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Exercise Induced Analgesia

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Why does exercise make you feel good? The popular idea is that exercise gives you “endorphins,” and this explanation is actually not far from the mark. The word endorphin is short for endogenous morphine, which is an opioid “drug” that may start to flow when you move. In this post, I’ll provide a detailed discussion of various mechanisms for “exercise induced analgesia” including activation of the body’s pain inhibitory system. We need this system working well not just so we can get a runner’s high, but to help prevent chronic pain. Regular physical activity might be the best way to maintain its health and proper function.

Top Down Control Of Pain: Descending Inhibition

One key mechanism for exercise induced analgesia is descending inhibition of nociception, which occurs when certain brain areas suppress nociceptive signals in the spinal cord. This is called “top-down” control over pain, because the brain has an active say in whether pain occurs, as opposed to passively reflecting bottom-up signals from the body.

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For example, in an emergency, the brain might recognize that survival requires running, so it activates the descending inhibitory system to suppress nociception. (Interestingly, this suppression is selective, focused more on C fibers than fast acting A fibers, which means that “old news” about existing tissue damage is effectively tuned out, while the system remains alert to sensory information about new injuries  (Heinricher 2010).

The descending inhibitory system is generally activated by vigorous physical activity. During a marathon (which may be perceived as a minor emergency), the feet and knees may generate a lot of nociception, but much of it will be inhibited if higher brain centers determine that completing the marathon is a valuable goal. Not surprisingly, triathletes have supercharged descending inhibitory systems: they truly get high from running. People with chronic pain and fibromyalgia are at the opposite end of the spectrum – their descending inhibitory systems do not work very well at all, which is why they often feel worse not better during physical activity. Many experts believe that the behavior of the descending inhibitory system is a critical factor in explaining chronic pain (Ossipov 2012, 2015).

Key Anatomical Structures Involved In Descending Inhibition

The periaqueductal gray (PAG) was the first brain region shown to activate an endogenous pain inhibitory system, as its stimulation caused immediate pain relief (Kwon 2014). The PAG receives inputs from parts of the limbic system and brain areas involved in processing emotion, fear, and motivation. These connections are understood to be mechanisms by which thoughts and emotions can affect pain. For example, the PAG plays a role in the placebo response.

The PAG influences descending inhibition primarily through its connections to the rostral ventromedial medulla (RVM), which can also facilitate nociception. The decision about whether to facilitate or inhibit nociception is based on considerations by higher level brain areas about the meaning of the nociception and how to respond to it (Melzack and Wall 2014).

Just as suppression of pain could be advantageous in highly stressful or dangerous situations where other behaviors must pre-empt pain responses and recuperative behaviors in order to ensure survival, facilitation of pain could promote recuperative behaviors during illness, and enhance vigilance in situations where threat is possible, but not imminent.

(Heinricher 2009). Two types of neurons have been identified in the RVM as being responsible for pain modulation: on-cells and off-cells. Off-cells trigger descending inhibition, and on-cells create descending facilitation (Kwon 2014). The dynamic balance between on and off is dictated by behavioral priorities, fears, and other factors evaluated by higher structures in the brain (Heinricher 2009). It has been suggested that an imbalance toward facilitation may underlie pathological pain states (Ossipov 2012).

A primary target for descending modulation is the dorsal horn of the spine, which is the point where peripheral nerves connect to the spinal cord. The dorsal horn acts as a “gate” on nociception, because its sensitivity helps determine whether nociception moves from the body to the brain. Sensitivity is determined in part by ascending sensory information (the amount of nociception from the periphery), but also the descending modulation from the PAG-RVM system. Thus, inadequate inhibition can be an important cause of central sensitization and chronic pain states (Ossipov 2012).

There are a wide variety of chemical substances that act to inhibit nociception, including endogenous opioids, cannabinoids, serotonin, and catecholamines. For example, opiod peptides bind to opioid receptors on many parts of central and perisperhal nervous system, and this decreases the excitability of the nociceptors, causing them to fire less (Da Silva 2018).

