When are specific physical interventions needed to treat pain?

The Challenge

The low back pain literature suggests that a specific intervention (e.g motor control exercises, targeted strengthening etc) are no more effective than general graded activity interventions.  Suggesting that treating pain is not really about fixing some sort of impairment that is causing the persisting problem.  I've suggested before is that most successful exercise programs avoid certain exercises/positions/movement behaviours to calm things down and then any activity/exercise program can be helpful in building things back up (link here).  Its simple symptom modification.  If something hurts you stop doing it for a bit and then you slowly go back to building a tolerance to it.  But I am always plagued with the idea that maybe there are certain cases where a person NEEDS a specific exercise or something physical MUST be addressed to resolved pain.

For many painful states there might be no physical impairment that needs addressing to get out of pain, decrease disability and resume meaningful activities.  In fact, the meaningful activity now becomes the REHABILITATION EXERCISE.  Meaning, if the person wants to deadlift/run/play/garden then that is the rehab.  We slowly expose them to those activities and they adapt and tolerate them.  This is all fertilized by good pain science education.  We help change their beliefs about their condition and ultimately they give themselves "permission" to start doing the important things again.  Hodges and  Smeet (2015) wrote:
 

"Pain Science allows graded exposure to physical activity while challenging cognitions that cause avoidance of movement and activities"

 

REHAB BECOMES LESS ABOUT FIXING AND MORE ABOUT FACILITATING

Seeing the person as strong and adaptable rather then in need of fixing changes how we choose our exercises.  There are now  no prerequisites to start doing the things that are important.  For many cases people aren't in pain because they are weak, tight or have "altered" firing patterns.  Thus, maybe we don't have to specifically address these things to get people out of pain and get them moving again. Its the exposure to daily activities that permits adaptation as Max Zusman eloquently wrote more than a decade ago.

"Exposure of chronic pain patients to exercises or daily activities without danger to convince the brain of its error"

WHEN ARE SPECIFIC EXERCISES NEEDED?

This is a challenging question.  There must be some conditions where we need to find the exact right thing to do in terms of physical interventions.  In other words, an impairment exists and only one solution exists to correct that impairment and get the person out of pain. Its a nice thought experiment.  Can you think of conditions where there are very few possible solutions to the pain puzzle?  Where your therapeutic options become limited? 

Below is a very simple schematic that outlines the 3 different physical interventions we have at our disposal.  At the bottom is a line that might help guide your choices of interventions.  More specific interventions are on the left and less specific interventions are on the right.

 

So when might specificity be needed?

 

In the above schematic we see the role of Symptom/Activity modification.  One component of this is simple: FIND PAIN: CHANGE PAIN.  If it hurts to do something you can either avoid it for short while or you can confront it and perhaps desensitize the movement. If it hurts to bend then you lift with a neutral spine for a short term and also choose exercises that might reinforce the new movement behaviour.  BUT, that is different than saying your hip flexors are tight/weak, your glutes don’t fire, your calves are tight AND we need to fix those things before you can start running/deadlifting/gardening.  

 

BUT…maybe those impairments are important sometimes?

 

And that is the question we need to ask “Is this physical impairment/condition relevant to the patient’s painful state?” or “if this is not addressed will they remain in pain?”.

Cases where maybe you need to "fix" something to allow desensitizing

Example 1: Limited dorsiflexion gives fewer options for spine positioning

Perhaps there are instances where that lack of dorsiflexion stops you from changing a movement behaviour that keeps sensitizing the system.  You can’t build back up because you can’t calm things down. For example, if someone likes to squat deep but at the same time their back gets aggravated when they flex their spine past a certain amount.  Without them increasing their ankle dorsiflexion (or perhaps their thoracic extension) they won’t be able to modify their spine angle to avoid this aggravating posture.  Here, the impairment is relevant.  But if you have a runner who runs solely on flat surfaces which requires very little dorsiflexion then limited dorsiflexion would not be relevant.

 

A caveat here:  even the above example might not require a specific intervention for dorsiflexion.  Many therapists can make the case that they could desensitize the spine so that the patient can go back to the same kinematics without pain.  Point being, there are a lot options.

Example 2: Heavy load activities but a specific weakness decreases movement options again.

Another example could relate to weak hip extensors.  If someone has sensitive knees to squatting and bending under load.  Its reasonable to shift the stress for a short period of time to the hips to allow the knees to desensitize - simply hip hinging would do this.  Most people can do this regardless of their hip strength because they are no where near their maximal abilities.  They just have to learn the technique.  But if you are working with someone who jumps or squats heavy then the hip extensor weakness might preclude the ability to shift the stress to the hips from the knees or the spine. In this heavy load case, the impairment now becomes relevant.

But the person with run of the mill low back pain isn’t in pain because they are weak or their glutes are inhibited.  They might have decreased ROM, decreased strength or altered firing patterns but these aren’t relevant because the person’s life never demands that they use the full capacity of each joint so the deficit never impacts the function else where. 

In cases like these no SPECIFIC physical impairment needs addressing.  These are the cases that are much less about fixing and more about facilitating. 

Some other examples of specificity

A rule of thumb (naturally debatable :) ) would be the more you think a peripheral nociceptive driver of pain is occurring the more value you might achieve by adding local or specific treatment.  A great example would be tendinopathy.  We recognize that central factors are certainly important but it is also assumed that the Tendon needs specific loading to adapt, heal and decrease nociception.  But, there may not be a specific exercise needed - just progressive loading and load management.

This blog is too long.

I've gone on enough.  The point here is just to think how often we really need to "specifically" change or fix something.  I personally believe that specific "fixes" are quite rare and even when a "fix" is needed it might only be temporary.  This approach recognizes how adaptable we are.  Where are job is to calm stuff down and then build back up.  Once things are calmed down then we progressively load or progressively expose the person to the meaningful activities they want do.  The body and ecosystem will adapt.

Heck, I even believe on putting strength on dysfunction.  But, that's another story.