4 Simple Rehab Program Templates

Single leg opposite arm row, an upper body “pulling” exercise which demands stance leg and trunk stability and control.

[Note: This is an expanded form of an excerpt from the manual from my workshop Introduction to Kettlebells for Rehabilitation, which I developed and teach with exercise sciencist and personal trainer James Ross. As a brief background, we categorised the exercises into either push/pull for the upper/lower/core. The concepts below can be applied however you categorise movement for programming purposes.]

It’s easy to find exercises online.

Whether you search by joint, muscle group, movement pattern, you will find hundreds, if not thousands of examples.

This alone should tell you something: there is no one way to exercise.

In fact, the only two rules for exercise that are anything close to written in concrete are:

  1. On adaptation: start where you are (i.e. your current ability), do what you can (i.e. don’t push too hard too soon) and progress over time (without progress you stop adapting).
  2. On specificity: you have to practice what you want to get better at (i.e. if you want to run faster, you have to practice running faster).

With that said, there are definitely better and worse ways to exercise, regardless of your goals.

Better ways are more efficient, more effective, safer and more enjoyable. Worse ways are the opposite.

When it comes to clinic rehabilitation for musculoskeletal pain, exercise is an important intervention. Increasing evidence is mounting showing that for many orthopaedic/musculoskeletal conditions, a well structured rehabilitation program yields similar outcomes to surgery over the long term.

Please don’t confuse this with me saying exercise is the only intervention required for clinical rehabilitation.

It stands to reason that structuring an exercise program optimally will yield better results.

With that in mind, the following are examples of templates I commonly use when designing exercise rehabilitation programs for clients in practice.

Bare Minimum

This is simply a single movement exercise “program”, which I often utilise when there are many barriers to adherence. It can also serve as a “gateway” to a more comprehensive program in early stage rehab.

I would typically advise 1-3 sets performed to fatigue as a minimal dosage. With a set/rep based approach we can manipulate intensity via the rep range. This can be a good way to develop strength, strength endurance or even speed/power.

Otherwise a time based approach (i.e. try and do as many sets of 5 in 10 minutes as you can). With a time based approach, we are using sub maximal loads and accumulating volume. This can be a good way to develop strength endurance and work capacity.

There are 2 main ways to design this single movement program.

  • Load the painful movement:
    • Pain management via local tissue effects and central inhibitory effects
    • Develop functional capacity in local tissues
    • Enhance physiological buffer zone
  • Load the non-painful movement:
    • Pain management via central inhibitory effects
    • Develop functional capacity systemically
    • Address weakness/limitations
    • Enhance physiological buffer zone

The bare minimum approach can also be used with multiple movements – i.e. one movement each day, performed for the prescribed sets/reps/time. These are then cycled through.

An example of a 3 day cycle might be:

  1. Squat
  2. Push up
  3. Inverted row

Each of which is performed for as many sets of 10 reps as possible in a 10 minute window on consecutive days. After the third day, start the cycle again.

Whichever approach you take, with bare minimum programming, you typically want to use compound movements, as they maximise efficiency. So for lower body, things like squats, lunges, step ups and hip hinge variations reign supreme.

Minimalist

Using two exercises allows as to train the whole body or agonist/antagonist movements across a joint. This is a great compromise between time efficiency and effectiveness.

Again, these can be prescribed for sets/reps or time periods (I wouldn’t go less than 10 minutes for two exercises, as the volume ends up being too low).

Some common ways to pair movements include:

  • Upper/Lower pairing
    • Use either complementary pairing i.e. upper push/lower pull or similar pairing i.e. upper push/lower pull or vice versa
    • Pain management via both local tissue effects and/or central inhibitory effects
    • Develop whole body functional capacity
    • Enhance physiological buffer zone
  • Agonist/Antagonist pairing
    • Upper or lower push/pull (e.g. push up and row or squat and kettlebell swing/leg curl)
    • Ideal when local tissue factors are the dominant clinical feature
    • Pain management via both local tissue effects and/or central inhibitory effects
    • Develops local tissue capacity which can enhance the physiological buffer zone

Whole Body

I use Chad Waterbury’s definition of a whole body workout: each workout consists of at least one lower body exercise, along with an upper body push and pull.