Immune System Changes

Physical activity can also affect pain by causing complex changes in the behavior of the immune system, both locally and globally (Petersen 2005; Sluka 2018). For example, exercise can modulate the phenotype of macrophages in muscle, making them more likely to release anti-inflammatory as opposed to pro-inflammatory cytokines. There is research indicating that regular exercise can reduce the level of circulating inflammatory cytokines in the bloodstream, in patients with fibromyalgia and healthy controls. Other research shows that regular exercise may reduce glial cell activation in the central nervous system, reduce inflammatory cytokines, and increase anti-inflammatory cytokines in the dorsal horn (Sluka 2018).

Conditioned Modulation

Another reason exercise may kill pain is through conditioned pain modulation or “CPM” (also referred to as diffuse noxious inhibitory control or counter-irritation). CPM describes the phenomenon whereby “pain inhibits pain.”

CPM has been studied for at least 70 years, because it’s fairly easy to study. Experiments usually look something like this: (1) a person receives a noxious stimulus (such as pressure) and reports pain level, and then (2) the person is exposed to a painful “conditioning stimulus”, such as cold water immersion of the hand, and then (3) the person receives another round of the initial noxious stimulus and reports pain level. Usually, the second round will feel less painful, and the degree of pain relief is considered a measure of how well the descending inhibitory system is functioning.

Here are some interesting facts about CPM:

  • CPM is the likely mechanism for pain reduction in a wide variety of manual therapies, including deep tissue massage, acupuncture, dry needling, instrument assisted soft tissue manipulation, and foam rolling. If any of these treatments help with your pain, it is likely that you can get the same effect from the right kind of exercise.

  • CPM is less effective in patients with IBS, TMJ, tension headache, fibromyalgia and depression (Yarntisky 2010).

  • Pre-operative CPM efficacy predicts post-operative pain levels, including which patients transition from acute to chronic pain (Yarnitksy 2010).

  • CPM efficiency predicts the strength of exercise induced analgesia, and they probably rely on at least some common mechanisms (Stolzman 2016).

  • People who frequently engage in vigorous activity have enhanced CPM compared to less active people (Sluka 2016).

Can We Improve Descending Inhibition Through Exercise?

We know that physical inactivity is a risk factor for chronic pain, that exercise stimulates the pain modulatory system, and that a healthy balance in the system is necessary for avoiding chronic pain. This raises the question of whether regular exercise is a way to maintain and recover the proper function of the pain inhibitory system. Sluka and colleagues propose that the answer is yes:

regular physical activity changes the state of central pain inhibitory pathways and the immune system to result in a protective effect against a peripheral insult.

The evidence in support of this contention is confusing and mixed, but there are some encouraging results. In addition to the research discussed above, it has been shown that regular aerobic exercise is an effective treatment for fibromyalgia, and can also increase tolerance to ischemic pain in healthy individuals (Sluka 2016; Ellingson 2016). On the other hand, it has been found that aerobic capacity does not predict pain level in response to a given stimulus, and several studies show that exercise can cause pain in fibromyalgia or lead to flareups (Ellingson 2016). In general, almost any kind of exercise seems to help with almost any kind of chronic pain, but the effect sizes tend to be small.

Closing Thoughts

Exercised induced analgesia is not just about getting some temporary feel-good chemicals from a jog or weightlifting session. It is about tuning up a system whose proper function is necessary to keep you feeling good all the time.

A word of caution about the physiology discussed here: it’s very interesting to learn about all of the individual micro-level players in the descending inhibitory system, but we must remember that they interact in highly dynamic and complex ways. Therefore, their collective effect may be very hard to predict by analyzing the separate parts. For example, serotonin inhibits pain in some contexts but facilitates it in others. This is why therapies aimed at very specific targets (especially drug therapies) may have unintended effects, or even cause the opposite of the intended effect.

