3 Exercises To Help Patients With Back Pain

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.

What Kind of Exercise is Healthiest?

Physical activity is now considered one of the “big four” lifestyle factors (along with smoking, nutrition, and drug abuse) that have major effects on health. In 2015, the Academy of Medical Royal Colleges put out a report summarizing the benefits of exercise, calling it both a “miracle cure” and a “wonder drug.” [1] The report observes that regular exercise can prevent dementia, type 2 diabetes, some cancers, depression, heart disease, and other common serious conditions — reducing the risk of each by at least 30%. This is better than many drugs.

A recent analysis of data from more than 60,000 respondents found that people exercising 1-2 times per week had a 30% reduction in all-cause mortality compared to those who got no exercise. There was a 35% reduction for people who exercised 3-5 times. [2] Similar studies have concluded that a sedentary lifestyle is a primary cause of 36 diseases, and that exercise is an effective treatment to prevent them. [3, 4] Numerous experts have observed that if exercise came in a pill, it would be the most effective and widely prescribed medicine ever developed.

While the evidence supporting the health benefits of exercise is undeniable, I don’t find the metaphor of it being “medicine” totally appealing. First, medicine is something most people would rather not take, so the marketing is not very good. Second, the term medicine suggests cure of a particular disease, which is misleading.

Physical activity can improve your health in many different ways, just as light, water and soil will nurture a plant. But it’s not a targeted intervention that “fixes” a specific problem.

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I think a better metaphor for the benefits of physical activity is one recommended by Katy Bowman and Nick Tuminello: movement is like food. This analogy works on many different levels. First, nutrients in food are beneficial when consumed in some goldilocks amount — not too much and not too little. For example, you need a minimum dose of iron to avoid anemia, but too much is toxic. Many kinds of inputs to the body follow this pattern, even water. With physical activity, some minimum amount is essential, too much is toxic, and there is a broad range of happy mediums.

Another analogy between food and movement is that you need a well-balanced diet of many different nutrients, all of which have a different optimum dose. If you have a deficiency in Vitamin A, it won’t help to double up on Vitamin B. The same is true of physical activity. The bench press is a fine exercise, but if that’s all you ever did, you would become deficient in other areas of physical function.

If movement is like food, how do you eat a balanced diet? Part of the answer is that … it depends. A twenty-year-old athlete will need a different diet of movement than a 65-year-old with knee pain. In fact, two 65-year-olds with knee pain might benefit from completely different programs. To find what works best for an individual, you will need to explore a wide landscape of different options. The good news is that some parts of the landscape are more worth exploring than others. To get a rough idea where they are, we can look to two sources of data: (1) formal recommendations from government health groups; and (2) research analyzing the physical activity of hunter-gatherers living in natural environments. I think of these guidelines as major landmarks for orientation on the movement landscape. Fortunately, they both point in the same basic direction.

Recommendations From Health Groups

Numerous governmental agencies, including the World Health Organization, the U.S. Department of Health Services, and the National Health Service in the U.K., have published physical activity guidelines. [5, 6] They are based on expert analysis of the voluminous research looking at physical activity, fitness, and health. Here is a brief summary of their advice, which is almost the same for each source.

The Amount

The guidelines suggest at least 150 minutes per week of “moderate” physical activity or half as much “vigorous” activity. (See below for definitions.) But this is just the minimum, and a better goal would be 300 minutes of moderate activity per week. Adding more exercise may continue to reduce mortality until as much as 750 minutes per week, after which point the health benefits of physical activity seem to flatline. [7]

“Moderate” Activity Defined

Moderate activities are usually light aerobic exercise — continuous cyclic movements done at an easy pace. Examples include:

  • brisk walking

  • hiking

  • gardening or yard work

  • jogging, cycling, or swimming at an easy pace

Moderate exertion feels like you are working, but not in a way that is unpleasant or difficult to continue. Heart rate is about 60-80% of maximum, and breathing rate is elevated to a point where it would be difficult to sing, but easy to talk. You may break a light sweat but will not become significantly overheated. After finishing a session of moderate physical activity, you could probably complete another one if necessary.

“Vigorous” Activity Defined

Vigorous activity is higher intensity work that can be either continuous or intermittent. Examples include:

  • resistance training with weights, machines, bands, or bodyweight

  • sprinting or high-intensity interval training on a cycle or rowing machine

  • continuous running, cycling, swimming, or rowing at a challenging pace

  • heavy manual labor

During continuous vigorous activity such as running or cycling, you are approaching the fastest pace you can sustain for twenty or more minutes. Your breathing rate is high enough that you cannot have a conversation. Intermittent activities like weight lifting, sports or sprinting cannot be performed continuously, but only in intervals. Vigorous physical activity feels hard and requires willpower to continue. When you are finished, you will probably want to rest at least a day before completing a similarly tough workout.

