference between the two groups, actually!

The importance of patient expectations are discussed by the authors of the study. Initially there was no difference in expectation between the two groups, but by the conclusion, the exercise group reported greater satisfaction.  We know that patient satisfaction can strongly influence their adherence to recommendations, and their pain and disability.  This group had a set of ‘special’ exercises they could use whenever they experienced pain, which might have contributed to them feeling as though they had more control, and therefore lower distress when they did have a recurrence.

I’m not surprised there were no changes on FABQ – neither approach directly addressed the specific concerns the participants might have had about pain equalling harm.  It’s interesting that in both groups, participants were specifically told to use pain as their guide and to modify their exercise accordingly.  This is a strategy that can reinforce the sense that experiencing pain is a ‘bad’ thing and movement should be restricted.  I wonder what might have happened if both groups were asked to continue with their programme as normal even during exacerbations of pain.

A final couple of words: one day I hope to see a comparison between something like a graded programme of household tasks and a graded exercise programme.  Or a comparison between dancing and a graded exercise programme.  Then we might see whether it’s movement in general, or specific exercises that are helpful.

Similarly, I’d love to see what would happen if a non-physiotherapist supervised exercises – there could well be a treatment effect simply from having ‘the movement expert tell me I’m safe’.

And I’d love to see what would happen if a cognitive behavioural component was included in both situations – working with the person to see what their thoughts and beliefs are about their problem and their progress.

I do have a hunch that just doing normal activities in a systematic way, with a professional that the person believes in, and some specific work with the person’s thoughts and beliefs while they do their own activities, might do more than all the ‘special’ exercise programmes and gym paraphernalia can do.  Or maybe that’s my exercise-free zone chiming in.

Rasmussen-Barr E, Ang B, Arvidsson I, Nilsson-Wikmar L. (2009). Graded exercise for recurrent low-back pain: a randomized, controlled trial with 6-, 12-, and 36-month follow-ups. Spine, 34 (3), 221-228 DOI: 19179916

Richardson C, Jull G, Hodges P, et al. Therapeutic Exercise for Spinal Segmental
Stabilisation in Low Back Pain. Scientific Basis and Clinical Approach.
1st ed. United Kingdom: Churchill Livingstone; 1999.

Estlander AM, Vanharanta H, Moneta GB, et al. Anthropometric variables,
self-efficacy beliefs and pain and disability ratings on the isokinetic performance
of low back pain patients. Spine 1994;19:941–47.

Wessel T, van Tulder M, Sigl T, et al. What predicts outcome in nonoperative
treatments of chronic low back pain? A systematic review. Eur
Spin J 2006;15:1633–44.

Work conditioning, work hardening and functional restoration for workers with back and neck pain

In New Zealand most people who have been off work with chronic pain, and receive compensation from ACC, will have been a participant in some sort of fitness programme.  It’s almost a rite of passage for people to have a programme of functional restoration before or during an attempted return to work once the person has been off work for around 3 – 6 months.

There are a lot of different types of programme available:

• two of the Prof Mick Sullivan’Goal attainment’ programmes for sub-acute pain,
• Functional restoration programme – for sub-acute pain, involving activity with some ‘education’
• Pain management psychological services – for psychological strategies for pain management
• Activity focus programme – for chronic pain, involving activity and cognitive behavioural therapy approach for self management
• Multidisciplinary programme – a three-week intensive interdisciplinary programme with a cognitive behavioural approach, including reactivation

Occupational therapists unite: Wiihabilitation is more fun than prescribed exercises!

As the proud possessor of a brand new Wii and WiiFit, I’m a convert to the addictive powers of the Wii.  I’m not the only, and certainly not the first person to think of the rehabilitative potential of the Wii – in fact it’s been one of the most successful ‘cross-over’ toys that the computer geeks have come up with.

I am planning to use the Wii and WiiFit to study whether it can help develop balance, activity tolerance and especially increase proprioceptive awareness in people experiencing persistent pain and complex regional pain syndrome.  There are clinical guidelines I’ve just discovered here at RehabCare who have produced a podcast covering clinical practice guidelines for using the Nintendo Wii.  And I’ve just found an occupational therapist’s site called WiiHab!

