How ‘therapeutic’ are the exercises that you prescribe for your clients with musculoskeletal pain?

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It’s interesting to reflect on why so many people are suffering from back pain and other ‘injuries’ these days. It’s not just the elite athletes, but also the ‘weekend warriors’, those trying to be fit and trim at the gym and the ‘couch potatoes’.

back painIt is becoming better appreciated that local pathology and pain don’t necessarily correlate. Thus treatment protocols based on a ‘pathological diagnosis’ will not necessarily be successful. Looking at why the pathology might have developed may yield better results.

It is implicit that altered muscle function and ‘injuries’ go hand in hand – so we prescribe exercises for our patient’s particular ‘diagnosis’ – but are we really aiding their return to healthy function? – or helping to further maintain the ‘problem’?

You expect that your doctor will prescribe the right advice and medicine for what ails you. Likewise, our clients also have a right to expect that we will deliver appropriate treatment and prescribe functionally useful exercises which are tailored to their particular musculoskeletal system complaints.

Sadly, most of the clients I see have been prescribed exercises that are inappropriate. The exercises are sometimes creating the issues, but mostly they are reinforcing poor patterns of motor control that are driving the persons pain. No wonder so many end up with ‘chronic pain’, ‘central sensitisation’ and feeling depressed!

What can the research tell us?

core exResearch into low back and pelvic pain is increasingly showing us that there is a relationship between altered motor control and musculoskeletal pain syndromes. Rather than muscle weakness, the problem is one of altered coordination and how that person ‘organises’ his postural and movement responses – not only during his weekend and sports activities, but also during simple everyday activities.

So, with these important insights, why the current craze for and focus upon strength training? The ‘need to get strong’ and ‘develop more muscle’ is being promulgated everywhere – in both the fitness and therapeutic industries.

Could strength training be a big part of the injury problem? – the underlying ‘driver’!

Let’s consider what we know – and use some common-sense

Muscles that are ‘strong’ and work a lot tend to shorten and tighten. They pull more on their attachments – fascia, myo-tendinous junctions etc. They tend not to ‘let go’ or eccentrically lengthen well. So, when they don’t allow the joints over which they influence to move properly, things start to stiffen up – not only the joints but the fascial tissues also begins to lose its slide

This explains why people ‘training for strength’ always feel tight and stiff – they are! They constantly need ‘to use the roller’, have a massage and ‘do stretches’ – it’s relentless!

What is generally missed though, is how vulnerable the spine is in all this. The spine gives us our ‘uprightness’ and in order that we are stable, yet adaptable and flexible, complex patterns of control are evident. Research has shown that in people with low back and pelvic pain, various muscles contributing to the deep stabilising system of the spine are underactive and this is compensated for by more activity in the large more superficial muscles. This jeopardises joint and soft tissue protection mechanisms

Importantly, ‘strength training’ further pumps up these already dominant muscles. Movement patterns become more gross and stereotyped – and spinal control mechanisms including ‘core control’ suffer even more. The stage is set for problems. If spinal segments are overstressed they and the surrounding tissues become inflamed, changes in the neuro-muscular systems become apparent creating covert or overt symptoms near and far from the segment: – local and or referred pain into the limbs, further overactivity and tightness in the muscles and fascia and so on. A vicious cycle ensues.

Many prescribed exercises bother the spine and further imprint and reinforce aberrant patterns of movement, which become ‘learned’ and bear their imprint in the cerebral cortex. The spine is further and continually adversely loaded – a pattern generating cycle is set up.

How to ensure that the exercises you prescribe meet your client’s functional needs?

back extension

Firstly, one needs to have an appreciation of natural movement – how movement develops and to understand the joint myo-mechanics, control of force couples and other significant features that are operant. How the spine and proximal limb girdles are controlled is paramount. How someone ‘gets up’ and stabilises themselves against gravity will affect their ability to perform all other movements. This helps you know what function your are aiming to improve – and dictates the rationale behind an exercise

Then we need to be able to see where and how movement control diverges and appreciate the likely resultant effect on the tissues.

My clinical journey has been in mapping and codifying these altered responses. Common typical altered patterns of control are apparent. Appreciating these helps simplify your movement observations – and helps dictate what you need to do to help change things.

Only then are you in a position to understand ‘why’ the patient has the problem he has – there’s always a reason why he does! And then you need the skills to properly treat and advise him – and prescribe exercises which actually restore the missing basic elements of function. Those that will redress the provocative loading patterns on the structures in question.

‘Strength’ is reliant upon healthy patterns of underlying support and control from within. Without healthy patterns of control from the deep stabilising system of the spine and pelvis, many ‘strengthening’ and ‘stretching’ exercises render the spine and the tissues it influences very vulnerable. This is usually the underlying problem in the development of most ‘injuries’.