Movements That Challenge Strength

Most guidelines recommend that the above weekly totals should include at least two sessions that maintain or build strength in all major muscle groups. Although the majority of research on physical activity relates to aerobic exercise, there is a large and growing number of studies showing equally impressive health gains from strength training. Some of these benefits are not available with aerobic exercise, especially preservation of muscle mass, which declines with age, often to a point where function is significantly compromised. [8]

Movements That Challenge Mobility And Basic Coordination

Some popular guidelines, but not all, recommend inclusion of movements that maintain functional ranges of motion, and basic movement skills like squatting or single-leg balance. This doesn’t mean you need exercises specifically devoted to this purpose, such as stretching or corrective exercise. Many common activities challenge mobility and functional movement skills, including dancing, swimming, martial arts, gymnastics, climbing, calisthenics, or classic compound strength exercises like pushups, pull-ups, rows, presses, squats and lunges. On the other hand, if all you do is bike or run, you will not be challenging your mobility or coordination very much.

Physical Activity Levels Of Hunter-Gatherers

Another way to approach the question of how to move is to consider the physical activity levels of humans living in more natural environments. This is the same logic you would apply to analyzing the health needs of any other animal. If you had a pet cheetah and wanted to know how much running she should do to maintain good health, you would try to learn something about how much cheetahs run in the wild. If you had a pet chimp, you would take him to the climbing gym, not the swimming pool.

Anthropologists who study hunter-gatherer cultures observe that they generally enjoy excellent health and fitness, and have low to non-existent rates of chronic diseases associated with a sedentary lifestyle. [9] They engage in high levels of physical activity, but certainly do not consider it to be exercise or medicine. [10] Movement is simply inseparable from almost every meaningful event in their lives. Although each hunter-gatherer culture has a different lifestyle, there are some general patterns and averages that are informative.

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Men usually spend the day hunting, which requires lots of walking, occasional jogging, and the odd sprint. They sometimes climb trees, dig to find tubers, and carry food back to camp, which must be butchered. Women generally spend their days gathering plants and also caring for young children, who often must be carried. Back at camp, men and women engage in toolmaking, and food preparation. Downtime is spent sitting on the ground in positions like squats that challenge lower body mobility. [9]

Although they are moving all day, the pace is not grueling. Recent studies on the Hadza tribe in Tanzania show that they do about 135 minutes per day of moderate to vigorous physical activity. [11] That’s about 900 minutes of activity a week, just a bit past the point at which recent studies have found that adding more exercise stops providing any significant additional health benefits in terms of reduced mortality.

Some days involve hard work, but they are usually followed by easy days. Presumably, some days will involve maximum intensity effort, such as sprinting or carrying a heavy load. Interestingly, activity levels do not decline much with age. The 65-year-old elders keep up just fine with the young adults. A good percentage of the total workload is walking 5-10 miles per day. If you think in terms of steps, this is about 10 to 20,000.

How does this organic, all-natural program for fitness compare to the standard-issue government cheese? There are some obvious similarities. The majority of the work is moderate continuous movement like brisk walking. Vigorous activity is a smaller percentage of the whole and includes work that challenges strength (climbing, digging, carrying, butchering) or power (sprinting).

Many of the activities require mobility, coordination, and balance, such as walking over uneven terrain, climbing, and scrambling, digging, lifting and carrying odd-shaped items, throwing, and sitting on the ground. One major difference is that hunter-gatherers do a higher volume of low-intensity work, even compared to highly active modern humans. They are not doing more bench presses, but they are getting in more steps.

Interestingly, walking is exactly the type of physical activity that modern humans would probably like to do quite a bit more, if only they had the time. Paddy Ekkekakis studies motivation to exercise and observes that although high-intensity exercise is quite effective at delivering health benefits quickly, most people don’t do it because … (prepare to be shocked) … they don’t like it. But people tend to enjoy walking. Under the right circumstances, say being with a friend in a nice environment, they do not consider it to be exercise at all, but an enjoyable and invigorating experience that delivers immediate rewards.

Another notable feature of walking is that it provides health benefits with only a minimal risk of injury. More intense exercise (e.g., a set of barbell squats) offers a relatively narrow window between too much and not enough. The difference between a good workout and an injury might be just a few extra reps or plates on the bar. But the margin of error with walking is huge. After a healthy dose of walking, most people could double it and recover easily.

It makes sense that walking delivers the highest bang for your buck because this is the movement we are best adapted to perform. Like any other animal, our primary physical function is locomotion, and walking is the most energetically efficient way to get the job done. If you did nothing else but walk a lot, you’d be in better shape than most Americans.

