Exercise & The need for a Biopsychosocial Approach.
Written by Sid Anandkumar
Low back pain (LBP) is one of the world’s leading musculoskeletal disorders and some quick facts are depicted below in figure 1.
Though various causes have been attributed to LBP, the majority (85 percent) is non-specific, where it does not have a specific cause or pathology (Deyo and Phillips, 1996). Non-specific LBP is considered to be chronic when the duration is greater than 12 weeks and even after seeking help from health care professionals, 60-80% of individuals will continue to experience it one year later (Hayden et al, 2010). It is linked to a variety of factors which may be genetic (eg. family history of chronic pain), psychological (eg. anxiety, depression etc.), social (eg. low job satisfaction), physical (eg. maladaptive movement strategies), lifestyle (eg. smoking, sleep disturbances etc.) and neurophysiological (eg. central sensitization) (Balagué et al 2012).
Management of Non-specific LBP is multimodal in nature and exercise therapy is one of the most commonly used interventions. It has a moderate beneficial effect and regardless of the type of exercise (aerobic, strengthening, stretching, motor control training etc.), it has a significant effect on work disability (Oesch et al, 2010; Steiger et al, 2012). Though Non-specific LBP is multidimensional in nature, physical therapists often prescribe exercises from a biomechanical and impairment-based approach of the musculoskeletal system focussing on factors such as strength, range of motion, endurance, balance, motor control etc. However, changes in these physical parameters with exercises have been shown to be unrelated to pain and disability in low back pain (Steiger et al 2012), thereby suggesting that exercise-induced changes possibly mediate through other mechanisms - like influencing psycho-social (eg. changes in fear, catastrophic thoughts etc) or neurophysiological factors (eg. functional changes in the central nervous system) (Booth et al 2017).
With a thorough initial assessment, physical therapists should identify the various biological, psychological and social factors contributing to LBP. Based on this, physical therapists should prescribe tailor-made exercises to improve patient outcomes. Some factors which may influence exercise prescription under the lens of BSP approach (figure 2) are discussed below
This refers to a sense of partnership, understanding, respect and support between the clinician and the patient. The initial assessment forms a strong foundation which can help in creating a trusting connection and rapport, leading to collaborative goal setting and a common agreement on interventions. Therapists should engage in a patient‐centred communication continuing into the treatment sessions. A positive therapeutic alliance has been shown to be associated with improved outcomes in LBP (Ferreira et al 2013). On the other hand, we must be wary of factors that can weaken the therapeutic alliance - such as clinician behaviours (eg. being rude or critical), undermining goals, or uninvolved in patient expectations etc. which can ultimately lead to poor outcomes as well as reduced self-efficacy and exercise adherence.
It is imperative to educate patients from a therapeutic pain neuroscience approach considering the dynamic interactions of the various bioloigical, psychological and social factors. Mal-adaptive thoughts, attitudes, beliefs, behaviours etc. must be addressed as fear-avoidance, pain catastrophization, low mood, anxiety, stress, frustration etc. are associated with persistent LBP. Sometimes patients can associate movements and exercises with pain and structural damage or worsening injury, which can further increase anxiety and top to down pain processing from the central nervous system. If this continues in the long term, it can lead to “classical conditioning”, where exercise therapy or movements become strongly associated with pain, thus potentially leading to worse clinical outcomes. Reconceptualization of pain experience can reduce the top to down threat processing and provides a therapeutic window with which exercise therapy (bottom to top treatment approach) can be initiated. Exercises must be viewed as safe, meaningful, enjoyable and engaging, where “hurt” or post-exercise soreness doesn’t equal harm or tissue damage but a protective response from the body. Also, we should avoid the use of words that can potentially “harm” the patient (like “torn”, “Ripped”, “bone on bone” etc.) and use words that “soothe” and decrease threat to the whole central nervous system (eg. oiling the joints, increasing juices to the nerves, lubricating the discs etc.).
c) Patient expectations
Patient expectations can significantly influence treatment outcomes and positive expectations are associated with better health outcomes (Mondloch et al 2001). However, it is important that physical therapists should assist patients in having appropriate expectations of recovery. For example, if a patient with chronic LBP expects to be completely pain free with a “quick fix” exercise, failure to achieve this may lead to more frustration and anxiety, thus sustaining/worsening pain and disability. Negative expectations and poor communication (eg. from friends, family, media, internet etc.) can lead to reduced exercise adherence and must be addressed by therapists through meaningful dialogue. For a pain focussed patient, it is important to set up expectations where exercise is viewed as promoting physical activity, function and quality of life with pain relief being a secondary goal in the patients journey to recovery. As it is not possible to dose exercises proportional to each patients pain threshold in LBP, they should be time contingent as opposed to being pain contingent.
d) Patient attributions to success vs failure
Attributions are described as the process by which individuals explain the causes of behaviour and or events and make sense of the various experiences (Stilwell et al 2017). If a patient had a positive clinical experience with a particular exercise in the past (eg. yoga) and judges it to be the cause for their LBP recovery, this shapes patients expectations for similar interventions being successful in the future. Hence, it’s important that we should consider not only patient preferences but also past experiences when prescribing exercises. On the other hand, negative patient attributions can impair recovery and sustain LBP. For example, patients may attribute their low back pain due to a “weak core” or “unstable spine” and that they need to do “core and stabilization” exercises to prevent pain. This can create negative perception/cognition for patients leading to a host of issues like hyper-vigilance, beliefs of increased vulnerability or that the spine needs constant protection with abdominal bracing etc. This can lead to increased trunk stiffness and lumbar compression, which can further worsen pain. Hence, just as how pain is context driven, physical therapists must consider the context with which exercises are taught.
e) Self-efficacy and self regulation
Self-efficacy (that is the degree to which a patient believes he/she can get through a problem by their own) also influences outcomes and a low self-efficacy is closely associated with impairments, distress, and pain severity (Jackson et al 2014). Identifying patients who can self-regulate, self-monitor and appraise their responses to exercises and or pain should be considered by therapists as it can influence recovery. Even if patients experience pain and increased muscle tension with functional movements, teaching them self-regulation strategies through breathing and appropriate thoughts can help them with positive adaptive responses. For example, when treating patients who constantly brace their abdomen while bending down, the ability to self-identify faulty movement patterns/ excessive muscle tension and employ relaxation strategies for the abdomen while avoiding catastrophic or unhelpful thoughts can improve the fluidity of movements. When patients experience, believe and learn that they are capable performing challenging functional or movement tasks in a consistent manner, it increases their self-efficacy which in turn improves the patient’s exercise behaviour and adherence. On the other hand, for patients who are highly stressed and anxious with a low self-efficacy, higher level of exercise supervision maybe required.
A few exercise prescription considerations in chronic LBP (Booth et al 2017) are shown in figure 3.
Prescribing exercises with impairment based biomechanical model to elicit changes in strength, endurance, range of motion etc. has limited value in chronic LBP. Therapists must consider the dynamic interplay of various contextual factors such as patient preferences, expectations, therapeutic alliance, level of pain education, and self-efficacy/self regulation when making clinical decisions with exercise therapy.
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