Therapeutic exercise and real life
As physical therapists, or other professionals working with people with musculoskeletal problems, we like therapeutic exercise! It’s what we do, it’s what we know, it’s what we learned, it’s what science shows to be beneficial. We like it.
Problem: patients don’t like it as much as we do. And although we are fully aware of this problem of compliance, we generally don’t spend much time thinking on how to fix this.
Problem: therapeutic exercise works, but not always that great. This is probably also related to the compliance problem…
But there are more problems with therapeutic exercise, and many of these issues are not being recognised by most in our profession. Therapeutic exercise does not take into account the complexities of real life: the complexity of the movement tasks, the complexity of the human organism and the complexity of the environment in which we live. Therapeutic exercise (often) is not realistic.
Real life is, well umm, realistic… Maybe we should prescribe more real life to our patients? I think we do, but there are some problems with real life: it is complex, and therefore it carries with it some dangers. For people with pain/injury real life is difficult to dose, has tasks that could be detrimental to health, does not apply specific loads to specific tissues, is, in other words, less safe.
But hey, therapeutic exercise can handle those problems: exercise is easy (relatively) to dose and control, can be very tissue specific, and certainly safer.
Is this a catch 22? Therapeutic exercise is a reduction of the complexity of real life, an attempt to divide real life into its parts and to focus on these. But in a complex system, we know the whole is not the same as the sum of its parts!
I propose two options:
1. Therapists should focus more on ‘prescribing’ real life activities, but should try to manage the risks by educating their patients on dose, control, safety etc. Of course this is nothing new, on the contrary, but, in my experience, it is heavily underused.
2. Therapists should make their exercises more ‘real’, and this with a natural movement mindset. This could be done by using some of the following principles:
make your exercise more goal-directed and meaningful, use practical movement forms
let the organism use its self organising capacity
use a constraints-led approach: change task, environment and organism to create movement situations that are useful
think in terms of adaptive and maladaptive responses to threats
An example to clarify what I mean. Let us take a person with low back pain, in a sub-acute stage, and with a difficulty (pain, limited in range, apprehension) of bending forward:
Instead of giving her a lumbar standing flexion exercise, give her a reaching exercise. Reaching is a practical movement, goal directed and meaningful. Reaching is probably one of the most important reasons why we move our spine in real life (looking is another big one).
Don’t say to your patient how to do the movement, only say what to do! E.g. touch my hand (or try to), reach for that object, reach for your feet, … Let the organism choose the way to move. It will not always move in the right way (what is the right way anyway?), but hey, maybe it moves in the most adaptive way for that body in that particular situation. Maybe there’s still some useful protection. Also, let the person try, explore and experience that movement. Real learning will be the result. Pain can be ok, or not, that will always be a clinical decision to make, but it definitely gives feedback. Maybe there’s another way to reach that point, without pain. Maybe pain goes away with more, gently repetitions…
Really important: don’t give one reaching task but use many variations. For this, use the constraints-led approach: change task parameters, change the movement environment, and change the organism
Task: reach forward, upward, sideways, downward, with one hand (left and right), with to hands, standing on two legs or on one leg, sitting, sitting on the floor (different options), lying, slow, fast, …
Environment: stable surface, unstable surface, slope of surface (uphill, downhill, sideways, diagonal), on balance beam, different objects to reach for, in different rooms
Organism: cause pre-fatigue in the involved muscles, extra cognitive involvement (double task), add mental threat/stress
Of course, don’t forget about dose and safety. This not only means managing tissue safety and tissue load tolerance, but also taking care of sensitisation, illness beliefs, fear-avoidance issues etc.
In a way, this approach carries more risk, and the task of the therapist is to manage these risks. By the way, people with pain/injury have their own protective strategies. But you cannot save a person from the dangers of the world by always protecting them. They need to learn how to handle these dangers themselves! This is true not only for parents and children, but also for therapists and patients.
Exposure to risks and stressors is necessary for adaptation, for growth, for improvement, for health, for wellbeing!
This approach probably also means that you, the therapist and dear reader, need to get out of your comfort zone and explore these strategies. Let go of the illusion of control, said master Oogway. Add complexity to your therapy, add risk to your exercises and experience what it does for your patients and for yourself. Maybe you’ll make your patients more robust (or antifragile) for the challenges or life. And in my experience, it will make the therapeutic exercises more fun, both for the patient and the therapist!