A Quick Summary

If you want to “play” with fitness as a way to improve general health, here are some “rules of the game” to keep in mind. Have as much fun as possible within these basic constraints:

  • Aim for at least half an hour and up to two hours of physical activity almost every day.

  • Movement should be varied in terms of volume, intensity, and type. Most activity can be fairly light. Walking is the most natural and beneficial movement for human beings.

  • Every few days, include some high-intensity work that significantly challenges your strength, power, and/or capacity to sustain high energy output for a short period of time. Climbing, running and resistance training are logical choices.

  • Include movements that challenge coordination, balance, and range of motion.

Or to put this in even simpler terms:

  • Move around a lot at a slow easy pace.

  • Frequently move with some urgency or pick up something heavy.

  • Every once in a while, move like your life depends on it.

And have fun!

Physical activity isn’t like taking medicine, you know.


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The preceding was an adapted excerpt from my new book called Playing With Movement: How to Explore the Many Dimensions of Physical Health and Performance.

In Defence Of The Advice To Remain Active For Back Pain

There has recently been some discussion around a lack of evidence for the advice to remain active during back pain. I personally believe there is a lot of value in the advice to stay active and here is why!

Firstly this HERE is from the folks over at Cochrane.

“Moderate quality evidence shows that patients with acute LBP may experience small improvements in pain relief and ability to perform everyday activities if they receive advice to stay active compared to advice to rest in bed. However, patients with sciatica experience little or no difference between the two approaches”

It is important to highlight the current state of play with regards to the evidence base, that there is MODERATE evidence of a SMALL relief for pain and this pretty much is in line with most other current recommendations/treatments that we have for back pain at this point.

Now I am going to give you a bit of my opinion as well!

Being active, IMO : ),  is NOT a treatment. It’s about being a human being and getting on with your life even though you have this very normal part of the human condition…..back pain.

It’s About Belief

Certainly, we don’t want to demonize the idea of resting or taking it easy if things are too painful, that is not evidence-based either, but we also know that the dominant view of back pain seems to be that we should rest it out and that for quite a few people the belief is that activity can be problematic for back pain.

This is highlighted in the two papers below that look at people’s opinions around what affects pain in the positive AND negative.

Darlow 2014 – Beliefs about back pain: The confluence of client, clinician and community.

Setchell 2019 What decreases low back pain? A qualitative study of patient perspectives

We also have two recent papers that form an interesting pairing when viewed together. Firstly we have a self-reported perspective of what triggers back pain flares from anyone who had had back pain at any previous time point (so maybe more a test of perceptions?). Here they found that physical activities and movements dominated the vast majority of the cited reasons for flare-ups

Costa 2019 – What Triggers an LBP Flare? A Content Analysis of Individuals’ Perspectives

Then we have a paper that looked at the same subject but asked the people to report it in a different way (longitudinally), at 3-7 day intervals over 6 weeks, and they found that physical activities were not so related to flares of back pain.

Suri 2018 – Do Physical Activities Trigger Flare-ups During an Acute Low Back Pain Episode?

The implication might be that when we ask people to remember what triggered their back pain it is a simple ‘go-to’ blame physical activities (especially when other things are not considered), but when the flare-up is more recent, 3-7 days, and presented with different reporting options the association between physical activity and flare-ups seems to decrease.

This highlights for me societal beliefs around the back and its relationships with activity and that we should be counteracting this idea in healthcare as much as possible!

It’s About Positive Messages

Overcoming some of the negative beliefs that we have around the body, pain and physical activity should be a goal of healthcare interactions. There are SO many NEGATIVE messages that we need some positive ones too.

I think the advice to remain active is such a message. Trust your body, get on with things, you will be OK! This is a strong, simple, and important message from my perspective.

There is the very real potential that there is not that much that can be done in the short term for acute back pain with advice and reassurance being pretty much all we have.

But could our short term attitudes impact on the longer term?

Short Vs Longer Term

What we do seem to have some data on is that having low pain self-efficacy, or the ability to go about our lives WITH back pain, does appear to have some relationship with outcomes of back pain in the longer term (this also seems to be apparent in other MSK conditions). In this paper HERE from Foster – 2010, we see that low pain self-efficacy is related to worse disability outcomes at 6 months.

The question is how do our own attitudes, and other people’s attitudes as well, towards our backs influence our behaviours? Food for thought perhaps?

Key Messages From Advice To Remain Active

Hurt does not equal harm – It’s OK to function with some pain, especially if it is not worsening and within tolerable levels. Pain does not give a reliable indicator of what’s happening within our bodies.

Rest is not the best treatment – Resting the back is unlikely to simply make it better and not much is likely to significantly change how the back responds in the short term.

