Therapeutic Exercise

What is therapeutic exercise?

This refers to exercise programmes that are specifically designed to correct a pathological state where there may be pain, posture disturbance, misalignment, inflexibility, joint stiffness, excessive weight, weakness post-surgery etc. It also refers to exercise programmes designed specifically to prevent the development of these problems. Unique to the concept of therapeutic exercise is that the exercises are: Prescribed. This means that exercises are customised to the medical/biomechanical needs of the patient in response to the problems that their body displays on examination, ie. a direct reflection of a skillful examination by the physiotherapist to determine the movement, posture, strength, stability fault etc that are causing the pain. Specific.(exercise specificity). This means that exercises should also be specific to the demands of sport or occupation that the patient is looking to return to. Potent and potentially harmful. They are not bulk prescribed and suitable for anyone and everyone. They need to be monitored to ensure correctly performed and the intended results are being seen. Exercise should be viewed as the challenge not the cure. It is your response to the challenge of the exercise that determines whether you win or the exercise wins in dictating new postures, skills and movement patterns.

Can all physiotherapists prescribe exercises?

Not all physiotherapists have the training, skill and equipment (eg. diagnostic ultrasound) to complete the job, let alone the interest, passion, patience, commitment to guide the patient through the process. In essence you are detraining old habits of movement and teaching the body new and better ways of moving.

Can’t I just go to the gym and use the weights to strengthen my muscles?

It is important to understand that exercise is a potent therapy. If you keep repeating a movement or exercise, your brain will start to re-set your settings to increase your skill and efficiency specific to this task. This means that if you are repeatedly performing the wrong exercise, you will get better and better at doing the wrong thing and detuning your body…fatigue…pain etc. Unfortunately, irrespective of whether you’ve invested time, money and effort in following the physiotherapist’s or personal trainer’s advice, if they did not diagnose the problem and prescribe the exercise correctly, they will mislead you. You efforts will not only be in vain, they will be counter-productive. More specifically, “strength” or lack thereof is not usually the key problem. More likely there are stability and flexibility issues at the core of the problem which need addressing first, before strength is considered. Many problems are perpetuated by brawn replacing brain. In absence of deep postural stabilising muscles to control posture and guide movement, the more superficial strength muscles predominate and produce poor quality movement and eventually pain and damage.

Does therapeutic exercise need to be supervised and monitored?

Absolutely and definitely yes. It is not enough to have pre-designed exercise sheets for all and any patient to take home without specific examination of their body and understanding of the sport/occupation that they are looking to return to. Unless educated and equipped otherwise, the patient, will by default of habit, perform the exercise incorrectly. “Practise makes perfect” is a dangerous saying. You will become perfect at whatever you practise. If you practise the wrong action, you will perfect the wrong action. This is where supervision is essential, and requires skill and interest on behalf of the physiotherapist.

What is the best form of exercise to perform therapeutic exercise? Does Pilates work?

There is no form of exercise that is universally therapeutic to all patients. There are no exercise panaceas; there are many exercise fads. The more time, effort and intention you devote to exercise, the more prescription is needed. If you are irregularly performing exercise without conviction, generic forms may be OK. Just because the exercise is labeled “Pilates” or is performed on a “Swiss ball”, or was designed by a “qualified instructor” does not guarantee results. The key issue in therapeutic exercise is to establish the patient-specific issues that need to be addressed, ie. from examination, what biomechanical issues need attention. The second issue is, what style of exercise does the patient enjoy and therefore, what is likely to generate compliance with exercises for long enough for the programme to have impact. Thirdly, and particularly if the patient is looking to return to sport or occupation specific tasks, you must select exercise mediums that are specific to that task. There is no point a footballer swimming laps in a pool if jumping and landing issues are his cause of knee pain. Non-specific exercise is OK in the earlier stage of exercise, particularly if you are guarding from producing symptoms, but the exercises eventually need to be functional. In summary, the best therapeutic exercise is a form that is specific to the patient’s end goal, is enjoyable, and enables the physiotherapist to prescribe new principles of posture and movement.

BELOW IS A TYPICAL EXAMPLE OF A PATIENT PRESENTING WITH BIOMECHANICAL PROBLEMS FOR THERAPEUTIC EXERCISE:

The scenario:

A middle-aged lady reports low back pain when she reaches overhead to her clothesline. She attends Pilates and Yoga classes, but finds this exacerbates her LBP. She states that she’d like to return to playing tennis.

The examination:

Analysis of her posture reveals a rounded upper back and forward head posture and her abdominal muscles are redundant (not toned). Closer analysis of her body reveals limited shoulder movement with shoulder pain produced at end of range elevation, stiff thoracic spine that lacks extension and poor awareness and control of her abdominal muscles. She also has early arthritis in her hips. Analysis of her performance of the overhead reach task demonstrates lack of contribution of upward stretch from her shoulders and upper back, and inability of her hips to extend to gain reach height. Abdominal muscles do not adequately control the lumbar spine on backward bending, so the lumbar spine tends to arch, producing pain. Second issue in the examination, is this lady’s ability to correct her own posture and movement pattern. (Some people simply need to be shown how they are doing the movement wrongly and they will correct it without fuss, and instantly control their pain.) This lady may be unable to correct the posture/movement even with education and cueing, because of the problems in neighbouring body regions; it becomes quickly apparent that her lumbar spine is the compensation zone for problems in other body areas – this is common.

