Exercise for pain - more about what you don't do?


Controlled trials of exercise for low back pain often suggest that the type of exercise doesn't matter.  And if you love "stability" exercises then these results can really challenge what you think and could even make us expert clinicians feel like we have less "special" knowledge...always challenging to be confronted with this.


 You may give specific exercises for the transverses abdominis with the intention of correcting some dysfunction in firing patterns or you might prescribe general trunk exercises (bird dogs, planks, stir the pot) with the intention of training the robustness of the stability system of the spine/core.

But what we often see is that there is little or no difference in improvements in pain or function when you do "Specific" training versus just general exercise (Some sample references here, here, and a recent blog here).

The discerning clinician will rightly suggest that these research studies don't choose the appropriate exercise for the appropriate patient.  That the exercises are too generalized and therefore don't address the assumed dysfunctions in the patient in front of the clinician.  So, a lukewarm blanket treatment will naturally have lukewarm results.  While this might be true, it hasn't been tested. But was eluded to with a secondary analysis done in a recent paper.

These authors showed that specific motor control exercises were no better than graded activity for low back pain (paper here) but if you went back and looked at the data differently you might be able to find responders to a certain specific exercise intervention (link here).  They found that those who had self reports of "clinical Instability" responded better to the motor control exercises that were sold as improving core stability.   Well, it looks like if you are "unstable" you need to be "fixed" with stability exercises.  

But hold on!  We have to be careful here.  Stability wasn't measured.  Just self reports of stability.  And we don't know what the patients were told.  If they patients felt that they were unstable, were told that they scored high on self report measures on instability and then were given an exercise program that they were told addresses motor control deficits that contribute to stability with have an Expectation Fulfillment Confounder (EFC).  Its not unusual that this subset would respond better because they have been primed to respond better.

But thats not my point of this microblog.  What I would suggest all of these exercise programs that appear to be "tuned" to the individual do is something else.  Something more powerful than stability tweaking. Its not that a clinician finds the right "stability" exercise to fix some motor control or stability problem its more likely that they do two other things:

1. They find the things that the patient does that keeps aggravating their pain and teaches them to STOP that.  Its essentially addition by subtraction.  How long this is avoided is contentious (another time I'll delve into that).

2. They sell exercises that become meaningful, confront the patient with their strength and then continue to progress these exercises in terms of load, intensity and meaning.

In a nutshell, stop doing things that hurt and start using your back again.  Using your spine again in challenging exercises is a cognition changer.  It is a psychosocial intervention.  People get confronted with their abilities and they have to change how they view their spine.  You make subtle tweaks to how someone moves and they start resuming the social activities that are important.  Now, what appears to be a biomechanical intervention predicated on stability has become a BioPsychoSocial intervention and you don't need to talk about stability since you actually aren't measuring it and probably aren't changing it (old post on this here)

I've said too much. This was supposed to be micro. More later.