Activity is not bad – Activity is not simply related to pain or damage. In fact limiting activities you enjoy might actually make the impact of back pain on your life worse.

Motor Learning Pitfalls and Autonomic Resilience

Sometimes, I’ve found that teaching a movement cue to a client can backfire.

Coaching a neutral pelvic position or a braced core to do exercise, for instance, are great techniques to perfect a squat and deadlift and train a person to lift a heavy load. However, if a client experiences pain or discomfort out of a regimented exercise setting, are these necessarily the best strategies to focus on?

Very often, I’ve seen individuals become extremely hyperaware of their body mechanics, whether it was due to cues from a clinician or because the assumption is that patterns from high-load fitness routines need to be maintained outside the gym.

My experience is that this can result in a couple of problems.

Pain Science

 

One is a concept that you’re likely familiar with by now; that being catastrophization. If we, as clinicians, don’t mind our language during our movement coaching, often enough, a person can develop a belief that anything outside of these trained movement cues will result in injury.

As you can guess, believing that “losing form” will equate to pain can lead to that belief becoming a reality. This is classic fear-avoidance coping and is why someone can perform a 300lb deadlift and then throw their back out when they finally bend their spine to tie their shoes.

For this reason, it’s important to educate clients about the resilience of the body to perform non-deliberate movement as well as to mix these types of movements into their exercise programming. While it’s important for me to teach many of my clients how to do a proper hip hinge, it’s equally important to recondition them on how to round their spines to pick up a sub max load.

At the same time, it’s also crucial to teach clients that these cues are not meant to be minded for every movement in day-to-day activity. Again, this would enforce these fear patterns and lead to what we discussed above. However, it also enforces a reliance on deliberate thought to perform these movements, which takes us to our second point.

Autonomic Neuroplasticity

 

Once we remember to add in these additional “natural movement” cues to accompany exercise instruction, there might still be a disconnect between the clinic and real-world conditioning.

What we need to consider is that the conscious focus on movement in the clinic or fitness setting (whether it be a traditional exercise or a natural back bend) doesn’t necessarily translate to the nervous system being able to replicate those cues in a safe manner, subconsciously.

This boils down to neuroplastic deficits within the central nervous system itself following an injury, with altered motor patterns becoming the new norm (Grooms, 2016). We can describe this by thinking about the thought processes that lead up to movement. In an “exercise” environment, the signals that precede movement are directly to do with that specific motor pattern; sending the signal to the muscle and joint on what to do and how strongly and fast to do it. Outside of this environment, these thought processes are much more complicated and the movement will need to follow more complicated reactionary signals. For instance, often we will need to simply extend our arm, reactionarily, in order to catch an object rather than having that moment of anticipation to ready the nervous system and compute the necessary speed and force that will be required beforehand.

What this implies is that being able to do a back bend in the clinic when all of your focus is on it only gets us part of the way toward being able to do the same thing at home when relying on autonomic function instead of deliberate action. This is why athletes who have undergone ACL reconstruction and rehab can be, clinically, cleared to return to play yet still be 40 times as likely to reinjure their knee compared to their peers (Wiggins et al., 2016).

Clinical settings commonly revolve around focusing on internal cues when learning movement patterns, such as relaxing one muscle, stiffening another, or bending deeper at this joint. However, external cues, such as “reach for the floor”, “aim for the target”, or “focus on the field” have been observed as being incredibly important in sports settings. These cues help to bring the attention away from the body and to the environment instead, creating a more practical situation by decreasing conscious body control.

With ACL reconstruction, again, being the studied example (Gokeler et al., 2019), it is found that relying solely on internal cues does not provide the best outcomes for when external factors are finally challenged again. Even when rehab conditioning is extremely sport or activity-specific, an ability to do a maximal sprint in a controlled environment might fail someone when they attempt to do the same thing with real-world distractions added. For this reason, a lot of rehabilitation research is actually starting to involve the use of virtual reality (Grooms, 2015) to retrain autonomic capabilities.

Obviously, we don’t expect every clinic to equip itself with a VR headset. So that brings us back to the importance of mixing in external cues with the internal ones as we educate our clients in new motor patterns. The clinical setting can take a lot of great lessons on how to do this from the performance world, with a mixture of the two types of cues, periodization of a program, and an understanding of individual variance being hugely important factors.

Takeaways

 

So from all of this, we can understand that mechanical cues and deliberate exercise patterns are still a step in the rehab process. Throughout, however, we need to reinforce that a client’s well-being is not dependent on these patterns being maintained around the clock or that conscious control does not need to be exerted over their maintenance.

