There is a current trend to treat painful problems with exercise, conflating it as rehabilitation.
Before I elaborate, let me make a few things clear:
- Done correctly, exercise is a good thing, for most people
- Exercise can be part of the recovery process from pain and injury
- Exercise has many health benefits
- I promote exercise actively – if you follow my social media accounts you’d see that
However, exercise is not therapy, nor is exercise rehabilitation.
Yes, exercise can be part of rehabilitation, but it isn’t the same as rehabilitation.
We must keep in mind, however, that motor skill learning and exercise are not synonymous. – Stevans and Hall, 1998
I teach a workshop that talks about using kettlebells for rehab.
In it, I present this argument that performance training and rehab are on the same continuum, with health somewhere to the right of middle.
My point is this:
Performance training is aiming to maximise performance of a particular task.
Rehab is aiming to improve physical performance in one or more aspects.
The principles of stimulus and adaptation still hold.
What doesn’t hold is that you can use performance training to achieve a rehab goal, if the deficit is not performance related.
There is a saying that you can’t put fitness on top of dysfunction.
That’s not completely true, but nor is it true that simply adding load makes things better.
Solely focusing on resolving dysfunction (whatever that means) and solely focusing on building capacity (performance) are both inadequate.
So what happens when rehabilitation is inadequate?
- Presenting issue (often pain or injury) is not adequately resolved
- Increased risk of future injury
- Impaired performance (be it at sport, work or activities of daily living)
Strength Training Is Not Rehabilitation
I have a weak back.
I need to train my core.
My knees aren’t as strong as they were.
Almost every day I hear stories from patients correlating their pain with weakness.
There is a meme floating around about the relationship between strength and pain that is growing in power and becoming really hard to undo.
If there was a direct link between strength and pain, we would not see strong high level athletes suffering from chronic pain.
But we do.
The main reason I suspect we see this link is two fold:
- Visually, strong people fill our idea of health and fitness.
- Simplicity: it is easier to blame on weakness, teach somebody how to strengthen the so called weaknesses and then use strength as an outcome measure.
Strength training can definitely be part of a rehabilitation program.
But getting strong alone is not the reason we see improvements in pain.
Strength training, done properly, improves movement quality, load tolerance and builds confidence. All these contribute to improving pain in certain conditions.
Stretching Is Not Rehabilitation
The second common issue is “tightness”.
People often feel tight and cite this as a reason they need to stretch.
Therapists then perform an assessment.
They say this feels tight, this is weak. Stretch this. Strengthen that.
If only it were that simple!
Stretching is a valuable technique. I use it as part of my own personal exercise programs, and often prescribe stretching to patients.
Stretching has value beyond lengthening muscles (which it actually doesn’t do*), like improving body awareness (interoception) and relaxing both body and mind. All of this can help people in pain improve.
But alone, stretching is not rehabilitation. In fact, changes to flexibility are not associated with improvements in pain.
Oh and by the way, feeling tight doesn’t actually correlate with being “stiffer”. This has been shown in research. One is a perception of the body, the other is a physical property.
“Cardio” Is Not Rehabilitation
Whether it is going for a run, stationary cycling or walking – all these forms of exercise can have positive effects on health, pain and function.
However, again, is it rehabilitation?
Time again we see improvements with these (and other) cardio activities, which do not correlate to improvements in fitness or endurance.
Again, this isn’t to say cardio exercise has no value in a rehabilitation program, it is simply saying, that cardio in and of itself is not rehabilitation.
What Is Rehabilitation?
Comprehensive rehabilitation should involve restoring optimal function to both the sensory and motor systems, in a manner that builds resilience and enhances adaptability.
Huh? Does that sound complicated? It kind of is. We are talking about the body, which still remains a mystery to us.
We don’t know it all.
But what we do know, is that rehabilitation should be tailored to the individual, and process based.
It should include education and a graded exposure that takes context into account.
It should have objective outcomes that measure improvements in function, but should also focus on resolving the presenting pain or injury as best as possible as well.