The interpretation:

When someone reaches with arms overhead (eg. to reach clothesline) the lumbar spine and pelvis should remain relatively stable as result of bracing of the abdominal muscles, as the major peripheral joints such as shoulders and hips provide movement and range. The upper back should also provide some extra movement if needed. In this lady’s case the abdominal corset muscles don’t support her lumbar spine. In addition the hip, shoulder and upper back joints are stiff for reasons of arthritis, disuse, posture etc. This produces a relative flexibility problem. While the source of pain may be facet joints in her lumbar spine, the cause of her pain is excessive extension force in the lumbar spine due to inadequate lumbar spine stability and reduced flexibility in the areas that should be moving, namely hips, shoulders and upper back.

The problem:

A simple rule of thumb with any machine is, use it consistent with the maker’s specifications, or it will not perform optimally and components are likely to fatigue and break down. It may not wear overnight, but over years of repetition, there will be accumulative impact as well as establishment of faulty movement and posture habits. As a body part becomes weakened, it become vulnerable as the weak link in the chain, and is more likely to be exploited for movement and flexibility. This lady has a faulty path of least resistance whereby her lumbar spine is called upon to produce movement and flexibility beyond it’s usual role and apart from it’s design purpose. This will effect the performance of the task and the wear pattern, and produce pain in the area of compensation, as well as other areas that now don’t work properly either.

The challenge:

To correct this faulty movement pattern and restore the body’s functioning and coordination back to a more ideal state, without producing new problems in a body that may have limited adaptive and learning abilities, ie. improve her above-head-reach ability by stabilising her low back concurrent with increasing mobility in her hips, shoulders and upper back (but without aggravating hip and shoulder problems).

The difficulties:

  • Does this lady’s body have the potential to revert back to the ideal state?

    • The younger the body, the more adaptable it is to change. If there is already arthritis affecting joints, and structurally weakened spine segments, and well established bad habits of posture and movement, then compromise may be needed.

  • Does this lady have the body awareness, skill, motivation and persistence to address these issues to a point where they become a new better habit?

The approach to correction:

First and foremost, this lady needs to be educated. Cognitive understanding of the problem, it’s correction and ability to monitor progress are essential:

  • What is the ideal and preferable way to perform an overhead reach whereby the various links in the chain (shoulders, upper back, lower back, hips etc) perform their duties correctly.
  • What is wrong with her body; how does she perform the task incorrectly.
  • Why does this faulty pattern of movement produce the pain she experiences.
  • What is a reasonable expectation for treatment outcome.

Secondly, she needs to be taught the exercises that are going to correct her biomechanical and posture/movement problem. These may need to initially be taught in component form rather than one big series of exercise. The aim is eventually to put all the exercise components together into a functional task. She needs to understand how to perform the exercise correctly, and how her body is likely to perform it incorrectly. She needs to understand the idiosyncrasies of how her body is likely to ‘cheat’ the movement. This needs an understanding of the principles of path of least resistance and relative flexibility. She needs to understand how to stabilise one body segment, while another moves. But, you must remember that she will by default, perform the task incorrectly, and if she goes back to the overhead task without due thought and technical skill to change, she will revert back to old habits. Correction will only occur when her body parts have worn into their new role, stiff joints have loosened, weak muscles strengthened etc, and her brain has learned to re-sequence and coordinate the movement. Paradoxically, it is the tasks that she struggles to perform safely and correctly that form the basis of her exercise programme (therein lies the risk of exacerbation), albeit broken down into palatable components. Once she has mastered control of the components, the aim is to put the new sequence together to perform the tasks that are important to her occupation/sport etc.

The exercises might include:

  • Hip joint stretches into extension (with due care not to allow the low back to extend).
  • Lumbopelvic stabilisation exercises with use of diagnostic ultrasound to re-train the deep stabilising muscles of the spine and pelvis.
  • Thoracic mobilising exercises (with due care not to allow the low back to extend).
  • Shoulder capsule stretches (with due care not to allow the low back to extend).
  • Combination exercises then moving towards reinforcement and function.

The reinforcement:

Remember that you are dealing with human behavior, albeit posture and movement. Unless the correct posture changes and movement pattern changes are repeated and reinforced during normal everyday tasks, they won’t become a habit. This requires mental energy and motivation, therefore, the easier and more natural you can make the exercises to perform in everyday tasks, the more likely they are to become reinforced as new habits. In this lady’s circumstances, she needs to understand that every time she reaches her hands overhead is an opportunity to either reinforce new and improved habits of movement, or regress to the old habits and establish the problem further, eg. taking off a shirt overhead, washing hair in the shower, yawning with overhead arms, reaching up to cupboards, Yoga maneuvers, Pilates maneuvers etc.

Beware:

In this lady’s situation, care and respect is needed to avoid exacerbation of dormant problems in her hips, upper back and shoulders. These areas should be considered the primary problem areas, and they may or may not have capacity to resume responsibility for correct posture and movement. It is important to be realistic and not overly idealistic. The younger the body, the more ability it has to adapt to change without side-effects. However, young people often don’t have the discipline or persistence to keep to a task. The older the body, the more wise and the more discipline it is likely to be; usually through experiencing pain and wanting relief. However, older bodies are more set in their ways, and caution is needed with striving for ‘perfect’. Remember, if it ain’t broken, don’t fix it.

Progression of exercise:

Once this lady is cognitively familiar with her idiosyncratic problems and how to correct them, the challenge then is to find forms of exercise that she enjoys to reinforce this new behavior. In this instance you’d look over her Pilates and Yoga routines to find examples of overhead tasks (or similar) that provide her a challenge against which she can perfect and reinforce her new skills, i.e.. it is not Pilates that is fixing her! The next progression towards exercise specificity is to look at the game of tennis and identify areas of potential concern, e.g.. overhead serve. The tennis serve can be taught with particular attention to addressing her bodily problems. Once technique is correct, work on repetition, load and sport-specific skill and strengthening routines, while all the time being cognisant of her body’s strengths and weaknesses.