Finally, we also need to remember that the quiet, clinical environment is usually not one that our clients spend the majority of their days in, so we also need to prepare them for the real-life hazards, distractions, and mental states that their normal workplace, sport, and home settings will challenge them with.

A client’s life is individual, and so is the preparation for it that we provide.

Let’s Stop Playing It Small Together

Alright, I have a confession to make.

I came to the realization a week or so ago while listening to a podcast that I’ve…well…I’ve been playing it small.

While I put out a blog post or so a week, teach some continuing education courses on first aid along with pain science and exercise, I’ve still been playing it small.

There are certain things I’m really comfortable with and other things that make me pull back and question myself, my abilities, and my thought processes. So rather than just face, those things head-on I shrink back.

This happens especially on social media.

I see some of the groups where people are asking questions, or making statements, and rather than throw my $0.02 in, I shrink, and it’s usually out of fear.

The fear I’ll get called out, fear I’m not smart enough, fear that my voice or my opinion doesn’t matter (well truly to some I know it doesn’t but that’s not the point here).

So, then a strange thing happened. I was sitting with my buddy Eric Purves telling him this as we started discussing doing a mastermind group. I looked at him and said f@#k it, I’m not playing it small, I’m putting this out there.

I opened the laptop and put it out on Facebook. To my surprise, the post got 83 reactions and 117 comments.

Also to my surprise was the response in the comments. From physio friends asking what they can do to help promote, lots of people wanting to attend, and of course a couple of negative ones. BUT, the positive far outweighed the negative.

As I pondered this I realized I’m not alone. It’s not just me that needs to stop playing it small…so does our profession, and here’s why.

Education

I will forever be a proponent of advancing our education and making it better.

As I talk to other colleagues in different parts of the world (and it happens here too) we sometimes shy away from sharing our opinions or challenging the opinions of other healthcare practitioners because our education was shorter, or not perceived to be as good a quality as theirs.

This was the way I felt for MANY years.

However, a few years ago I came to realize that if you talk to any of those other healthcare practitioners (if they’re worth their salt) they want their education to get an overhaul as well. If any of them are taking any quality continuing education courses, they soon come to realize that many of the things they were taught in college aren’t worth the textbook it was written in.

Now I’m sure there will be some who argue with me on this, but with those other professions, their education isn’t better, it’s just different. Yes, they get more recognition because they have a degree behind their name (and their associations probably lobby a lot harder) however, it’s no more evidence-based than ours (maybe even less in some cases).

In reality, we’re all fighting the same uphill battle, our entire healthcare system needs an overhaul when it comes to helping people in pain.

So if you’re trying to have a discussion with another manual therapist there’s nothing wrong with challenging their treatment narratives as long as you’re approaching it from an educated standpoint (and obviously done with some sort of decorum).

We can’t challenge and say ” your approach is wrong because I do ‘x’ treatment which works because I do it and I know it works!” However, if we can approach the topic with a statement like: “the newest research shows us that our understanding of ‘x’ isn’t what we thought it was and has since changed to …” will get us much farther into the discussion.

I realize this might be tough because there seems to be a hierarchy within our manual therapy world and for some reason, we are frequently seen as the bottom of this. But, I have to wonder, is this reality, or are we playing it small?

The reality is, our entire healthcare system needs an overhaul in education when it comes to helping people in pain, not just our education.

Time Is On Our Side…Yes, It Is!

This may be our greatest asset.

The more I come to understand the patient perspective on persistent pain (thanks to Keith Meldrum’s help) the more I realize just what a difference time with a patient makes.

I love this quote from Ken Leong from a Facebook thread, and glad I was able to use it with his permission.

Massage therapy is almost tailor-made for [the biopsychosocial] approach. The therapist has much more time than a MD to really get to know their patient or client: where they’re from, their culture, customs, what their family life is like, their history with athletics, sedentary actives, repetitive activities, their stresses, their sleep patterns, their nutrition, their living situations, who they live with and interact with daily and weekly, their commuting stress, their occasional (and therefore dangerous) heavier physical exertions, etc.
The patient or client also has time in treatment to reconnect with their mind and body, to figure out where the aches and pains came from, what are their self-perpetuating patterns are, how they can change them…
It’s like you’re tall and in front of the volleyball net, and someone sets you up for ‘the spike.

We’d be blind NOT to use all this biopsychosocial opportunity!

