Working in musculoskeletal practice, it’s easy to forget the scope of the issues that we are dealing with. Low back pain is a leading cause of disability in Canada, with 1 in 5 Canadians suffering from high intensity low back pain over a 6 month period (1). Nearly 1 in 5 Canadians suffer from chronic pain lasting more than 3 months (2). In Ontario alone, over a year-long period, 22.3% of people saw a physician for a musculoskeletal issue; that’s 2.8 million people! (3). So the natural next question is what as physiotherapists can we do to help these people in pain? What is our most potent treatment tool for managing musculoskeletal pain? While we have a number of tools in our toolbelt, is there a tool that we should be bringing out a bit more often than the rest?
There are a few reasons why I think there is a general answer to that question. The answer is not a newly minted manual therapy technique, nor is it ACT, CBT, MDT, ART, PNF, or any other 3 letter proprietary intervention, and it’s not even anything that gets plugged into the wall… In fact it’s humble, well known, and called EXERCISE. A recent systematic review of treatments for the most common musculoskeletal pain sites – neck, back, hip, knee and multi-site pain – found that exercise had the strongest recommendation – greater than other modalities such as manual therapy or oral pharmacological management (4). This was corroborated in a huge number of reviews: 10 Cochrane reviews, four clinical practice guidelines and 3 policy documents. Bottom line – we are very confident that exercise is a highly influential and effective treatment tool that physiotherapists are well positioned to administer. While there are issues with these reviews and they can’t inform all of our practice (they don’t give us specific recommendations for specific patients), they can inform us about what our power tool might be.
To zoom in on a specific treatment area let’s look at a review of lumbar spine pain where the authors compare active versus passive care. A massive review of lumbar spine treatment in the US of over 750,000 individuals looked at whether people received “adherent” versus “non-adherent” care (5). How did they categorize adherent care? This was defined as having over 75% of the treatment being active – either “exercise therapy” or “neuromuscular re-education”. The authors found that patients that received adherent (aka active) care had a significantly lower rate of going on to have advanced imaging, spinal injections, lumbar surgery, and had lower medication costs over the subsequent 2 years.
Importantly, this review is not saying that we can’t or shouldn’t use manual techniques or therapeutic modalities. Indeed, the authors state that manual therapy in the first 2 weeks of care is part of clinical practice guidelines based on research of positive effects with early manual therapy in acute low back pain (6). I would suggest that the thesis is that exercise shouldn’t get left out, and that it should usually make up a large portion of a treatment session.
So how can we best implement our exercise programs? There’s no use in having this “Power Tool” if patients don’t understand why we’re getting them to use it. Exercise can be uncomfortable. It’s hard work, and it’s sometimes painful. We need to employ considered strategies to motivate patients to engage and adhere to their exercise prescriptions.
So what are patients saying about exercise for musculoskeletal pain? Patients prefer individualized exercises that are tailored to their normal activities (7). Interestingly, this review of patient feedback emphasized the value of demonstrating exercises, observing their performance, and giving feedback based on technique. Patients seem to have a bias against cookie-cutter approaches, which is echoed in treatment guidelines for lower back pain (8). I’m not saying that perfect technique is necessary for an exercise to be effective – rather, technical tips and instruction seem to increase patient buy-in and enthusiasm.
There’s another major tip that I personally think is critical— keep it fun! Our exercise programs should try to match the intensity and type to the patient in front of us, but also introduce variability and a good bit of fun to the process. It’s often the case that many different types of exercise will achieve similar benefits. For instance, with low back pain treatment, core stabilization, moderate-intensity aerobic exercise, strength programs and flexibility programs, lead to a similar magnitude of benefit (9). That leaves us in a position to pick what exercise resonates with our patients. If there’s an exercise that the patient finds meaningful or fun, their adherence will go up and they will realize the benefits. I’d argue that a good deal of the art of exercise prescription is making it fun and meaningful.
