The therapeutic effects of exercise have been widely advocated over many centuries largely on the basis of imperical evidence. Whilst there has been some variation in the methods of application (largely based on historical and cultural differences) there is now a growing body of evidence to substantiate the use of therapeutic exercise across a spectrum of medical conditions (ACSM 1997). There is also increasing interest in the prophylactic role of therapeutic exercise (Clyne 1995).
The constraints of evidence based medicine dictate that intervention should only be undertaken on the basis of proven efficacy. Therapeutic exercise has been shown to have a possible role in a number of conditions including the following:
- Chronic Pain
- Low Back Pain
- Musculoskeletal Pain
- Cardiac Rehabilitation,
- Pulmonary Rehabilitation
- Chronic Fatigue Syndrome.
Disciplines which have been predominately passive in nature i.e. manipulative therapy have been forced to reconsider there efficacy and incorporate more dynamic patient management strategies (Waddell 1998).
This has been driven not only by the requirement for evidence based medicine but also to create patient management strategies which are patient focused and minimize demands upon the health care providers rather than creating a patient dependence as is the case with passive procedures (Koes 1991).
The physiological effects of exercise impinge upon many physiological systems including;
The focus of this course is largely related to the musculoskeletal system.
The interaction of physiological and psychological components must also be acknowledged at this stage. The historical medical model (based on Cartesian Philosophy of separation of mind and body) is no longer valid as it has become increasingly clear that these are intimately interrelated components.
Thus some of the benefits induced by physical means have much greater ramifications for the individual as a whole, in terms of improved self-esteem, confidence, self worth, motivation and empowerment. Part of this course will focus on the use of group dynamics to achieve some of these objectives.
Mechanism Driven Management Strategies in Physiotherapy
Since the demise of the Cartesian philosophy of mind body separation in recent decades and the evolution of integrated multidisciplinary pain evaluation, primary care practitioners are now faced with a complicated care management pathway.
Certainly within the Allied Health Professions there is inadequate undergraduate training in clinical pain physiology and this is likely also reflective of other medical disciplines. The International Association for the study of pain has produced a core curriculum which needs to be adopted on a wider scale. The broader classifications of pain mechanisms have been defined as the following:
- Peripheral neurogenic
- Central ( neuropathic )
These classifications provide an intellectual framework, which allow us to dissect components of pain patterns in order to match the most appropriate rehabilitation strategies. In recent years much emphasis has been placed on the so-called bio-psychosocial model and this has certainly shifted the focus from exhaustive searches for structural, nociceptive drives to explain patient symptom patterns. This has lead to a plethora of psychosocial questionnaires which attempt to predict outcomes and factors which present barriers to effective rehabilitation.
The first practical difficulty we encounter is defining what constitutes a “successful outcome”. These can be classified as:
- Patient orientated outcomes
- Clinician orientated outcomes
- Purchaser orientated outcomes
With regard to low back pain the most commonly used outcome measures are reduced disability, reduction in pain and return to work.
Obviously the waiting factor / relevance of specific outcome measures need to be tailored to individual cases. For example there is little point is using absenteeism or return to work in the case of a legal secretary complaining of an upper quadrant overuse syndrome who still remains at work.
Return to work with moderate levels of discomfort may represent a successful outcome for a construction worker who sustained cervical soft tissue injuries. The issue here is that the care provider and the patient need to have some objective targets with a defined care pathway and rehabilitation milestones to achieve in order to attain these goals.
This is a fairly well accepted philosophy in pain management programmes but unfortunately is not the norm in primary care pain management. Given that the majority of patients present to Physiotherapists, Doctors, and other health care practitioners primarily complaining of pain and loss of function, this is the obvious focus of the clinical examination and subjective history.
The alert clinician should be attempting to match the physical signs with the reported level of dysfunction and the symptom characteristics. Some patients may display overt fear avoidance type behaviour (lethargic movement, cessation of activities of daily living, exuberant verbal pain descriptors, vivid gesticulation and hyper-vigilance) which are fairly evident to the observant clinician.
However, the vast majority of patients present with some degree of physical limitations, specific functional deficits and re-produceable clinical signs. The clinical challenge then becomes one not just of interpreting the source of the physical signs (structure and mechanism) but the wider ramifications of these features for the individual patient. Clearly factors such as pain intensity, pain characteristics, reported level of disability, inherent beliefs systems, fear avoidance beliefs, pain coping styles, socio-economic factors and culture, influence these responses.
From a physiotherapy perspective one of the primary challenges is to integrate these components and deliver a management plan to optimise return to function. In my opinion this constitutes a completely different challenge to patients who enter chronic pain management programmes.
Patients who have failed multiple interventions but who are still willing to commit to some strategies that are likely to improve their function are essentially in a “back’s to the wall” situation where they have nothing to lose. Because of the programme structures patients are exposed to a variety of disciplines (clinical psychology, pharmacology, rehabilitation and pain education) which they would otherwise not be exposed to.