In my view, the more practical perspective is to keep in mind the purpose for which the descending inhibitory system evolved, which is to help you perform personally valued movements in the face of potential physical danger. Descending inhibition is there to keep you moving even when the movements are generating some nociception, especially when those movements are meaningful and intrinsically motivating. To keep the system healthy, challenge it to perform this function at a goldilocks level of intensity as often as possible, and see if it adapts to get better at its job.

This is how we improve the function of all the different bodily systems that help us move around, including muscles, tendons, bones, and the cardiovascular system. When they are put under an appropriate level of challenge or stress to do their jobs, they get better at doing them. Perhaps something similar holds true for the descending inhibitory system. Find movements that make you feel good, or that at least give you a “good pain,” and do them frequently.

References

Da Silva Santos R, Galdino G. Endogenous systems involved in exercise-induced analgesia. J Physiol Pharmacol. 2018;69(1):3-13. doi:10.26402/jpp.2018.1.01

Kwon M, Altin M, Duenas H, Alev L. The role of descending inhibitory pathways on chronic pain modulation and clinical implications. Pain Pract. 2014;14(7):656-667. doi:10.1111/papr.12145

M.M. Heinricher, Tavares I, Leith JL, Lumb BM. Descending control of nociception. 2010;60(1):214-225. doi:10.1016/j.brainresrev.2008.12.009.Descending

Ossipov, Morimura. Descending pain modulation and chronicification of pain. Curr Opin Support Palliat Care. 2015;9(1):38-39. doi:10.1097/SPC.0000000000000055

Petersen AMW, Pedersen BK. The anti-inflammatory effect of exercise. J Appl Physiol. 2005;98(4):1154-1162. doi:10.1152/japplphysiol.00164.2004

Polaski AM, Phelps AL, Kostek MC, Szucs KA, Kolber BJ. Exercise-induced hypoalgesia: A meta-analysis of exercise dosing for the treatment of chronic pain. PLoS One. 2019;14(1):1-29. doi:10.1371/journal.pone.021041

Price TJ, Ray PR. Recent advances toward understanding the mysteries of the acute to chronic pain transition. Curr Opin Physiol. 2019;11:42-50. doi:10.1016/J.COPHYS.2019.05.015

Sluka KA, Frey-Law L, Hoeger Bement M. Exercise-induced pain and analgesia? Underlying mechanisms and clinical translation. Pain. 2018;159(9):S91-S97. doi:10.1097/j.pain.0000000000001235

Ellingson LD, Stegner AJ, Schwabacher IJ, Koltyn KF, Cook DB. Exercise strengthens central nervous system modulation of pain in fibromyalgia. Brain Sci. 2016;6(1):13. doi:10.3390/brainsci6010008

Melzack and Wall. Textbook of Pain Ed. 6.

Zhuo M. Descending facilitation: From basic science to the treatment of chronic pain. Mol Pain. 2017;13:1-12. doi:10.1177/1744806917699212

Yarnitsky D. Conditioned pain modulation (the diffuse noxious inhibitory control-like effect): Its relevance for acute and chronic pain states. Curr Opin Anaesthesiol. 2010;23(5):611-615. doi:10.1097/ACO.0b013e32833c348b

Alsouhibani A, Vaegter HB, Bement MH. Systemic exercise-induced hypoalgesia following isometric exercise reduces conditioned pain modulation. Pain Med (United States). 2019;20(1):180-190. doi:10.1093/pm/pny057

Stolzman S, Bement M. Does exercise decrease pain via conditioned pain modulation in adolescents?”. Pediatr Phys Ther. 2016;28(4):474. doi:10.1097/PEP.0000000000000313

Ossipov MH. The Perception and Endogenous Modulation of Pain. Scientifica (Cairo). 2012;2012:1-25. doi:10.6064/2012/561761

Yamamotová A. Mechanisms of exercise-induced hypoalgesia. Psychiatrie. 2018;22(1):33-38. doi:10.1016/j.jpain.2014.09.006.Mechanisms

How Often Should My Patient Do Their Exercises?