(you can have two or more workouts as part of the program, to ensure you develop a variety of movements)

The benefits of a whole body workout start shifting towards central pain inhibitory mechanisms and developing the physiological buffer zone.

Again, you can program this based on sets/reps or time. With more exercises you have the option to perform straight sets, a combination or straight and alternating sets or a circuit format.

As a general rule, straight sets will bias local tissue factors slightly more, while alternating and circuit formats will bias work capacity/central factors slightly more.

I like whole body rehabilitation programs as they allow for work on both strengths and limitations simultaneously, which is good for compliance. We all like to succeed and do what we are good at.

They are also great options for in-season maintenance for athletes. Training 2-3 times per week allows the use of 6-9 key exercises, while other areas can be prioritised – i.e. tactics, skills, recovery (and work, family, social life etc).

Comprehensive

The comprehensive program, using the principles outlined in this manual [referring to our rehab manual] simply means taking one exercise from each category: upper body push and pull, lower body push and pull and core.

You can perform these in a circuit form, paired sets or straight sets depending on the desired outcomes.

This type of program trends more towards maintenance of capacity and physiological buffer zone, as well as ensuring central pain inhibitory mechanisms continue to function optimally.

Comprehensive programs are fantastic for the following scenarios:

  • End-stage rehabiliation of athletes before the return to play
  • Mid-to-end stage rehabilitation of non-athletes who are not otherwise active
  • Health-promoting effects of older people, who may be suffering from age related sarco and ostepenia, as well as reduced cardiac capacity
  • Simple preventative home exercise programs for sufferers of chronic low back pain
  • A way to engage sufferers of conditions like fibromyalgia in strength training (you can minimise the dosage and spread the loading across the whole body)

Conclusions

Rehabilitation is complex, but it doesn’t have to be complicated.

By having a set of different templates you can draw on for different scenarios, you can make your exercise prescription more systematic and efficient, leaving more time and brain power to think about and discuss the more human variables surrounding rehabilitation.

Things like goals, interests, barriers and facilitators to adherence and everything else that is important in holistic pain management.

Nick Efthimiou Osteopath

This blog post was written by 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.

Rehabilitation Is More Than Just Exercise

Exercise is NOT a magical pill – it is great for many things though.

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.

A slide from my Kettlebells for Rehab Workshop

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?

  1. Presenting issue (often pain or injury) is not adequately resolved
  2. Increased risk of future injury
  3. 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:

  1. Visually, strong people fill our idea of health and fitness.
  2. 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.

 

Nick Efthimiou Osteopath

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.

 

 

How To Recover From Any Injury

Image credit: Marcus Needham

Pain is a complex, emergent experience.

Tissue injuries are not.

Tissue injuries occur when the loading on the tissue exceeds its capacity.

This can be an acute issue – think of a sprinter suddenly straining their hamstring mid race – or a chronic issue – think of a builder developing elbow pain over time.

In both circumstances, the principle is the same.

The formula for managing an injury is fairly simple on a macro level:

  1. Decrease the volume, intensity and/or frequency of aggravating activities to manageable levels
  2. Improve biomechanical efficiency
  3. Increase capacity with progressive overload


What is challenging is how to achieve these objectives in living, breathing humans who have needs, wants and annoying things like emotions that make us behave irrationally.

This is where a clinician needs to have excellent listening and communication skills, be a master of persuasion and thoroughly understand the physiological and biomechanical aspects of movement, stress and adaptation.

This post is going to outline a few of the methods I use to achieve the above outcomes.

Decrease Volume/Intensity/Frequency of Load

The most obvious thing to do when we are injured is often the hardest.

