It’s been a tough few weeks for exercise in healthcare both on social media and in the research. A recent systematic review has shown it provides little to no benefit for acute low back pain. Then a very interesting blog called it ‘snake oil’ and a ‘dirty word’. And finally, a discussion on twitter questioned my favourite slogan of ‘you can’t go wrong getting strong’.

It’s fair to say that exercise, as a treatment for pain and disability, has a lot of critics, questions, and uncertainties around its efficacy and effectiveness. And although I am, and always will be, a very ‘strong’ advocate for exercise within healthcare I have to reflect and ask myself why do I use it as a treatment so much?

If I am being brutally honest I use exercise with most of my patients because I am biased towards it, but also because I think it’s expected and assumed by patients that’s what us physios should do. There is a very strong tradition and culture that physios give out exercises when you go to see them for pains and problems, just like doctors give out medications, chiros give out back cracks, and surgeons slice and dice.

Although I think exercise has many benefits and is one of the most evidence-based and supported treatments we physios have, I think it’s often over-complicated, but under-promoted, however, I don’t think it’s sufficient to help many in pain and disability improve and I don’t think many patients actually ‘need’ it as a treatment.

Now before you all go lose your minds and head down to the comments section to call me a hypocrite or express disgust, disappointment, or just to gloat and say ‘I told you so’ keep reading on a little bit longer.

Let me explain!

I think we can all agree that all pain and disability is individual, complex, and multifactorial. From the enigma that is non-specific low back pain, to something as ‘simple’ as an Achilles tendinopathy all aches and pains can confuse and confound us, regardless of the cause of the severity of pain or level of disability we really just don’t know what is needed to be addressed to help them.

For example, when someone has low back or Achilles pain do we need to ask them to move more or less? Do we need to increase their strength, power, or endurance? Do we need to improve their knowledge, confidence, or pain self-efficacy? Maybe they just need to lose some weight, stop smoking, sleep a bit better, and relax more??? The factors to consider are almost endless.

Now there are some conditions where we do have a better understanding of what needs to be addressed more to help some improve, for example after an ACLR ‘it’s the quad’ as my mate Erik Meira would immediately say. But for many other pains and disabilities, the list of factors and variables is long and complex.

But to think that addressing just one factor will be sufficient is both naive and ignorant, even Erik reluctantly admits that it is actually more than just the quad to return to play after an ACLR. However, I think many therapists are failing with their exercise treatments because of their limited and reductionist way of thinking about it and in their use of it.

Using exercise monosyllabically just to increase someone’s strength, power, or even confidence when they have complex, multifactorial issues is only going to partially help or simply just fail. Working with patients with pain and disability we can NOT use exercise like S&C coaches working with athletes who often only have simple single factors to address such as strength, power, or endurance.

You’re not an S&C Coach!

It really is great to see more and more physios improving their exercise understanding and prescription skills and something I hope continues. However, I am concerned that more and more physios are using exercises with their patients like S&C coaches use them with their athletes, replacing poor old Mrs Miggins 3×10 shitty banded external rotations for 5×5 90% 1RM overhead KB presses at a tempo of 3301, coz S&C gainzzz baaaby!

Don’t get me wrong I think it’s great to try and get as many patients, even Mrs Miggins as strong and powerful as possible using S&C principles, but if you think it’s only about increasing strength or power for pain and disability then you and your patients are going to be disappointed.

S&C has become a bit of buzz word recently in rehab and many S&C coaches are training physios and are being revered like messiahs and the second coming, here to save physios from the error of their ways with their big biceps, fancy periodisation programmes, and 0-2 reps in reserve.

Don’t get me wrong I’m glad that physios are learning better exercise prescription from S&C coaches at last. But like I said earlier I think many physios give out exercises because it’s expected that’s what they should do rather than thinking that’s what they should do.

Also, physios often give exercises without involving the patients into the process because it’s 1) believed they should know best, 2) justifies their existence and fees, and 3) helps with the illusion of being more skilled and specific.

This is a mistake and something that I think needs a monumental shift in culture and training. To make exercise more successful we need a joint and collaborative approach working alongside patients expectations, beliefs and abilities, helping to guide and motivate them accordingly.