Ken G. Leong, RMT
If this quote doesn’t make you feel all warm and fuzzy inside for being a Massage Therapist, I don’t know what will.
Compared to every other manual therapist we have a massive opportunity to help patients simply because of the time we get to spend with them.
If we reel back to the above discussion around talking to other practitioners, how many of them spend the amount of time with their patients that we do? How many truly get to know their patients? How many understand what their patients are going through day to day?
While a few of them might, I’d say as a general rule (yes there are some outliers) they don’t get to in the same way we do.
This whole time thing isn’t just a matter of our interaction with the patient either. I’ve seen some discussions on different platforms where practitioners say things like: “I have a patient who wants a 60-minute treatment, but I only need 45min to get done what they need”.
While there’s nothing really wrong with this (as I hope the practitioner was trying to do effective treatment planning) but think about what that amount of time actually means to a patient.
This could be their time! This could be their break from the typical stresses of life. Maybe that hour is a break from being a parent, boss, caregiver, entrepreneur, or whatever other thing is causing stress in their life. That 60 minutes can make a massive difference in their weekly, or monthly (or however often you are seeing them) routine and life.
And this my friends puts us into a very valuable position in not only helping, but making a difference in our patient’s lives. 

Exercise & Movement

I know, I know, you don’t think this is in your scope. 

Well, in some places it is well within our scope and for others it’s questionable.

So I’d like to somewhat address where this is questionable.

From everything I’ve heard the argument is usually “it’s not in our scope to prescribe exercise, we have to refer out for that”. Every time I hear this I also notice that AROM (active range of motion) and PROM (passive range of motion) are still within scope. So, how is a patient actively moving not an exercise? If we are passively moving a part of the patient’s body while they’re on the table, how is this not exercise? If you can help a patient stretch on the table, how is this not an exercise?

We seem to think that recommending an exercise is always prescribing that you do a certain number of reps for a certain number of sets of ‘x’ movement (bench press, squat, deadlift, etc).

What if recommending exercise was simply recommending:

  • Go for a walk with a friend (one of the best things for low back pain).
  • Get on the floor and play with your kids.
  • Dig your hands into the garden.
  • Pick up your groceries.

Just get them to do something they enjoy!

Half of recommending an exercise for someone can be just giving them permission to do an activity. When they’re on your table if you can do AROM & PROM, then there’s no reason you can’t do isometric, concentric, and eccentric movements and this doesn’t require any fancy machinery or even a set of dumbells, you can simply just resist the movement while the patient performs them.

Doing this can be very effective in not only rehabbing an injury but they can also demonstrate self-efficacy, resiliency, capacity, and really isn’t that what we’re trying to do with any treatment? I hope so.

I think the bottom line here is that we have every opportunity (and probably more so than other healthcare professions) to make a massive difference to help people who are dealing with a painful experience. We need to use everything we have at our disposal to not only help our patients but to help push the profession forward. In no way am I saying everything is fine and we should stick with the status quo, we certainly need to continually push for better education to create evidence-based practice for all of us. So, I implore the profession to stop acting like me and playing it small. Let’s challenge the bad narratives regardless of who is using them and take a firm grip on the benefits we have as a profession to not only help our patients but help each other.

If you’re interested in learning more about these topics, we’ll be launching an online course about pain science and therapeutic movement soon and you can join the waitlist by clicking HERE.

 

 

A Simple Guide To Patient Centred Exercise

After ‘pain science’ and ‘biopsychosocial’ the latest buzz word on our horizon seems to be ‘patient-centered care’ or PCC for short.

Now for a buzzword, it is pretty poorly defined and we don’t really have a strict description, but I think PCC is really how we should be implementing the BioPsychoSocial (BPS) model and what the BPS model was really meant to be about rather than the more pain focused version we have today.

This blog aims to focus on how we might apply PCC in the context of an active approach to treatment but don’t be surprised if it meanders off course a bit.

Patient Or Person?

Most of the available literature in this area discusses “patient-centered care” but I much prefer “person” centered care as it turns the patient well ….into a person and a much more ‘real’ entity in a two-way relationship.

The term ‘patient’ has long been open to discussion and this is an interesting read on the subject and I picked out a couple of quotes.

“Do we need a new word for patients?”

Patient comes from the Latin “patiens,” from “patior,” to suffer or bear. The patient, in this language, is truly passive—bearing whatever suffering is necessary and tolerating patiently the interventions of the outside expert”

“An unequal relationship between the user of healthcare services and the provider”

These are interesting perspectives that highlight the potential perspective of the ‘patient’ as a passive recipient to be told what to do and without concern for them as an individual. After all tissues and pathologies really don’t care how they are treated so why the need to worry about it?

What Actually Is PCC?

Maybe by definition, PCC is tough to define for all? What is person-centered for one may not be for another, but there do appear to be some broad themes and ideas that can be discussed.