Why?

  • Necessity. We all need to continue working, caring for family or performing our activities of daily living (ADL). It can be hard to offload your injured body part when there is a baby crying or a load of laundry that needs doing. Let alone when you have a work deadline to meet.
  • Desire. This is an emotional issue. Many of us desire to continue doing something as it brings us pleasure, status, or allays a negative emotion like guilt or fear. For example, it is common for people to want to continue to push themselves exercising whilst they are injured because of body image issues.

However, in most cases, an all or nothing approach is not required.

You don’t have to stop something completely to reduce the loading effect.

Here are two examples from a patient who has lateral hip pain that I’ve diagnosed as a gluteal tendinopathy. In these cases we are reducing the volume of the load primarily:

  • Use the fitness tracker in her phone to estimate her daily activity level. Work out at what activity level her symptoms flare up. Stay below that activity level while gradually building up during recovery.
  • Track her walks accurately (pace/duration) and work out at what level her symptoms flare up. Stay below that activity level while gradually building up during recovery.

Here is another example of how I reduced the intensity of the load in a builder with elbow pain. He couldn’t stop working, and a lot of what he did (using tools) aggravated his injury.

  • Use tennis grip tape to wrap around the handle of his hammer. This increases the circumference of the handle, which reduces the mechanical leverage of the forearm muscles, taking the load off the tendons at the elbow.

In most cases, there are ways to continue doing what you need or want to do, with some modifications. And in most cases, this is actually better than complete rest.

Improve Movement Efficiency

Everybody knows Roger Federer. You don’t have to be a tennis fan to appreciate his skill and technique. He makes things look easy.

As we improve our skill at a task, we become more efficient as well. It takes less effort and as a result we tend to load our body less.

Roger Federer demonstrates this – his supreme technique has helped him accumulate very few injuries in his career, despite a demanding schedule and advancing age.

However, we don’t need to look to elite sport for examples of movement efficiency.

Think of your local pizza parlour. If it has been around for a while, watching the chefs put a pizza together is a picture of movement beauty (okay, I really love pizza). Every time I try and replicate this at home I just end up tired with a very messy kitchen bench.

Or let’s keep it closer to home. When I was younger, I didn’t know how to iron a shirt well. My mum could iron all of my dad’s and my brothers’ shirts in the time it took me to do one. All that effort, all that time under load. It’s easy to see how my inferior ironing skills could lead to more load on my body. Even though my mum was doing more total work, her body was adapted to it, and she did it in a way that was smooth and effortless. Contrast that to me, not adapted to ironing (still not) and very tense and inefficient.

When it comes to rehab for an injury, it’s not just the capacity of the tissue that we have to worry about, but the efficiency of movement, which affects the loading on that tissue for each movement/activity.

Improving movement efficiency is a topic in and of itself.

My approach is based on the following formula: 

The input is related to sensory information from the nervous system. The better the quality of sensory information, the better the output. This is why rehab should begin on the sensory side. Sensory input can be improved with manual therapy, which is likely one of it’s biggest roles in modern practice.

Processing is based on cues and context. We can change both, but we have no idea how it will affect the processing. I’m not a big fan of the word processing, as it sounds to much like a computer, and we are not a computer or machine.

I discuss this in more detail here, and also here.

Increase Capacity

Remember at the start of this post when I said:

Tissue injuries occur when the loading on the tissue exceeds its capacity.

Well it makes sense that as well as reducing the load on the affected tissue(s), we increase the capacity as well. This has two benefits. No, actually, it has three benefits:

  1. Loading tissues helps with repair.
  2. Loading tissues that are painful helps (re)build confidence in the injured tissue.
  3. Increasing tissue capacity protects against future injury.

I like to use a two pronged approach here:

  • A targeted exercise approach
  • A graded return to activity approach

This isn’t revolutionary. It doesn’t have to be. It just has to be done well.

