Three Therapeutic Exercise Progressions For The Hip

I joined a great gym last year and quite often when we are doing lower body exercises, they take us through a great warm up.

I have to give them credit because I can’t help but think these would be a great therapeutic exercise progression for the hips that we can easily use in our clinical setting.

It doesn’t take much room and all you need is an exercise band (and maybe something to hold for balance) and you can easily take your patients through this.


Here is the first progression you can use.


Here is the second progression, a little bit tougher.


And the third progression, a little bit tougher again.




  • Make sure you start with the easiest exercise first.
  • Let your patient be part of the decision-making about when to progress and make it harder.
  • Start with the least resistance first.
  • It doesn’t have to be complicated, just get them started.

Education In Rehab – WTF Does It Mean…?

Education, education, education. How often do you hear this term in relation to modern MSK practice?

Sorry, I got that wrong. Education & exercise, Education & exercise, Education & exercise : )

All the bloody time is the simple answer!

But education, just like exercise, suffers from the issue that we talk about it in very general terms but have little in the way of actual frameworks for application. Every guideline going seems to point towards these as core treatments but often without any real direction. I can see why therapists fall back on more traditional perspectives faced with uncertainty.

So education about what? When? How? To who? The usual questions come out when we unpick it a bit. Education has been hijacked by PAIN education over the last few years but in reality, its formed a backbone of MSK practice…..well forever. Education is something I talk about in class A LOT,  but I do feel people are like hurry up and get to the REAL treatment Ben, i’m getting bored over here.

Is education seen as PROPER treatment? I am not convinced yet.

People Always Have Wanted Information


This is nothing new!

How often have you had someone come in and say “My back pain has been going on a little bit longer than usual and I thought I had better have it checked out”.  We know back pain, as an example, can last for 2-6 weeks and it’s perfectly normal for this to happen. But if someone has only ever had the problem before for a few days it’s probably a bit worrying and they want to know what is going on to decrease the worry that can flourish in stressful situations.

People definitely come to see us to get rid of their pain, but they also want to understand their problem, the implications and know how to manage it as well.

Louis Gifford highlighted a few things that is fairly universal amongst people. What is it? How long will it last? What can we do about it? Another question I get asked regularly is “Can I still do….”. People still want to do things but not to make the problem worse but often get scared into reducing activities rather than receive knowledge to sensibly manage them.

Education Or Knowledge Transfer?


We use the term education, but for me, that can conjures up images of stern teachers in front of naughty school kids and does not really reflect what we often do with people.  Maybe it is really about helping someone make coherent sense of the issue, decreasing the uncertainty and danger around the problem and providing paths forward. This is more of a partnership perspective that incorporates knowledge transfer than traditional didactic models of teaching. So maybe knowledge transfer or sense-making is a better term?

What Can We ‘Educate’ About?




What Is It?

Probably the most important thing that people want is a diagnosis. If we know what it is we can effectively treat it, right? Er…maybe as we know in so many MSK issues that are simply not possible from a structural perspective. In the absence of this, we need a positive & coherent narrative around the problem. That could include pain ed but information about pain does not need to dominate.

“Cases of nonspecific musculoskeletal pain where, although the source of the pain is unclear, diagnostic imaging is not indicated, and the pain may not always be completely alleviated with treatment. In such cases, concrete, clear, and consistent information can help the recovery process, even in the absence of a specific diagnosis” Carroll et al 2016

How Long Will It Take?

Prognosis and the factors that influence it can be really helpful with often unclear diagnoses like back, knee or shoulder pain. Setting realistic expectations is important as well. Too high and it can lead to disappointment when they are not reached, too low and the motivation to engage in the process can limit the outcomes.

What Can I Do About It?

Health and lifestyle, exercise, activity and self-management are all areas that we can help people with. Helping people to effectively create management plans is sorely missing IMO. Again perhaps this is not seen as treatment?

What Does The Person Want To Know?


For a really effective transfer of knowledge maybe taking the time to find out what the person WANTS  to know is important. Just throwing out information might lead to important questions remaining unanswered. There are so many questions that people have that we may not have considered or we feel are not important. If they are important to the person they should be important to us!

“What concerns you the most about your problem?”

“Do you have any major concerns you would like to talk to me about?”

“What’s your biggest fear about this?”

“What’s the most important question I can answer for you today?”



It needs to make “biological and biographical sense” as my friend Joletta Belton would say. This was the great failing of pain education IMO, it does not automatically integrate with the person’s story, it’s like talking to a stranger in a pub when they are telling you about their life story and you are being talked AT without the conversation ever relating to YOU. A friend that just talks about themselves is another example, you just want to get the hell out of there, or . So make sure your knowledge transfer actually fits the person and their story in a way that relates.



Maybe this is why some of the things we expect to be helpful don’t succeed? Without a knowledge of what to do, why they are doing it and how it is going to help, exercise, as an example, does not relate to the person and their problem?

Lots of my failures (professional ones : ) may have come from not aligning in terms of treatment philosophy with the person I am working with. My vision of what to do does not match theirs and in part that might stem from my inability or failure to ‘educate’ about the what, why’s and how’s.