Patient (person) centered care has previously been defined as:

“willingness to become involved in the full range of difficulties patients bring to their doctors, and not just their biomedical problems” – Stewart 1995

“the physician tries to enter the patient’s world, to see the illness through the patient’s eyes” McWhinney 1989

Two-person medicine (rather than one person)” – Balint e al 1993

(Quotes in Mead et al 2000)

For me, a good start for PCC is not to see the therapist or technique or method or exercise as the star of the show. It’s about the PERSON that really needs our help. That does not mean fanfares, razzmatazz, and pedestals, it really means that we try to think about what THIS person in front of me needs, what is it like to walk a mile THEIR shoes?

Another very simple way to look at it is, how would YOU like to be treated?

Mead et al in “Patient-centredness: a conceptual framework and review of the empirical literature” defined 5 key aspects of a “patient-centredness”

  • The biopsychosocial perspective (the patient’s life)
  • The patient as a person
  • Shared power and responsibility
  • Therapeutic alliance
  • The doctor as a person (Personal qualities such as Humanness)

Wijma et al explored “Patient-centeredness in physiotherapy: What does it entail?”

They defined PCC as

“Patient centeredness in physiotherapy entails the characteristics of offering an individualized treatment, continuous communication (verbal and non-verbal), education during all aspects of treatment, working with patient-defined goals, a treatment in which the patient is supported and empowered, and a physiotherapist with patient-centered social skills, confidence, and knowledge”

What PCC Is Not

There are some criticisms of PCC that seem to centre around the idea of consumer-driven healthcare and doing ‘whatever someone wants you to do’. Maybe the idea of ‘shared decision making’, intrinsic to PCC, seems to open up this idea of consumer healthcare for some.

These discussions are often dominated by the type of treatment and the application of more passive modalities and we really need to guard against this reductionist perspective of PCC.

Rather than MAKING the decision based on someone’s preference, PCC instead really should be about people being involved in decisions, a key part of PCC, and this should reflect the best information around treatment that we have available and frank and honest conversations around the best course of action. Not simply “what treatment do you want”.

Makoul & Clayman in “An integrative model of shared decision making in medical encounters” discuss a number of steps involved with shared decision making

  • Define or explain the problem
  • Present options
  • Discuss the pros and cons (benefits/risks/costs)
  • Assess patients’ values or preferences
  • Discuss patient ability or self- efficacy
  • Provide doctor knowledge or recommendations
  • Check or clarify understanding
  • Make or explicitly defer the decision
  • Arrange follow-up

 

What Do People Really Want?

That leads us nicely into “what DO people want” and this does NOT seem to revolve around their favourite treatment type.

PCC is perhaps thinking about what healthcare can do for the end-user, the person rather than how do they fit into the broader healthcare world. What better way is there to do that than ask them : ).

The increase in qualitative research is fantastic and really helps us understand what people think, feel, and ultimately need.

This is a really interesting paper regarding a two-person perspective in back pain Listen to me, tell me’: a qualitative study of partnership in care for people with non-specific chronic low back pain

The authors here identified some key areas.

Partnership With Practitioner

“All participants expressed the need for mutual enquiry, problem-solving, negotiation and renegotiation between care-provider and care-seeker to establish mutual therapeutic goals “

‘Ask Me’

“All participants reported that engagement with their health care-provider improved if they were explicitly asked for their opinions and goals.”

‘Understand Me’

“Consideration of life circumstances and preferences was important to all participants in developing therapeutic partnerships and optimising exercise outcomes”

‘Listen To Me’

‘Explain it so I can understand’ – Valuing competent and empathetic listener

I know my own body   – Participants framed the ability to ‘know your own body’ as empowering

This sentence particularly resonated with me however

“Tension existed between patients’ wanting a genuine voice in the partnership and them wanting a care-provider to give explicit diagnosis and best management instruction

Does It Matter?

A question I often hear asked about person-centered care is does PCC actually improve ‘outcomes’? I suppose my response would be does the effect of PPC on outcomes actually matter and which outcomes are we discussing?

Although we know that contextual factors have an effect on outcomes we don’t know if PCC specifically improves the most common outcome measures, but, in my opinion it is the RIGHT way to treat other people regardless of if it changes pain, function, or whatever. Although we don’t really have much data currently, my biases say for many it would make a difference, if not to common outcome measure then to the person’s experience in healthcare (which might be an outcome measure in itself).

 

The Application Of PCC

Maybe we should NOT see a person-centered approach to activity/movement/exercise just about the type of exercise or the sets and reps. Instead, it’s about all those things AROUND the moving as well and I will focus mostly on these (you can retain your exercise bias : )

Starting With The End In Mind

Unless we define what recovery might look or feel like it is probably hard for anyone to know if they are actually getting there. Really the role of the therapist should be to see where someone wants to get to, where they are currently, and then help them bridge that gap.

The best place to start might be with the end in mind and this first and foremost really involves listening. Listening and understanding is, in my opinion, the real essence of PCC but many people don’t feel that this always happens in their HealthCare experiences.