In the targeted exercise approach, I use a simple progression. I like someone to be able to (where possible) perceive the tissues properly (sensory awareness) before we work on the following:

  • Isometric to dynamic
  • More stable to less stable
  • Simple to complex
  • Less task specific to more task specific

There is some evidence to suggest local loading, particularly with isometrics has a pain relieving effect, which is why I start there.

More stable positions allow people to focus on the movement or activation required, without the extra motor and sensory demands of stabilising their body in space.

Starting simple allows more mental energy to be directed to recruitment patterns, while progressing to complex reinforces these patterns in different contexts.

Finally, starting less specific to the task allows for the load to gradually be progressed as tissue capacity increases.

Graded Return to Activity

This is an expansion of the first topic, reducing the load.

Put simply, we simply reverse the process, gradually increasing the load until the tasks can be performed normally again.

A good rule of thumb is to progress no more than 10% per week, to allow the person and the tissues to adapt. You cannot go too slowly, but you can absolutely go too quickly.

Conclusions

This is my current approach to treating tissue injuries.

You have to remember that not all tissue injuries present with pain, and not all painful presentations are related to tissue injuries.

When pain is the primary problem, we can use a similar approach if localised tissue sensitivity is deemed to be the main contributing factor.

Finally, we know that past injury is a big predictor of future injury. So while the pain from an injury subsides as the tissue heals (the tissue will heal if you give it a chance, regardless if you rehabilitate function or not), if you want to minimise your chance of re-injury in the future, it pays to be thorough.

 

Nick Efthimiou Osteopath

 

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.

 

 



 

 

Why You Should Choose Conservative Health Care

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You can’t cut out pain. – every *good* orthopaedic surgeon ever

Despite what we know about pain, many people are subjected to poor medical management for their pain on a daily basis.

From the recommendations of medications that don’t work for certain conditions (ahem, anti-inflammatory drugs and low back pain), to expensive courses of passive therapies that have extremely low effect sizes.

Not only do these treatments not work very well, they are is an enormous waste of everyone’s resources. To make matters worse, many of these management strategies are not benign, meaning they have the potential for negative side effects.

When it comes to poor medical management, over the counter medications and ineffective passive therapies are the (very small) tip of the iceberg. Many costly, and potentially dangerous drugs, invasive therapies like injections, nerve blocks and the “grand-daddy” of them all, surgery all carry high risk profiles and for very small benefit, especially over the long term.

It’s right about now that I should add some moderation to this post:

I’m not saying these treatments are completely worthless all the time. In fact, I have had many patients who have benefited from the right prescription or surgery over the years.

What I’m saying, is that these treatments often come with big costs and risks that are not fully disclosed when they are recommended (although nearly every surgeon does a better job at explaining the risks of their treatments to patients, many still overplay the benefits or don’t fully explain the alternatives).

With this in mind, the sleeping giant in the treatment of most painful problems, especially those involving the musculoskeletal system is good conservative health care.

I emphasise the good, because there is so much bad out there.

No, I’m not trying to be negative and put down other health professionals. I am simply stating, that based on my experiences with patients (and supported by research), many have not had adequate conservative care to begin with, which is how they’ve ended up with chronic conditions in the first place.

What Is Conservative Health Care?

Conservative health care is based around interventions designed to avoid radical medical therapeutic measures or operative procedures. 

They are typically lower in cost than more aggressive treatments, which a much safer risk profile.

The downside is that some conservative treatments don’t have a large effect size, and many work in general, not specific ways.

Some examples of conservative health care include:

  • Education, advice and reassurance
  • Lifestyle changes
  • Dietary changes, including supplementation
  • Exercise based interventions
  • Physical/manual therapy
  • Certain medications

When Should You Seek Out Conservative Health Care?

Conservative health care is not appropriate for all health problems.

Serious and life threatening conditions typically need more aggressive and/or invasive treatments. Examples of such conditions include major infections, cancer, organ diseases and major trauma (though there are many more).