A few caveats before we adjourn... While the review on musculoskeletal pain mentioned above found moderate to large effect sizes with exercise treatment (this would indicate these treatments are showing large changes in pain), other reviews have found smaller effect sizes on pain and disability particularly in the lumbar spine (10,11). Exercise is not a panacea for pain, and we will need to consider all the things that are sensitizing the patient in front of us to have optimal outcomes. This could include factors such as biomechanics, sleep, stress, kinesiophobia or pain beliefs (12,13,14). In chronic low back pain there is some promising evidence that combining exercise or a graded-exposure approach with ‘Explain Pain’ education leads to the better outcomes in pain and function (15).
When we’re talking about musculoskeletal pain in these broad terms we can only make broad recommendations. That said, there are some guidelines that have been suggested for chronic presentations that I think are helpful to keep in mind when we are treating patients, which I’ve included below (16). These recommendations and guidelines offer a starting point when implementing our exercise programs.
Understanding contemporary pain biology and ‘explaining pain’ are key competencies required for biopsychosocial treatment.
Frequently reassure patients that it is safe to move/pace-up despite their symptoms.
Exercise prescription should be time, as opposed to pain, contingent using a tolerable/not tolerable dichotomy.
Having ready‐made responses to flare‐ups can reduce severity.
Exercise should be individualized, enjoyable, meaningful, and related to patient goals.
Many patients with CMP will respond to lower exercise dosage than recommended for healthy individuals (i.e. graded low to moderate intensity).
Closely observe and monitor exercise then provide feedback and correct poor technique.
Encourage patients to self‐monitor exercise (diaries, activity trackers, etc.).
Place emphasis on developing/restoring movement confidence and quality.
This excellent article was written by Nathan Hers and originally published in PABC’s February 2019 Directions Magazine.
Cassidy, J. et al. (1998). The Saskatchewan health and back pain survey. The prevalence of low back pain and related disability in Saskatchewan adults. Spine
Schopflocher, D. et al. (2011). The prevalence of chronic pain in Canada. Pain Research and Management
MacKay, C. et al. (2010). Health care utilization for musculoskeletal disorders. Arthritis Care & Research
Babatunde, O. et al. (2017). Effective treatment options for musculoskeletal pain in primary care: A systematic overview of current evidence. PLOS One
Childs, J. et al. (2015). Implications of early and guideline adherent physical therapy for low back pain on utilization and cost. BMC Health Services Research
Childs, J. et al. (2004). A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Annals of Internal Medicine
Slade, S. et al. (2014). What are patient beliefs and perceptions about exercise for nonspecific chronic low back pain?: A systematic review of qualitative studies. The Clinical Journal of Pain
NICE. (2016). Low back pain and sciatica in over 16s: assessment and management. Retrieved from https://www.nice.org.uk/guidance/ng59
Saragiotto, B. et al. (2016) Motor control exercise for chronic non-specific low-back pain. Cochrane Library.
Rainville, J., et al. (2004). Exercise as a treatment for chronic low back pain. The Spine Journal
Searle, A. et al. (2015). Exercise interventions for the treatment of chronic low back pain: a systematic review and meta-analysis of randomised controlled trials. Clinical Rehabilitation
De Oliveira Silva, D. et al. (2018). Kinesiophobia, but not strength is associated with altered movement in women with patellofemoral pain. Gait & Posture
Osteras, B. et al. (2015). Perceived stress and musculoskeletal pain are prevalent and significantly associated in adolescents: an epidemiological cross-sectional study. BMC Public Health
Bonvanie, I et al. (2016). Sleep problems and pain: a longitudinal cohort study in emerging adults. Pain
Pires, D. et al. (2015). Aquatic exercise and pain neurophysiology education versus aquatic exercise alone for patients with chronic low back pain: a randomized controlled trial. Clinical Rehabilitation.
Booth, J. et al. (2017). Exercise for chronic musculoskeletal pain: A biopsychosocial approach. Musculoskeletal Care