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One of the most common questions I get asked, after “which exercise is best to fix back pain?” is….

“How often should my patient do their exercises?”

One of the things we have to remember is that “how often” or FREQUENCY is tied into the INTENSITY and EFFORT and therefore need for REST & RECOVERY, and the one thing under-discussed and often unreported in studies is intensity!! We could do 3×10 or 5×5 or whatever, but without the accompanying intensity, the sets and reps don’t really mean that much.

Intensity and effort often get used interchangeably, if there is a technical difference to discern then intensity is more about the objective measures we make e.g. heart rate whilst running, and effort is more how hard we perceive this to be, so rate of perceived exertion (RPE) would be a subjective measure with the Borg scale designed to relate to current working heart rate. So whilst technically not exactly the same, intensity & effort do have a strong relationship in my opinion and RPE can be used clinically as a simple, rudimentary measure of intensity.

This does not mean that all exercises have to be intense, it might need to fit the current sensitivity of the patient and this lower intensity can often be done more regularly, and for many just moving in a non-threatening way might suffice. But there may also need to be progression and this can be where lots of therapeutic exercise programs can fall down as they are looking for a single exercise/dosage.

Based on the current data with exercise my personal belief is that the dosing such as intensity and frequency are probably more important than the TYPE for some people!

I wrote about this a while back –  “Exercise dosing for pain is not he same as exercise doing for fitness”

What Is The Aim Of The Exercise?

 

Your clinical reasoning should really determine which exercise, how much, and how OFTEN!

Now there is a fair bit of discussion of whether ‘general exercise’ is better than ‘specific’ exercise whatever those two things are exactly, but my personal belief is we should always have some reasoning around WHY we are doing something. Unfortunately, although it’s a simple answer I just don’t really see “just do some exercise” as being THE answer to back pain for example.

So what is the aim? Well, we often have two main types, a more physical adaptation aim or a pain/function-focused aim.

Let’s start with the physical adaptation side of reasoning.

Strength

So strength and strengthening often get used interchangeably but might be different. Actually increasing force production or strength can require some intense exercise and higher effort levels. Sets and reps are often programmed but not the intensity as previously discussed. You could do strength programming variables but without sufficient intensity, and therefore you may not need the same rest as with more intense training but also might not get the same benefit. The load here should really dictate the reps as stopping at 5 reps with another 5 in the bank because the load is too light isn’t really going to cut it.

Our views of programming are changing with regards to strength and hypertrophy but intensity matters here and therefore frequency does too.

Load/Tissue Tolerance

This is a common aim, the concept of ‘strengthening’ an area to take a bit more load or activity.  A common mistake is to assume painful movement or being intolerant to an activity or load is CAUSED by excess load. Load is a very catch-all term and ANY painful movement or joint could be described as being load ‘intolerant’ if it causes pain, this would be a basic correlation NOT causation mistake.

Generally heavier loads are advocated and therefore higher intensities and lower frequencies although we really don’t know that much here, load tolerance I doubt is a solely tissue phenomenon.

In some cases a load tolerance approach might work by actually taking away load as much as a stimulus to increase tolerance, so addition by subtraction. We simply keep the body moving whilst taking away an aggravating load is a plausible rationale especially with exercises of limited intensity.

How does your exercise prescription also fit in with the other stuff the person is doing? This also should tie into your reasoning around frequency. With very active people, where volume might be an issue, sometimes LOWER intensity exercise performed more FREQUENTLY can also be of benefit.

The Spanner In The Works & Graded Approaches

 

It would all be so easy if therapeutic exercise was just about physical variables such as strength, but unfortunately, it’s not. We all know it’s great to get parameters to work with but anyone who has been in clinic knows that the real test is in how the person RESPONDS.

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It’s the interplay between intensity, frequency and PAIN that’s that really should guide us rather than theoretical parameters for fitness. And it’s not just pain as a sensation but the person’s beliefs and behaviours in response to and around pain in general that also need to be considered.

