Blurring the lines: Physio, OT, exercise & context

I frequently joke with many of my colleagues that I’m an OT in a physio’s body. Most of my work in pain management involves supporting people, increasing self-efficacy, addressing concerns or worries about misconceptions of fragility of the body and of course getting people moving.

So, yeah I’m a physio and I often question what I actually do?  I mean I rarely use hands on or acupuncture, I don’t tend to use electrical equipment, although I see TENS may have some use again (Sluka, Frey-Law, & Hoeger Bement, 2018), I rarely use tape and I don’t really do any form of manipulative therapy.

I would say the bulk of my intervention is getting people moving and by that, maybe 50% is devoted to exercise. As we all know (because we are bombarded by it) there are many benefits to exercise, I’ve written about it here and here. We also know it doesn’t really matter what kind of exercise you do for pain or disability whether it’s for core stability (M. B. Shamsi, Rezaei, Zamanlou, Sadeghi, & Pourahmadi, 2016)Motor control (Unsgaard-Tøndel et al., 2010)aerobic walking (Shnayderman & Katz-Leurer, 2012) strength and resistance training (Searle, Spink, Ho, & Chuter, 2015) people do get better whatever way they exercise (M. Shamsi, Sarrafzadeh, Jamshidi, Arjmand, & Ghezelbash, 2017; Lewis, Morris, & Walsh, 2008).

So, I guess unless you are working with athletes that require specific training then it doesn’t really matter what exercise the person living with pain does.  So, where does that leave us? Well I’m sure you’ve all answered that question by shouting, “DOSAGE!” You are not wrong and I have written about this in the past here as have other bloggers here and here.

Before I attempt to answer my initial question, I want to discuss an additional area that perhaps physio’s do need to start thinking more broadly about – behavior.

I would take a guess and say that most clinicians working in pain management (and vocational rehab) will have witnessed pain behaviours. Some of you may even be familiar with the learning principles of classical and operant conditioning.  I‘m not going to go into depth around either of these learning principles, but I will say we might have to start considering these learning models a lot more in theses areas.

Learning Models

Let’s look at classical conditioning and in particular the notion of extinction. Extinction is considered to be the weakening or even disappearance of the associated strength between the conditioned stimulus and the unconditioned stimulus (Goubert, Crombez & Peters, 2004). Pain is an unconditioned stimulus – A biologically relevant signal that encourages a person or organism to escape from a threatening or dangerous situation. Thus, facilitating survival (Vlaeyen et al., 2013). Highly effective in the presence of tissue damage.

When it comes to tissues being fully healed and pain persists, (as some researchers/clinicians propose) there may be conditioned stimuli that perpetuate a pain experience. Conditioned stimuli can be biological, psychological, social, environmental, cultural, they can also be interoceptive (within the body) such as muscle tightness, proprioceptive such as body positions or postures and exteroceptive – features of and engagement with the environment.

In this case, pairing between a conditioned stimulus (which might be spinal flexion) and an unconditioned stimulus (pain), extinction is designed to weaken the association.

Exercise and Extinction

Exercise may be viewed as an example of extinction. Consider someone who experiences Low back pain. This person experiences pain on movement and consequently uses various behaviours to ‘avoid’ or ‘escape’ performing activities that is believed to cause more harm. As a result, prolonged inactivity leads to deconditioning or ‘disuse syndrome’ (Verbunt, Seelen & Vlaeyen, 2004).

Exercise is often seen as a means to attenuate pain (Koltyn, Brellenthin, Cook, Sehgal, & Hillard, 2014; Naugle, Fillingim, & Iii, 2012; Todd, Shurley, & Todd, 2012; Vaegter, 2017)with the understanding that getting stronger will address muscle weakness and reduce pain.  Now, before I continue backing myself into a corner, I am aware of other evidence around exercise such as Nijs et al’s, (2015)work on altering pain memories. Nijs and colleagues explain how clinicians can alter pain memories by integrating pain education and then applying an ‘exposure without danger’ principle, which if any avid reader of research would know is effectively just a modification of Bill Fordyce’s work.

It is also noteworthy that the ‘deconditioning’ and ‘disuse syndrome’ constructs continue to receive scrutiny due to a lack of empirical evidence (Bousema, Verbunt, Seelen, Vlaeyen, & Andre, 2007)

Anyway, back to my previous point of using exercise as an example of extinction. Physio’s use exercise to condition people to return to activity or work, with an understanding that if people get stronger, confidence will improve and pain will attenuate. In New Zealand physiotherapists are involved in return to work programs and exercise is a significant part of the program.

So, the patient hurts their back in a specific context, such as a work environment, performing a specific work task. The exercise program however, prescribed by the physiotherapist is often aimed at addressing muscle, tendon and bone because the injury is viewed as a tissue-centered problem and not a context-specific, person-centered problem. This is where it can get a bit blurry, Extinction is often context-specific.

Therefore, whilst the patient may increase their muscle strength through exercise in a clinical environment, once reintroduced into the work environment where the person hurt their back there is the risk of pain and disability returning due to context.  This helps to explain part of the challenges of the disuse syndrome theory.