Exercise can definitely (and usually should) be part of this process, but I have seen many fit and “dysfunctional” people over the years, along with many people who have “rehabbed” themselves to become stronger and fitter but still suffering from their initial complaints.
There of course, is a balancing act – it’s not always about the pain – and often improving function in spite of pain is the best outcome, but that doesn’t make exercise alone magically turn into rehab.
How Do You Do It?
Educate, Educate, Educate
Without properly educating someone about what they are doing and why they are doing it, rehabilitation lacks meaning. When things lack meaning we don’t give them appropriate focus, which leads to lack of results.
This is why the who treatment encounter should be centred around education from the beginning.
Create the appropriate context, and then each intervention fits into that context.
Sensory Rehabilitation Should Precede Motor Rehabilitation
When somebody has referred pain down their arm or leg, I will test their reflexes.
A reflex tests both the sensory and motor function of the related nerves.
The body has to sense the stimulus (the tap of the reflex hammer on the tendon) and then respond to it.
If you have impaired sensory function, but your motor function is fine, then you won’t demonstrate normal reflexes.
Rehabilitation is similar.
If you have impaired sensory function, your motor function (movement, strength etc) will not be at the level it should be.
Initially, rehabilitation should aim to restore sensory function – this can be achieved in many ways with manual therapy/taping (sensory nerve stimulation), body awareness exercises (enhancing interoception), mobility/flexibility exercises (enhances sensory input), motor control exercises (enhances proprioception).
If someone displays poor sensory awareness, improving this will often develop their motor qualities concurrently, as outputs are a product of inputs and processing.
This is why simply exercising doesn’t always improve things. It’s not just what you do, but how you do it.
Rehabilitation Should Be Contextual
Soldiers in the army face numerous challenges when deployed. An uncertain and continually changing environment, unpredictable tactics from enemies, and the threat of death create extremely high stress situations.
In these high stress situations, our brains go into survival mode – thinking decreases and insinctive behaviour increases – unfortunately, what is instinctive is often dangerous, so these behaviours must be stopped.
As a result, training for soldiers involves as real as possible simulations, to cause an adaptation to the brain.
As the soldiers are exposed to realistic threatening scenarios, they become less and less sensitive – their brains do not enter survival mode as easily – allowing them to think and act intelligently, even under extreme stress.
With pain, our brains are protecting us from a threat, real or perceived. If you experience pain while you are working, and you work in a fast paced financial office, rehabilitation in a calm clinic room only goes so far.
Rehab should progess in context, from safe and secure to challenging and confronting, to allow the brain to adapt its response.
This is one of the most overlooked aspects of rehabilitation, in my opinion. It is why education is so important, and also one of the hardest things to do.
Rehabilitation Shouldn’t Be Based Solely On Sets and Reps
Fixed set/rep schemes work great in theory.
However, given the dynamic nature of the human body, some days we can do more, some days it’s less.
Creating an environment or set of parameters that allows you to “fail forward” is usually more optimal than grinding out movement to achieve a number.
One of the ways this can be achieved is with self-limiting exercises.
Another is with auto-regulation using a “rating of perceived exertion” (RPE) scale. This requires good sensory awareness. See earlier point.
While exercise is often focused on achieving a number, to ensure progression, rehab is slightly different. Numbers can play a role, but shouldn’t be the main focus. Quality and feelings should, at least in the beginning.
Conclusions
Exercise is definitely an important part of the rehabilitation process, but what we have learnt in recent years is that it doesn’t matter as much what you do, but rather that you do something and how you do that something.
When we frame exercise in terms of capacity (load, volume, range of motion etc) without paying attention to the contextual factors involved in someone’s presentation, we are missing a large part of the problem at hand.
And while it is easy to measure strength and endurance gains, it is much harder to measure gains in body awareness, confidence and resilience.
I myself have been guilty of defaulting to the former many times, purely because patients often demand something tangible, and this is what I am familiar with.
The challenge for everyone involved in rehabilitation from pain and injury is to bring the bigger picture into focus, and to really shift the emphasis towards rehabilitating people, not problems.
This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.
This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.