Introducing a patient to the concept of behavioural modification in the acute or sub-acute phase of a musculoskeletal complaint is a completely different proposition and one which many patients are not prepared to accept. The challenge for the physiotherapist then becomes one of how to induce behavioural modification not with direct cognitive strategies but to use movement, manipulative therapy, functional re-education in a way that re-establishes movement patterns or functions which may initially have been painful and which patients still report as been symptomatic.
This is a classic rehabilitation crossroads where the treating therapist ascertains from physical examination that as is appropriate to increase the level of functional loading and yet the patient still displays fear avoidance behaviour. At this point a common pitfall is a breakdown of trust in the relationship between therapist and patient as the patient feels that their concerns are not been addressed, that their pain is been disregarded or that they are suspected of been a malinger.
All pain has a source and a mechanism! Typically the therapist becomes increasingly distressed because of the discrepancy between physical signs and functional capacity with objective pain measures not viable. It is at this crossroads that the therapist / clinician has a number of practical, behavioural modifications techniques at their disposal.
- Is to break the functional movement pattern into individual components to allow the patient to explore new mechanics and responses to individual movements before integrating these in a composite manner, relevant to function.
- Specific physical examination of the painful site before and after performance of a movement. This is very useful practically.
If one can demonstrate that the performance of a movement hasn’t increased muscle spasm, initiated inflammatory joint reaction or produced a comprise in movement then one can use educational strategies to explain what patient’s are feeling if they are still reporting some discomfort and allay any fears about structural disruption/ inflammatory responses.
These are important practical strategies if rehabilitation is seriously attempting to steer individuals towards successive milestones. If at some point the structured progression of functional loading produces an aggravation of symptoms which correlates with a deterioration in physical signs then I believe it is appropriate to look for specific nociceptive drives with specific physical examination and reassess the functional component of the rehabilitation programme.
If patients tend to plateau at this point with consistent aggravation of specific nociceptive drives (specific joint irritation, specific neural irritation or more diffuse pain patterns the physiotherapist must consider cross referral for pain management procedures such as joint or nerve blockade. Whilst this type of cross-disciplinary management is increasing it is still far from satisfactory at a primary care level.
Likewise to improve the outcome of these procedures information from the rehabilitation setting regarding specific sites of irritation and response to loading should certainly be used in planning interventions. One-off assessments with isolated examination of “tender areas” is often not a true reflection of the primary focal pain sites.
Obviously in order to accurately record and quantify this type of information therapists need to have some specific evaluation skills to structurally differentiate the site of symptoms with relevant physical examination techniques. This includes a battery of tests far beyond simple range of movement evaluation.
It requires evaluation of specific joint movement characteristics to identify hyper or hypo mobile segments. It requires detailed examination of muscle interactions to determine if postural mechanisms are potentiating a source of joint irritability. It requires detailed knowledge of normal muscle function in order to ascertain if abnormal patterns of muscle activity are perpetuating myofascial pain syndromes. It requires knowledge of nerve sensitivity provocation tests (mechanical hyperalgesia) in order to determine if there is a peripheral neuropathic component to a patient’s pain pattern and also to determine the site/sites of neural irritability.
It also requires therapists to recognise when symptom patterns are no longer compatible with localised nociceptive mechanisms (hyperpathia, symptom site fluctuation, non-mechanical provocation, bilaterallity, dysathesia, and diffuse hyperalgesic states).
Recognition of pain patterns which are evolving from a localised structural tissue irritation to a more diffuse centralised pain state is absolutely imperative if chronicity is to be reduced. In practical terms this requires physiotherapists to be able to liase with general practitioners and pain management teams to switch to centrally acting medications as required.
The practicalities of referral to pain management facilities often mean many months of waiting with increasing time to establish patterns of potentially irreversible neurplastic/ behavioural change. The search for more specific molecular mechanisms of pain such as abnormalities in the activation of NMDA receptors, elevation of nitric oxide levels, lowered serotonin (5HT) are some of the biological markers which are being used in some chronic pain investigations in an attempt to match therapeutic drugs to specific mechanisms. Whether these become tools available in primary care or exclusively in chronic pain management clinics remains to be seen.
In summary given that chronic pain is essentially a management issue as opposed to a cure the fundamental objective of primary care practitioners should be proactive prevention in the initial management phase.
Dublin Physiotherapy Clinic
11 Stadium Business Park
Ballycoolin. Dublin 11
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Many of you will be familiar with the concept of functional training in rehabilitation, so a brief review of historical aspects will suffice here.
Functional training from a rehabilitation perspective has been used for many decades with the obvious goal of returning an individual to their pre-injury functional status.
The astute reader will note that this implies a degree of individuality and specificity in rehabilitation strategies depending on the individual’s response to the injury in question and the planned functional goals to be achieved. In this discussion we are concerned with a return to playing sport, which has different functional requirements depending on the sport of choice.