Graded activity and exercise are concepts that relate a bit more to habituating to pain and graded exposure to cognitive factors such as fear or catastrophizing. Here we don’t have ANY real parameters apart from those that are based around physical ability and pain tolerance. So frequency is really a thing that is tough to set BEFORE you work with someone. This is part of the inherent uncertainty in therapy that we have to get used to but can be guided by a thorough history of pain and exercise participation.

Graded Activity & Exercise

These are approaches that originally looked at improving chronic fatigue but are equally applicable to pain too. Again the intensity is important, if we are pushing the level of grading towards the more intense then longer rests and decreased frequency might be important. If more about building a movement HABIT then less intense and more frequent.

Graded Exposure

Graded exposure is slightly different in that it is more about cognitive factors such as fear and anxiety around moving than pain or actually than a physical change. But frequency is NO LESS important. True exposure sessions are mentally fatiguing and because of this physically and emotionally tiring. If we want to reinforce this with additional work at home we would have to consider this in terms of frequency and individual levels of fatigue.

Reasoning In Action

 

Here is how my reasoning might work with the two different aims. I like to use effort level as a guide to intensity as it is a simple subjective measure that is easy to use clinically across a variety of exercises/activities and I find rate of perceived exertion (RPE) is good for this. Now intensity and effort are NOT the same thing but generally the more intense an exercise the more effort is required especially the more of it you do.

Physical

Although the data around adaptation and reps/sets/intensity is definitely changing compared with what I was taught back in the 90’s, I still think that intensity is key for physical adaptation. With more intensity, we need more rest so frequency might only be 2/3 times per week. Bodybuilders were smart at training regions of the body on different days to maximize recovery whilst also getting in their overall training needs.

So we probably need at least a 7/10 RPE.  If you are looking for strength (force production) then I would say we should probably bias heavier mass to create that intensity too.

Tolerance might be different in that intensity could be created by a lighter load but you have to get in more reps to make the intensity. If we think about all the different activities and types of loads coupled with access to loading equipment then adjusting load and reps for intensity helps us a bunch. Remember that all this also ties in with their current level of sensitivity too and we often have to adjust this based on responses.

Graded

My reasoning here would be how can we build a HABIT of moving. HABITS are built more by frequency than intensity.

So let’s identify something that is going to be valued or ties into the values. We don’t always have to enjoy things but we do have to see a worth in doing them to continue to do them. Based on how someone’s pain behaves in terms of types of activities that trigger, severity of pain and how much it takes to do so (irritability) we can start to build a picture and reason a  dose of that activity.

So although we still have to be guided by the person’s RESPONSE, I would aim for intensity lower (3-5 RPE) and a frequency of daily or every other day, remember it does not have to be the SAME activity/exercise that is performed each time.

It is important to remember where you start with frequency and intensity should not be where you finish with it, but sometimes we need to start lower to get higher!

Key Points

 

  • Just go do some exercise might be why lots of exercise programs ultimately fail
  • Sets and reps also need intensity/effort
  • Intensity is relative to what you want to achieve and intensity dictates frequency
  • It’s often about trial and error
  • Get used to it!

Amazing Low Back Exercises to Try Right Now.

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Sometimes coming up with exercises in your clinic room can be difficult. Even more difficult is finding some that you can recommend as good home care.

Last week we went over how to do a great exercise called the “Dead Bug”.

This week we’re basically going to flip that over and progress the exercise to something called the “Bird Dog”.

What I love about these, is you can do it right on your table, and they’re easy for a patient to do at home.

Once your patient is confident with doing this exercise on top of the swiss ball, we can make things more difficult by removing the swiss ball.

This can still be easily done on your table in your clinic room, but it’s just a bit more difficult and will build a bit more confidence than when you’re using the swiss ball.

 

Now we can ramp things up just a bit more after your patient is confident with these movements.

By using an exercise band we can make things just a little more difficult and still build more confidence in movement with our patients.

Give these a try.