Blurred Lines

What does this mean? Well, perhaps it means that physiotherapists working in return to work programs need to consider movements from a behavioural perspective more than a biomechanical perspective and that they could be heading out to work environments and training people in their work environments, drawing comparisons to what the person does in a work environment to a clinical environment. Now, wait just a darn minute! That’s an OTs Job I hear some of you cry! Indeed it is and there we have it, the ongoing existential crisis of what physios actually are?

Perhaps in the future Physiotherapists and Occupational Therapists roles in pain management and vocational rehabilitation may become a bit more blurry, perhaps even more than it is now. To the point where both professions merge. There seems to be plenty of talk about this (Nicholls, 2017).

Thanks for having a read of my musings

TNP

References

Bousema, E. J., Verbunt, J. A., Seelen, H. A. M., Vlaeyen, J. W. S., & Andre, K. J. (2007). Disuse and physical deconditioning in the first year after the onset of back pain. Pain, 130(3), 279–286. https://doi.org/10.1016/j.pain.2007.03.024

Goubert, L., Crombex, Geert., & Peters M. (2004). Pain-related fear and avoidance: A conditioning perspective. In: PAIN: Understanding and treating fear of pain. Oxford University Press, New York. ISBN 0198525141

Koltyn, K. F., Brellenthin, A. G., Cook, D. B., Sehgal, N., & Hillard, C. (2014). Mechanisms of exercise-induced hypoalgesia. Journal of Pain, 15(12), 1294–1304. https://doi.org/10.1016/j.jpain.2014.09.006

Lewis, A., Morris, M. E., & Walsh, C. (2008). Are physiotherapy exercises effective in reducing chronic low back pain? Physical Therapy Reviews. https://doi.org/10.1179/174328808X252000

Naugle, K. M., Fillingim, R. B., & Iii, J. L. R. (2012). A meta-analytic review of the hypoalgesic effects of exercise. The Journal of Pain, 13(12), 1139–1150. https://doi.org/10.1016/j.jpain.2012.09.006.A

Nicholls, D. A. (2018). The End of Physiotherapy. Routledge Advances in Health and Social Policy. Abingdon, Oxon. ISBN 9781138673557

Nijs, J., Lluch Girbes, E., Lundberg, M., Malfliet, A., & Sterling, M. (2015). Exercise therapy for chronic musculoskeletal pain: Innovation by altering pain memories.Manual Therapy, 20(1), 216–220. https://doi.org/10.1016/j.math.2014.07.004

Searle, A., Spink, M., Ho, A., & Chuter, V. (2015). Exercise interventions for the treatment of chronic low back pain: A systematic review and meta-analysis of randomised controlled trials. Clinical Rehabilitation, 10, 1–13. https://doi.org/10.1177/0269215515570379

Shamsi, M. B., Rezaei, M., Zamanlou, M., Sadeghi, M., & Pourahmadi, M. R. (2016). Does core stability exercise improve lumbopelvic stability (through endurance tests) more than general exercise in chronic low back pain? A quasi-randomized controlled trial. Physiotherapy Theory and Practice, 3985(March), 1–8. https://doi.org/10.3109/09593985.2015.1117550

Shamsi, M., Sarrafzadeh, J., Jamshidi, A., Arjmand, N., & Ghezelbash, F. (2017). Comparison of spinal stability following motor control and general exercises in nonspecific chronic low back pain patients. Clinical Biomechanics, 48(July), 42–48. https://doi.org/10.1016/j.clinbiomech.2017.07.006

Shnayderman, I., & Katz-Leurer, M. (2012). An aerobic walking programme versus muscle strengthening programme for chronic low back pain: a randomized controlled trial. Clinical Rehabilitation, 2–9. https://doi.org/10.1177/0269215512453353

Sluka, K. A., Frey-Law, L., & Hoeger Bement, M. (2018). Exercise-induced pain and analgesia? Underlying mechanisms and clinical translation. Pain, 159(9), S91–S97. https://doi.org/10.1097/j.pain.0000000000001235

Todd, J. S., Shurley, J. P., & Todd, T. C. (2012). THOMAS L. DELORME AND THE SCIENCE OF PROGRESSIVE RESISTANCE EXERCISE. Journal of Strength and Conditioning Research, 26(11), 2913–2923.

Unsgaard-Tøndel, M., Fladmark, A. M., Salvesen, Ø., Vasseljen, O., Unsgaard-Tondel, M., Fladmark, A. M., … Vasseljen, O. (2010). Motor Control Exercises, Sling exercises, and general exercises for patient with Chronic Low Back Pain: A Randomized Controlled Trial with 1-Year Follow-up. Physical Therapy Journal, 90(10), 1426–1440. https://doi.org/10.2522/ptj.20090421

Vaegter, H. B. (2017). Exercising non-painful muscles can induce hypoalgesia in individuals with chronic pain. Scandinavian Journal of Pain, 15, 60–61. https://doi.org/10.1016/j.sjpain.2016.12.005

Verbunt, J.A., Seelen, H.A., & Vlaeyen, J.W.S. (2004). Disuse and physical deconditioning in chronic low back pain. In: PAIN: Understanding and treating fear of pain. Oxford University Press, New York. ISBN 0198525141

Vlaeyen, J.W.S., Morley, S.J., Linton, S.J., Boersma, K., & de Jong, J. (2012). Pain-Related Fear: Exposure-Based Treatment of Chronic Pain. IASP Press, Washington, D.C. ISBN 978-0-931092-87-9.