This short excerpt is from the excellent From “Non‐encounters” to autonomic agency. Conceptions of patients with low back pain about their encounters in the health care system”  

Holopainen 2018

“Patients felt that they were not being heard. They felt that the encounters were expert-driven, and the HCP interrupted them and dismissed what they had to say, without listening to their wishes and opinions”

We also have to acknowledge that for some who have had pain for a long time this process of defining goals or recovery can be really tough. It’s often difficult to see outside of the pain and suffering to have a sense of what ‘life’ actually looks and feels like again.

“Patients identified the effects of pain on their lives. They reported that their circle of life had shrunk and they had given up doing things they used to enjoy” – Holopainen 2018

I try to highlight to people that they are not just moving for the sake of moving (although this can be a positive thing), we are moving to get further towards valued activities and goals that we have discussed and hopefully, this can tap into people’s intrinsic motivation.

A big problem, IMO, with goals, is that we can measure their success via their effects on more generic measures such as pain or function (certainly in research around physical therapies).

We have a wonderfully personal and specific thing, the goal, and we should actually measure the success of a goal by achieving……the goal! If that involves changes in pain then of course with a person-centered approach we have to involve pain in the goal. But we might have no changes in pain (our outcome measure) but reach a valued goal that has a huge effect on someone’s quality of life and may not always be captured by the more generic measures.

I do believe that the ‘WHY’ behind action has to be driven by the person. So much of what happens in therapy is driven by the biases of therapists about the best way to get people pain free or functioning better.

Maybe the ‘methods’ employed often fit better with the identity and values of the therapist rather than the patient?

Shared Decisions And Responsibilities

As we discussed earlier, PCC and shared decision making is not just doing what someone wants. We need to present the best available information and our professional opinion on the best course of action to properly inform decision making.

Autonomy has been shown to have an influence on exercise outcomes “Autonomy: A Missing Ingredient of a Successful Program?”. Perhaps some autonomy and choice might lead to better ‘bonding’ with exercise in rehab?

As there are a whole bunch of ways to exercise, move, and load it should be not to hard to present a number of options and allow people some choice on the best way forward. Equally, it is a therapist’s responsibility to give their opinion about the best course of action that they think will ‘fit’ the person based on the best data and a sprinkle of experience.

Laying out each other’s responsibilities in the process is an important step. I always say I am here to guide and help but you have to go and do it and believe in it for it to work. I believe we need accountability towards each other sometimes.

Planning

This for me really is true biopsychosocialism.

We are all people ‘embedded’ in the world with work, family, and social pressures. One of the best ways to implement a BPS perspective is to realize that any movement/exercise plan is not going to come at ‘no cost’ in terms of time, effort, and sacrificing something else.

People don’t just need something to do, they also need a plan to be able to do it. A destination is great but we also need a path to get there.

How many things do you never quite get around to doing because you don’t have a clear time, place, and structure to get it done?

When’s the best time to do some exercise? Before or after work. How much is OK? What should it feel like? Do they have the required information to facilitate doing it?

Another passage from From’Non‐encounters’ to autonomic agency” highlights this.

 “A lack of written instruction prevented them from doing prescribed exercises because they were unsure of what they were supposed to do”

Helping people to navigate their own individual social environments is also a beneficial way to help. We cannot often modify many ‘social’ things but we can help people understand and navigate them better. For example, how might someone access community support with getting more active? Are there free or low-cost resources that they can use? Are there support groups or family members or friends that might be able to help.

Acting as a guide rather than a healer can be really helpful for many!

Support & Motivation

Picking someone’s exercise form apart or highlighting some kind of movement dysfunction really is the opposite of PCC. It shows a complete disregard for how that might make someone else feel and how that might impact on their behaviours. But I suppose if you feel you are just dealing with a pathology then why should that matter?

We could say that view is quite the opposite of walking a mile in someone else’s shoes.

Perhaps we can think about how we might lift someone up rather than pick them apart. Think about highlighting strengths and positives. We entirely underestimate the power of motivation and optimism in healthcare in my opinion. This is a fundamental part of the role of the coach or trainer in the world of fitness but has been lost in the translation of exercise to the world of medicine.

People even say this themselves!

“patients reported that they needed someone to push them, like a personal trainer” – Holopainen 2018

 

Conclusion

 

  • Person-centered care is defined by the person
  • PCC is not just giving people what they want
  • People are people not just patients (passive recipients)
  • Think about “walking a mile in someone else’s shoes”
  • Think more about shared decisions (within evidence base)
  • Start with the end in mind, tie into valued activities
  • Help people navigate their ‘world’
  • Build people up rather than knock them down