Doing movements like these will reinforce everything you did with your hands on the table and bring about greater outcomes with your patients.

If you’d like to learn more on how to incorporate more things like this into your treatments, and generate greater outcomes, register for our newest online course “Clinical Applications Of Pain Management Using Therapeutic Movement” by clicking HERE

4 Ways to Bring These Low Back Exercises to the Next Level

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The dead bug is one of the more popular exercises to help strengthen the low back. However, there are mutliple variations you can use in order to help your patients rehab a low back injury, or even non-specific low back pain.

Here are just a few variations you can use, starting with the simplest version.

Once your patient is really comfortable doing this simple version, and can do it with minimal discomfort for how ever many reps and sets you decide, then you can start to make it more difficult.

This next version is good as you’re more involved in the exercise with them. 

Just grab an exercise band and give them some tension while the use the band to stabilize the shoulders and strictly use the lower body for the movement.

 

This next version is only providing some stabilization through one shoulder, while the other shoulder and opposite leg do the work. 

If you don’t have a dumbbell or weight in your clinic, you can stand to the side with an exercise band and provide tension similar to how you did it in version #2.

This final version also involves an exercise band and makes the exercise just a bit more difficult, and a bit more coordinated.

If your patient is able to do all of the above variations this is a great option to continue increasing the difficulty and helping your patient with their low back strengthening.

As always your reps and sets will be up to your clinical decision making along with combined goal setting with the patient. Doing therapeutic movement with your patients doesn’t have to be complicated and most of what you need to do can be done right in your treatment room.

We just have to instil the confidence in patients that they are capable of doing it, while working together with them in their goal setting. Be confident and try doing some more exercises and movement with your patients. It will not only benefit them, but your practice as well. 

Does Exercise ‘Work’ For Pain? – Scrutinizing The Question!

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Exercise has become a popular treatment for many musculoskeletal issues over the past few years but surprisingly little is actually understood, even after tons of research, about how to use it in clinical practice and maybe even if it’s worth using?

In this blog, we will look at the actual question of “does exercise ‘work’ for pain” as ‘works’ tends to be a phrase that gets bandied about a lot without much clarity. Similar to “the research shows” when often the deeper you dive into the research the LESS clear it often becomes, especially around pain.

I will write a few more posts on the “everything works/nothing works” perspective, how it might work and how specific we may need to be in future posts.

Well Does It Work?

 

Well, it depends on what you mean by work? Which condition? What are you comparing it against? Do you mean pain? Do you mean disability? Did it have an effect on physical function or some biomotor variable? All of these things are quite different questions that often get lumped into the catch-all term ‘works’.

We need to think as well about WHY we might come to a conclusion on if it ‘works’ or does not. Is it because I have read widely in this area? Is it because who I follow on Twitter tells me it does or doesn’t or am I simply following my biases? A little bit of epistemology perhaps.

Like ANY intervention, exercise should be thoroughly scrutinized and the basic reality is we have to be prepared that exercise will not work for everybody, it is not a magic bullet or panacea and a lot of what we do is a bunch of informed trial and error really, but we will come back to that later in another post. We have to remember we are dealing with HUMANS who tend to be wonderfully variable in their responses as most biological organisms are.

We now discuss pain as being a complex, multifactorial experience (blah blah blah) so why do we expect one thing to come along and solve it all for everybody? For some it will be revelatory, for some, it will do very little and for others, even flair them up, so we need a bit of perspective but as a standalone treatment I think there is a lot to like here especially with the benefits for our health and well-being.

Just Hurry Up And Tell Me…..

 

The whole idea of “it works” could stem from how we have traditionally looked at the research. To show a difference between two interventions or ‘usual care’ it has been common to use a significance level of p = 0.05 to indicate something ‘works’, so the observed difference in effect between two groups is likely to be at least as big as reported and this then is used to reject or accept the hypothesis of a study. Generally, something like “treatment A WORKS better than treatment B” or something along those lines. Is exercise better than manual therapy? Is it better than usual care? You get the picture. I am no statistician or researcher, only a humble clinician so bear with me here.