Most rehabilitation specialists would agree that the fundamental measure of success is the ability to “perform at maximal function”. The issues of debate usually centre around:
- Whether to use functional exercise as an initial priority.
- Whether to place prerequisite criteria for progressing to functional exercise e.g. base line flexibility measures, stability measures, agility, coordination and power.
- The use of over load / external resistance to achieve progressive increases in power output.
- Key variables to manipulate in exercise progression e.g. load, speed, plane of motion, movement sequence.
Perhaps the biggest source of discussion in this regard is the use of fixed weights / machine systems relative to free weights. In the non-elite athlete there are some attractive aspects to using fixed weights as the machines themselves provide some degree of stability, are relatively safe, allow max or near max loads to be utilised and can be undertaken individually.
Unfortunately the artificial stability provided by machine systems dictates that a critical aspect of functional strength is not trained and therefore of debatable relevance in functional loading. On the other hand free weights use allow mass activation of stability and mobility muscle groups, more closely approximates functional movement patterns and requires higher levels of skill and coordination particularly if technical or explosive lifts are being attempted. Most serious athletes will incorporate some degree of free weights into their training.
The gap between these two approaches can be neatly filled by incorporating batteries of functional tests which explore movement control and coordination in varying combinations of body position, primarily with body weight as the external load, but progressing with small proportional increases in resistance as control allows. It can be reasonably argued that inability to control one’s body weight through a full functional repertoire of positions which are likely to be encountered in the course of the game situation may predispose to injury.
One of the current difficulties related to repeated tests / re-tests of functional measures are the measurement systems used. These tend to be somewhat “low tech”, can sometimes rely on the individuals perception of effort to perform a desired task or require an external examiner’s observation of the quality and sequencing of movement. Needless to say there maybe many hours of debate regarding differences of opinion on these issues!!!
Nonetheless a useful concept in this regard (popularised by American Physiotherapist Gary Gray), utilises the concept of threshold training in which the extreme position which an individual can control is measured relative to that of the other side. Any further change in position produces falling or loss of balance or some compensatory adaptive mechanism – indicating failure.
Components of a total body functional profile.
- Reliability and validity.
- A full spectrum functional testing.
These concepts should be borne in mind when deciding what battery of functional tests to include for an individual or as part of a team training / screening protocol. The other critical point to recognise is that loading is occurring in three planes of motion simultaneously – tri-plane motion.
In clinical practice it is often by combining three planes of motion simultaneously that one can expose weaknesses, which do not appear evident when testing an isolated plane. If one analyses the movement patterns involved in most sports we can see that they can be broken into groups of core functional activities e.g. jogging, running, decelerating, excelerating, twisting, pivoting, jumping and pushing.
Each of these complex movement patterns can be broken down into components and each can be stressed using varying combinations of challenges e.g.
- Range of motion.
- Sequence of motion.
- Eyes opened / closed.
- Corporating simultaneous trunk and limb movement.
- External resistance e.g. elastic tubing, bungee cords or dumbbells.
All allow varying degrees of difficulty to be explored in order to be determine the functional threshold of control.
Gray groups his functional tests under the following categorisations.
- Balance tests.
- Balance reach tests.
- Excursion tests.
- Lunge tests.
- Step up tests.
- Step down tests.
- Jump tests.
- Hop tests.
Functional self-test menu
Below are listed a group of self-test movements which can be administered and the degree of difficulty noted. Please note that there can be many different reasons for an inability to perform complex patterns which could include flexibility, stability, power, endurance or coordination deficits.
1. In- line lunge with body rotation.
Stand in a long stride position with front and rear legs in one line and feet pointing forwards in the same direction. Heels must stay on the ground. Bend front knee and hold leg position still. Add alternating twists of the upper torso to left and right side.
2. Single leg stance with toe touch.
Standing on one leg bend forwards to touch toes with the hand on the same side as your standing leg. Return to upright and reach arm overhead. Focus on maximising hip and knee bend in order to increase the leg stress. Ensure that standing leg does not roll inwards.
3. Kneeling lunge with trunk side bend.
In a kneeling lunge position, with both legs in line, side bend the upper torso from left to right. If toes grip floor strongly, tap floor to prevent fixing.
4. Single leg stance forward / downward leans.
Stand facing a wall, goal post or barrier about 3ft away initially and stand on one leg. Reach forward with the index finger to touch the ground as far out in front to reach the ground if possible. Return to upright and reach with opposite hand.
5. Single leg stance reverse pivot.
Stand on one leg with back to wall or post or barrier. Reach overhead with left and right hands alternately to try and touch behind without falling over. If it is too easy move a further distance from the barrier.
6. Incline lunge with trunk rotation
Lunge at 45° from straight ahead position, holding dumbbell in opposite arm (6 to 10kgs) reach down and across to the outside of the forward foot. Return to upright. Alternate sides.
PS to initially feel the coordination for this drill try work without weights.
There are infinite numbers of variations of these types of drills which can be exciting, fun, challenging and very revealing. We will come back to some of these concepts in the future.