Goal-setting – more than just for the New Year

Yesterday I had the pleasure of catching up with some of the participants from our three-week pain management programme.  It had been six months since they attended the programme, and it was time to see how they had got on.  Sadly for some it seemed that best intentions hadn’t lead to results, but for one in particular, life was very different.

As I listened to her talk about how life had changed, a comment she made really stood out.  She said ‘I looked back at what I had written six months ago and I thought how different things are now.  I’ve done everything I said I would do’.

The power of goal-setting – and not just setting the goals, but writing them down, then, as a certain brand of sportswear says ‘Just do[ing] it’.

One of the amazing things about her situation is that the last six months have not been plain sailing for her – she had two health set-backs that could have distracted her from her goals and been used as a great reason for not achieving.   But she drew on the skills she had developed from the programme, and turned the set-backs into opportunities for developing in other areas, then simply began again.

This person also talked about how the goals she had achieved made her feel.  She said that she was in control, she knew what she wanted and was going to do it, instead of pain, her case manager, her family’s needs, or even her health dictating what was important to her, she did.

A few weeks back I talked about goal-setting theory, and this woman’s experience is a great demonstration of how the theory works.

Just to review, Locke and Latham (2002) define goals as ‘the object or aim of an action, for example, to attain a specific standard of proficiency, usually within a specified time limit.’

Latham proposed there was a positive, linear relationship between difficulty and level of performance, and that having a target seems to work better because people have something to aim for, and are clear on what needs to be done.

Why goals work:They are directive, they energise, they affect persistence, they affect action indirectly by leading people to discover relevant information and strategies that they can use to achieve the goal.

Importance and confidence drive commitment to goals, and commitment is increased by being public about a goal, others inspiring action and being supportive, and seeing success along the way. A goal serves as the standard for evaluating one’s own performance, so the higher the goal, the higher the demand from the person, the less satisfied a person is with their current situation.

Self-efficacy or confidence is influenced by ensuring adequate training is available, and verbal communication that expresses confidence the person can do it. The combination of goals plus providing feedback is more effective than just setting goals – it’s important to monitor goals and record achievement.

With encouragement, people who start to develop new skills will find ways to extend themselves by setting themselves new goals.

When learning a new skill, specific instruction to ‘use your new skill to complete this task within 20 minutes’ will be more demanding but help learning and achievement much more than ‘complete this task as well as you can’. The pressure of getting the job done ‘as well as you can’ forces the person to revert to old habits which then interfere with learning the new methods – and ultimately slows the goal achievement too.

Small goals that are relevant to a longer-term goal will assist achievement and increase self efficacy – but often smaller, immediate goals are poorly formed and don’t actually contribute to the end-goal.
A good example of this is the use of exercise programmes for people who are on their way to returning to work with chronic pain. Exercise programmes may be great for increasing fitness and confidence to move despite pain – but to many people they become the focus for achievement instead of a step along the way to returning to work.

Exercise programmes are often provided in the assumption that a factor interfering with returning to work is general fitness. In fact, it seems that fitness per se is not the problem, it’s much more about confidence to carry out work tasks – which can only happen in the workplace. People don’t seem to generalise from a fitness setting to a work setting.

To return to the woman I described at the start of this post: she had written goals that were specific, she had smaller goals that she developed to help her achieve her long-term goal. She focused on what she had to do rather than the outcome (ie she said she wanted to be out looking for a job rather than ‘be in paid work’) – this is important because she can focus on her actions rather than having an outcome dependent on other people. And her actions are known to increase the chance of the end-goal being achieved.

When she had a set-back, she knew how to go about setting her own goals, how to use positive self talk, and how to monitor her progress. She was held to her goals by her family who supported her goal, and by returning to the review with us where she wanted to be able to tell us what she had achieved.

Learning for the day? Given the tools to do it, and goals the person thinks are important and that they feel confident they can achieve – not a lot can get in the way!

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