However, much as I hate to admit this, the uncomfortable truth is that most things we physios see tends to have a favourable natural history and often gets better with nothing more than time. Basically meaning that they get better no matter what exercises we give or what other treatments we do or don’t do with them. (ref, ref, ref)

This is a hard pill to swallow and accept for many physios and other therapists, especially after spending years of hard work and dedicated study learning about the complexity of human anatomy, physiology, and pathology and its treatment. To be told that it doesn’t really matter what you do with your patients because they will get better, or won’t regardless, is both a slap in the face and kick in the ego-testicles.

Awkward!

And I get it, I still hate that awkward feeling even after 20 years of practice of assessing a patient fully, checking that there is nothing serious or sinister, realising their issues, pain, and disability will most likely improve with little more than time, reassurance, and simple advice to keep moving as much as they can. This makes you feel a little embarrassed and useless inside, like your not doing enough to justify your fees, that your skills, efforts and dedication in helping others is worth little and actually not that important or needed.

So to mask these feelings I think a lot of us tend to over conflate and over complicate what we do and say, hoping to fill that awkward gap of waiting for natural history to kick in by over-treating and doing more than really is needed. Be that with some fancy advice, education, manual therapy, joint manips, colourful tape, cupping, scrapping tools, pointy needles, machines that go bing, or fancier exercises.

Still use it!

However, although I have been quite critical of exercise highlighting its small effects on pain, and how it doesn’t outperform placebo, and how I think most patients don’t actually ‘need it’ to get better. I still strongly advocate and recommend it with all the patients I see.

Yeah, I know what a hypocrite right, but hear me out. Although I don’t think formal specific exercise is needed for many pains and disability, I do think formal specific exercise is needed for general health and well being.

Now I have seen a lot of debate and discussion recently on this topic with some saying healthcare clinicians shouldn’t be so dogmatic, prescriptive, or harsh with their exercise recommendations. That they need to understand and appreciate not everyone enjoys or likes exercise and instead prefers general activity and other types of movement, and these are just as important for health and well being.

But I think these discussions are confusing two very different things, that is exercise and activity, and although used interchangeably they are not the same. It’s also not that one is better than another, its that BOTH are essential for an individuals health and well being, and BOTH should be encouraged and advocated more.

Go hard or go home!

General recreational activity and other lower-intensity movements are great and an essential component for an individuals health and well being. But no matter how much you wriggle, worm, contort or twist it you just can not escape from the harsh facts that regular intense, robust, difficult, awkward, even painful exercise is ALSO essential for and individuals health and well being. (ref, ref)

As much as movement matters, so does intensity, and to think you can go through life at a constant low intensity without needing to challenge your body and mind hard and often is both misguided and mistaken (ref). Our bodies and minds respond to the stresses and pressures they are exposed to, toughening and hardening them. Without stress and pressure, there is no robustness or resilence.

Now, I have also seen some comments from some acupuncturists with delusions of grandeur who think that we should only be focusing on treating an individuals pain and disability, not using exercise for health, well being, robustness and resilience. They also claim that using the secondary benefits of exercise as a justification for its treatment for pain and disability is just an excuse.

Well, I think these are pathetic, asinine, narrow-minded comments used by some clinicians more interested in their own agendas of trying to justify their use of passive interventions for helping pain and disability.

I see this a lot recently with clinicians and researchers trying to justify the use of things like manual therapy or acupuncture by comparing their pain-reducing effects to those of exercise. This is like trying to justify the nutritional benefits of doughnuts by comparing their effects on satisfaction to sticks of broccoli. They’re just not comparable.

Exercise and pain

As I’ve already mentioned exercise doesn’t demonstrate strong effects for most pains or disabilities, but that doesn’t mean it doesn’t reduce pain at all. Exercise has been shown to reduce pain via various different mechanisms, such as endogenous opioid analgesia, diffuse noxious inhibitory control, habituation, conditioned pain modulation, and expectancy violation.

The issue is that most studies are small, with a high risk of bias, and normally done on healthy individuals (ref). I am well aware that exercise for pain is not a panacea and its effects on pain can be similar to most other treatments such as analgesia, injections, acupuncture, manipulations, massage etc.

However, if I am going to choose a treatment for someone’s pain and or disability out of all those that are available that all have similar effects, then I am far more comfortable choosing one that has some well known, well researched, positive secondary effects on an individuals health and well being. This is not ‘excuse based practice’, this is ‘exercise-based practice’.

As always thanks for reading

Adam

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