When conservative health care is most optimal, is when a condition is chronic and stable, or progresses slowly, when the condition is self-limiting (i.e. it will resolve with time, and symptomatic management is all that is required) and when the condition is non-specific (it can’t be attributed to a single cause), like many low back pain presentations.

Usually, a general practitioner will be able to advise you when conservative options are suitable, so that’s often a good place to start.

Conservative Treatment For Pain

Pain is the number one reason people consult their GPs, however, a lot of pain is very poorly managed from the begining, leading to the progression towards chronic and more debilitating pain.

This is where I feel that conservative management can really shine.

Almost every chronic condition will improve to some degree from improving your health generally.

Additionally, many chronic pain presentations will benefit just as much, if not more in the long run, from good conservative management.

Unfortunately, many people miss out on receiving good conservative care when they need it most, leading to them needing/wanting more aggressive treatment options when their condition has progressed.

The Benefits of Conservative Health Care

Conservative health care has a number of benefits for all parties involved: patients, practitioners and 3rd party payers (insurance companies, governments etc).

One of the biggest benefits is economic.

Let’s take chronic low back pain as an example, because it is so prevalent, and so widely researched.

The cost of these conditions to the Australian economy in 2012 was more than $A55 billion. Back pain and osteoarthritis, the most common of musculoskeletal conditions, accounted for 52% and 41% of cost respectively.

When we look at the costs, most people intuitively think of the cost of treatment (consultations, investigations like imaging, medication etc), however, the bigger cost is the indriect cost, that is the cost to society and the individual of lost income, productivity and quality of life as a result of their condition.

While the direct costs of chronic conditions is around A$9 billion annually, the indirect costs are a staggering A$54 billion annually!

With such high costs, you’d think that prioritising excellent conservative care from the outset would be high on the agenda for all involved.

Unfortunately, many clinicians do not follow the clinical care guidelines which are developed by compiling the best evidence from researchers around the world. In fact, only 20% of low back pain patients received care inline with the guidelines.

These guidelines are designed to ensure the best possible management of each condition, yet with only one in five people getting treatment based around them, many are missing out and going on to develop chronic pain, which ends up costing them in time, money and quality of life.

Other benefits of conservative health care include:

  • Safety – by definition, most conservative health care is low risk.
  • Availability – there are typically many more health professionals able to deliver conservative health care than specialists who deliver more invasive treatments.
  • Sustainability – conservative approaches can typically be maintained over the long term, which can help manage chronic conditions.

What stops people getting good conservative treatment?

I believe that most of the time, most people are doing the best they can. As a result, the lack of implementation of clinical guidelines for conservative care is not down to any one factor, but here are a few:

  • Market forces – funding for public health services is always stretched, so GPs cannot spend adequate time educating patients. Private practice clinicians are often limited in the number of times they can see someone due to a patient’s ability to afford treatment.
  • Expectations – patients often want to be “fixed”, not understanding, or wanting to participate in more active management for their conditions.
  • Practitioner knowledge and skill – most health practitioners are skilled in diagnosis and treatment, not in facilitating behavioural change. This makes it hard to create long term, empowered change.

With this in mind, we can see the challenges that need to be overcome to offer the best available conservative care.

What is needed to improve conservative treatment?

  1. Government and insurance companies need to appreciate the long term cost savings conservative care offers, and fund it accordingly. If a surgery costs $20,000 spread across direct and indirect costs, and that surgery could have been prevented by 2 years of physical/exercise therapy, then even at $100 per session, twice per week, you are coming out at break even. However once you add in the rehabilitation costs of surgery, and the costs of the increased risk, the physical therapy option is actually cheaper.
  2. Patients need to take responsibility for their thoughts and actions. Yes, circumstances can affect everyone, which can make life harder and less fair for some, however, taking 100% responsibility for how you respond and act will mean that you are in the best frame of mind to improve your situation and your condition.
  3. Educational institutions need to adapt to the changing demands on healthcare and focus more on communication and behaviour change. Simply increasing the awareness of this important skill will lead to those interested healthcare practitioners pursuing further education.
  4. Health practitioners must accept that they can always improve, and seek out ways to develop their skills to better serve their patients. This includes seeking out appropriate continuing education, but it also means enhancing their networks and their ability to utilise these networks to benefit their patients.