So we might say exercise is better than usual care or whatever else, but the real question should be HOW MUCH better or the actual magnitude/size of the difference. The p-value is a statistical tool and not a measure of the actual average size of the effect. Something can be statistically significant without really making a difference to our patients and this is where minimal clinical important difference comes in (MCID).

A clinically meaningful change for pain has been discussed as being somewhere between 1-2 points on an 11 point VAS/NPRS dependent on what it is being tested against such as ‘usual care’ or another specific intervention. Other magnitudes of clinical significance have pointed a 20% or 30% change from the baseline and this makes sense as a 2 point change for a baseline of 4 is far more significant than a 2 point change on a baseline of 8 for example.

We have to be aware that these cut-off values such as 0.05 are also a bit arbitrary. If we critique the significance of p = 0.05 then we probably have to do the same for MCID too. The real value of any effect may only really be possible via subjective evaluation by the person experiencing them and their expectations of what that change should be.

We may also have to consider how we view the ‘mean effect’ as this may not actually reflect THE effect that MY patient gets (for a whole load of potential reasons). The mean represents the average response and is sensitive to those that respond very highly and also people who respond lowly or even negatively. In trials with small sample sizes, as much of exercise & pain-related research is these more extreme values can significantly alter the mean.

We should also take into account the standard deviation of the mean response and this is a measure of the variation within the group of participants being studied. This could mean (get it…) that the variation in response when applying the treatment in the clinic could also be pretty wide too. A confidence interval (CI) is another measure of uncertainty/variability around the potential treatment effect on a wider population. The CI reflects the inherent variability/error in the process of sampling taking into account the size and variation within the sample.

The last question here is does exercise research always reflect clinical practice? Personally, I tinker with the type of exercise, intensity, frequency, volume etc to ‘optimise’ for the person whether that’s in relation to their response or ability to achieve the program. If I am not getting the desired response then I feel quite at home playing with the variables. Is this right or wrong? I have no idea but standardized programs used to study exercise often don’t do this.

You Really Didn’t Answer The Question…

 

So what was the point of all this, well we can start to see that “it works” is a pretty nebulous term really. It’s the classic clinical conundrum of applying the world of research to our patients and how we should expect them to respond. Predicting the future is always tough and worlds of research and clinical practice is definitely not a game of certainties.

We have to consider the actual size of what ‘works’ and how likely is my patient to actually respond in this way and I see it as a bit of a “probability wrapped up in a probability”. This often makes clinicians feel uncomfortable as we tend to like certainties and sometimes research can be portrayed as more certain than it really is IMO.  But we really have to look at the trials, who they are studying, how many people, what exercise/dosage and what’s the spread of responses amongst other things to even get close to answering the question.

Next time we might actually answer the question ; )

3 Exercises To Help Patients With Back Pain

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As you know, we’re big advocates for therapeutic exercise around here.

This is one of those occasions where I’ve had to do some self care to help a little pain spot I deal with. On the left side of my mid to lower back I get this one little spot that flares up once in a while. so I went to a friend of mine to get a little work done in the area.

They recommended doing some back extensions on a machine at the gym, however, most of us don’t have access to a gym in our clincs.

So, I figured out a way that any of us could do some effective therapeutic exercise right in our treatment rooms just using a theraband, and here’s what I came up with.

Here’s how to do an Isometric, Concentric, and Eccentric load for extension.

 

Here’s some ideas for rotation.

Another great exercise for rotation is the Palloff Press (also one of the exercises my friend recommended for me). This is usually done with a cable machine at the gym but can easily be done with a theraband as well.

Takeaways

  • Communication with your patient regarding comfort level for length of time and repetitions are key.
  • Start with isometrics, then move on to concentric, then eccentric.
  • Remember, a bit of discomfort is okay, just don’t cause pain with the exercise.
  • Make sure your patient is comfortable doing the eccentric portion as it may cause more muscle soreness.

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