  • Education IS treatment
  • What does it really mean?
  • People have always wanted information from therapists
  • Think person centred rather than teacher style
  • What is it? How long will it take? What can I do about it?
  • Find out what the person wants to know
  • Apply information in context

Things I Wish I Knew About “Rotator Cuff Disease”

It was the first time I’d seen this patient. 

When I asked what brought them in they showed me how they could only get their shoulder to about 90* abduction and it had been this way for two years. 

Digging a little deeper to find out what happened, they explained they had a rotator cuff surgery due to a tear. 

This was life-changing for them. 

Not only could they not move their shoulder correctly, but it also resulted in a change from a job they loved to one they hated due to the lack of mobility. 

So, was surgery the best approach in this case? 

While I’ll never know the true answer to this, I can look at the most up-to-date research and attempt to make an educated guess ( and I think I know where this is going). 

Rotator Cuff Disease

A recent paper¹ came out on this topic, and I’ll admit I was surprised to see them refer to this condition as a “disease.”

However, when we look at the dictionary definition of disease² it states: 

disease, any harmful deviation from the normal structural or functional state of an organism, generally associated with certain signs and symptoms and differing in nature from physical injury.”

So, in this case, the limited function of the shoulder has deviated from its normal functional or structural state, so I guess it can be classified as such. But, I would never want to communicate it to a patient that way as it suggests a more damning diagnosis than it is. 

Now, in order to define this “disease” they put some classification around it which includes: 

  • Pain that is worse at night
  • Pain exacerbated by specific movements which included overhead activities
  • Loss of function and weakness

In addition to the above rotator cuff disease was basically used as an umbrella term to classify issues with the rotator cuff regardless of the cause and would include: 

  • Positive painful arc test (physiotutors gives a great example of how to perform the test HERE)
  • Positive external rotation resistance test

These tests together were the most accurate diagnosis unless it was a full-thickness tear. In this case, the use of a positive lag test was most appropriate. Here is one example of how to do the test, but this can also be done with the shoulder at 90′ rotation, called the “drop arm sign.” 

It is also worth noting that the review found an increased prevalence of this with age, especially in those people who performed repeated overhead activities. 

What Do We Do For Treatment?

So, this paper was a BIG review; there were 3620 participants in 60 different trials with a median age of 51. 52% of these were women and the average duration of symptoms was 11 months. 

What they found was that people were rarely given just one intervention. 

This makes it really difficult to say if just manual therapy, just exercise, or a single other intervention was the best approach as there was always a combination of things offered. 

The average duration of therapy offered was six weeks. When they looked at what manual therapy was offered, this included: 

  • Joint mobilizations
  • Massage
  • Spinal or neck mobilizations
  • PNF stretching
  • Dicutaneous Fibrosis (I had to google this as I’ve never heard of it, but it’s IASTM with a stainless steel hook)

Exercise interventions included: 

  • Strengthening
  • Stretching
  • Progressive resistance
  • Pendulum exercises
  • Eccentric training
  • Postural training
  • Motor control
  • Proprioceptive training
  • Self-mobilization (yay for self-care)
  • Dynamic humeral centring (movement aimed at humeral head depression) 

Interestingly, they compared the above to some other trials that included things like steroid injection, NSAIDs, surgery, naturopathic care, and a few other interventions. 

When it was all said and done, they compared what was seen as high-quality evidence to low-quality evidence. 

Under the umbrella of “high quality evidence,” their findings showed no difference between manual therapy, exercise, and placebo for overall pain, disability, and function. But there was also a risk as manual therapy and exercise were frequently associated with adverse effects like short-term pain (although very mild). 

When looking at “low quality evidence,” it was pretty consistent with the aforementioned high-quality evidence but also showed that the use of glucocorticoid steroid injections helped with global treatment success. 

Overall, this doesn’t sound like a real positive for manual therapy and exercise, but there are some things to consider. Throughout the studies, manual therapy and exercise were always incorporated with some other type of therapy. Also, much of the exercise used was very vague by description and didn’t include whether this was done supervised in the clinic, or at home. Finally, while the comparison to glucocorticoid steroid injection seems like it could be of benefit, this was based on low-quality evidence, so this doesn’t give the intervention much credence. 

Looking at what they considered placebo, they used modalities like ultrasound (which in other studies has been shown to have a high level of placebo). This review doesn’t really talk about the interaction between patient and therapist or other contextual factors of treatment. We might see a more detailed description of the exercises and modalities used as interventions if these were included. 

However, when we look at other papers that discuss the clinical guidelines of MSK care the best steps are typically shown to be: 

  1. Reassurance
  2. Education
  3. Exercise
  4. Some manual therapy

If we were to apply the same to issues with the rotator cuff, we’d likely see better outcomes than if these weren’t used. Even though this review says there is no clinically important benefit to manual therapy and exercise over placebo, it doesn’t mean they aren’t of benefit. But if we used those as a combination in treatment the high-quality evidence shows this to be the best approach. So, with any shoulder issue, continue to use exercise and massage. Just remember there are other factors that contribute to a successful treatment. Things like patient preference, demeanour, education, reassuring them, and providing validation will all help contribute to better patient outcomes. Let’s just remember to incorporate as much as possible.


Exercise Induced Analgesia

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.


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?

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.


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.


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.


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.

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