The Big Two

Of all these factors, the two most important are economic and cultural forces.

Money is always an influence on how we make decisions, and many people simply don’t have the financial freedom required to pursue optimal conservative care, especially privately.

While there are always those who are living on the edge, and literally have no room in their household budgets for anything about the essentials of living (housing, food, transport and utilities), there are many more who claim that health care is too expensive. Yet these people walk around with the latest iPhone on a high monthly plan, or drink/smoke/gamble regularly. For these people, who may be on average incomes, it is simply a matter of choice and priorities*.

This is where culture becomes important.

Our culture in Australian is heavily influenced by commercial interests.

Unfortunately, there is a lot of money to be made in selling treatments for conditions that offer a simple solution to a person’s health problem.

Whilst they appeal to our emotions, simple solutions are usually inadequate for complex problems.

So when you propose a long term course of conservative care, which involves active participation by patients, it is often a tough sell.

It is made even tougher by the massive marketing budgets pharmaceutical companies and medical device companies have. They use these to influence our culture.  Every night on TV there are commercials for different types of pain medications. Ironically, if most people spent just 30 minutes less watching TV, and decided to go for a walk instead, they probably wouldn’t need them anywhere near as much.

A Different Perspective

If instead of thinking in terms of expense (cost and time/energy), you changed focus to investment, then immediately you have changed your perspective on health.

When you invest in a term deposit, at the end of the term you have more money than when you started.

Conservative health care, done properly, is an investment.

Yes, you are spending time, money and energy to change your health, which has an initial up front cost. But, by the end of the treatment program, you should have improved health, reduced pain, better function and an overall better quality of life.

Get more years out of your life, and get more life out of your years.

These improvements can be thought of as your return on investment. Like a term deposit, conservative treatment is mostly safe, offers fairly predictable outcomes and is overall, low risk.

Once you have restored your health, the idea is to maintain it (just like you would with wealth). Usually this means you need to continue your healthy habits which you established during treatment.

A final word on perspective; if you are in debt, you must pay back your debt before you can invest. The bigger your debt, the more work and time it takes to repay. The same school of thought applies to health. While things can change quickly, true healing from chronic conditions, or even severe acute conditions, takes time.

If that puts you off, think about it like this: time will pass, regardless of what you do or don’t do. If you do nothing, you will be in the same, if not worse situation in a year or ten.

Conclusions

Conservative care is extremely important from both a public health and individual perspective. Delivered optimally, it saves money, improves outcomes and reduces the need for interventions with higher side effect or risk profiles.

There are some barriers to delivering good conservative health care at the population level. On an individual level, the two most important variables can usually be overcome.

If you are a patient: when you are seeking out a health care provider, discuss long term strategies and look for providers who will incorporate an active management plan.

If you are a practitioner, you should look to improve your communication and behavioural change skills. Telling someone what to do isn’t good healthcare. Guiding them through the process of how to do it is.

 

Nick Efthimiou Osteopath

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.

 

 



 

 

 

Notes

*For those who are truly struggling, most universities with allied health programs have student teaching clinics. These allow students to provide supervised care at reduced costs. In special circumstances, the fees can even be waived. Bottom line, no matter your circumstances, if you are really set on helping yourself, you can find a way.

References

(1) Medibank: Chronic pain costs economy more than $22bn a year

(2) Pain drain: the economic and social costs of chronic pain

(3) The burden of musculoskeletal conditions in Australia: a detailed analysis of the Australian Burden of Disease Study 2011

Effective Nutrition for Injury and Rehabilitation

Fresh Food

An often overlooked aspect of recovering from an injury is nutritional intake.

This post will look at nutritional needs for injury from a broad perspective including:

  • Energy needs during reocvery from injury
  • Macronutrient needs during recovery
  • Micronutrient needs during recovery

A future post will explore effective supplementation for pain and injury, but as always, it’s important to start with the “big rocks” first.

Before we go into further details, you need to understand the difference between pain and injury.

Injury occurs when tissues are stressed beyond their tolerance, resulting in damage as either a partial or full rupture of the tissue. Injuries usually fall into one of two categories: acute/traumatic, chronic/overuse. Whether soft or hard tissue is involved, each injury undergoes an acute inflammatory phase followed by a rebuilding phase. Both the inflammatory and rebuilding phases can benefit from targeted nutritional approaches.

Pain is the unpleasant feeling we experience, often, but not always, in response to an injury. We can also experience pain without injury, so just having pain is not an indicator you need to modify your nutrition.

To know whether you are suffering from pain resulting from and injury, or simply “non-specific” pain, you can ask yourself a couple of simple questions:

  1. Was there a traumatic incident that could have caused the injury, and did the pain start after this?
  2. Is this a new pain? (recurring pain is typically non-specific, or less associated with injury)
  3. Are there obvious signs of inflammation – redness, swelling, heat?

Answering yes to one or more of these questions could indicate an injury. If you are unsure, it’s best to seek out a medical professional for a diagnosis.

Energy Needs During Injury

As you can imagine, an injury results in an increase to our energy needs, as the body increases metabolic activity to repair the damaged tissues.

Most textbooks calculate an increase of approximately 20% on top of your energy needs, if you are sedentary and eating at maintenance (not gaining or losing weight).

If you are already highly active, you will actually end up eating less than normal, as being highly active would require eating greater than 20% above maintenance intake.

You don’t have to track your intake exactly, but rather be mindful that if sedentary, you will need to increase your energy intake during an injury, whereas if you are highly active, you will need to decrease it, but not all the way to your baseline maintenance intake.

Macronutrient Needs During Injury

Macronutrients are the three different constituents of food: protein, fat and carbohydrate (alcohol is also considered a macronutrient, but it should be obvious that it isn’t good for injuries or recovery).

Depending on your current diet, you may benefit from changing the macronutrient ratio of your diet.

Protein

For someone eating a fairly average diet, when injured, an increase in protein intake is beneficial. The recommended protein intake is 0.8 g/kg of body weight, whilst the recommended intake for an injury is 1.5-2.0 g/kg, double the baseline. If you are already consuming a high protein diet (as is common among athletes), you don’t have to change anything.

Fat

The amount of fat you consume in response to an injury isn’t as important as the types of fat you consume.

Recall that after injury there is an inflammatory phase. This is when the body increases blood flow to the effected area, breaking down the damaged tissue to prepare it for rebuilding.

If the inflammatory phase is prolonged and/or too extreme, healing can be delayed. This is the reasoning behind applying ice and compression to acute injuries.

Different kinds of fats can be either pro or anti-inflammatory. Thus it makes sense to limit your intake of pro-inflammatory fats during an injury.

There are 3 kinds of fats: saturated , monounsaturated and polyunsaturated. Dieticians generally recommend your total fat intake is evenly divided amongst the 3.

Certain types of polyunsatured fats, omega-6 fats, are pro-inflammatory. Typical western diets are already high in omega-6 fats, so they should generally be reduced, even more so during an injury. Common sources of omega=6 fats are flax seeds, hemp, canola, safflower (and their oils), commercial dressings and many nuts.

At the other end of the scale, omega-3 fats have an anti-inflammatory effect, and can be increased during injury. The best sources of omega-3 fats are marine oils (fish oils) and algae. Many people do not eat adequate amounts of  fish to get enough omega-3 fats, so it is commonplace to supplement. However, the quality of fish oil supplements varies highly, with many brands using low quality sources, along with poor transport and storage methods, which mean that it is unlikely that you are getting what you pay for. In fact, if the oils have already oxidised, then you are actually taking something that is likely causing your health harm*.

It is important to understand that whilst reducing inflammation slightly can accelerate healing, reducing inflammation too much (or eliminating it) can impair healing, thus, you want to eat adequate, not surplus amounts of omega-3, especially if you are also taking non steroidal anti inflammatory drugs (NSAIDs) like aspirin, ibuprofen (Nurofen) or diclofenac (Voltaren).

Carbohydrates

There are no specific dietary guidelines for carbohydrate intake and injury.

Understanding the injury process leads us to two conclusions regarding carbohydrate intake:

  1. We need some form of carbohydrate in our diet, as glucose is required for repair.
  2. Ideally, these carbohydrates come primarily from fruits and vegetables and whole grain sources, as excessive processed carbohydrate intake can be inflammatory.

So while very low carbohydrate diets are currently popular for weight loss/management, during a time of injury it is advisable to consume adequate amounts of carbohydrate.

Micronutrient Needs During Injury

Micronutrients are vitamins and minerals found in foods. As to be expected, the needs for certain micronutrients increases with injury.

One important thing to understand, at this stage, it is not clear whether simply having adequate amounts in your diet is optimal, or whether there is benefit to be had from “megadosing” certain micronutrients during time of injury.

Here is a list of micronutrients that play important roles in recovery from injury:

  • Vitamin A: supports early inflammation, reverse post injury immune suppression and assists in collagen formation. A dosage of 10,000 IU daily for 1-2 weeks post injury is likely safe, but be aware that Vitamin A accumulates in the body and can become toxic if taken in excess. Remember to consider all dietary sources.
  • Vitamin C: enhances white blood cells the help fight infection as well as improving collagen formation during repair. It also is a powerful anti-oxidant and immune booster. Recommended dosage: 1-2 g/day during injury repair.
  • Copper: helps the formation of red blood cells and acts with Vitamin C to form elastin – part of our connective tissue. Recommended dosage: 2-4 mg/day for the first few weeks after injury.
  • Zinc: is required for over 300 different chemical reactions in the body. It also helps with DNA synthesis, cell division and protein synthesis – all necessary for tissue regeneration/repair. Recommended dosage: 15-30 mg/day during initial stages of healing.
  • Calcium and Iron: more in the preventative category, as deficiency in either or both minerals are quite common, leading to increased risk of stress fractures.

It is important to remember that these recommendations are guidelines only. For specifics, it is best to speak to a qualified practitioner well versed in nutrition (or a dietician) to tailor a diet and supplement plan specific to your injury needs. Some of the above if taken continuously can lead to toxicity, whilst others can cause interactions with other nutrients if taken in excess.

Conclusions

The main key to managing your recovery from injury with nutrition is to ensure you are getting adequate amounts of everything you need.

If you already eat a healthy diet and your weight is in the healthy range, it is likely you don’t have any excesses or deficiencies (it is still possible), so continuing to do what you already are is probably your best course of action, with perhaps a modification of total intake up or down as needed.

There are certain supplements that can help with injury and pain resulting from certain conditions, and we will explore those in a future post, however, in terms of this article, the majority of your nutrient needs should be met with food. If you feel you might require specific supplementation, it is best to speak to a qualified health professional (in Australia, go with an AHPRA registered professional as your starting point).

 

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.

 

References

(1) Berardi, J., Andrews, R., The Essentials of Sport and Exercise Nutrition, 2nd Edition, Precision Nutrition, ON

(2) Foods high in omega-6: http://nutritiondata.self.com/foods-000141000000000000000-1w.html?

*The two brands of fish oil we recommend in Australia are BioCeuticals and Metagenics. These are “practitioner only” ranges (we can order them), though you can often source them from health shops with a naturopath on staff.