Whilst Exercise CAN be a wonderful tool to use during the rehab process we must remember it is not a stick on, we can’t just fire and forget or plug and play and for every success there are also failures. There just is not such a thing as a magic bullet in rehab.
Sorry about dat!
Before we get to the analogy stuff we might want to first ask WHY we might want to help people understand what is happening to their bodies and how ANALOGY can help with that?
In some cases it can be much more about HOW we do things rather than WHAT we actually do.
For all the studies we have extolling the virtues of exercise, although make sure you consider the effects sizes, an important question to ask is how generalisable are they to the real world? If I was being all sciencey and shit we could term this the external validity of a study.
Why might these studies lack external validity? In the tightly controlled world of the scientific study participants probably tend to adhere a little bit more to the protocol laid out than they do on their own, otherwise studies would never get finished. Researchers can also employ things like intention to treat analysis (ITT) that are designed to scientifically smooth out things like dropouts and missing data.
Out in the real world when we throw in the complications of life, exercises, however evidence based, in some cases can tend to fall by the wayside. This is a problem with human beings they don’t always just fit neatly into EBM boxes. In fact they can render all the science a touch redundant through things like their beliefs, preferences and lifestyles.
“Differences in the definition of adherence used, measurement and estimative of how many patients do not comply with their prescribed exercises vary, but evidence converge on a figure of 50% or higher” *HERE*
We can all agree that that is a pretty high percentage of shit that is not getting done! What we CAN say is exercise is likely to infer some benefits IF IT GETS DONE! SO how do we go about doing that? And that of course is the $1 million question!
This is an awesome piece of research that looks at barriers to people adhering to therapeutic exercise programs *HERE* . One of the major reasons that people don’t adhere, or a much better term to use, commit, to exercises or exercise programs when they have pain is the fear of INCREASING that pain
Here is a slide from my recent presentation at the San Diego pain summit.
Now this is completely understandable. Our fears drive our behaviours, so if I am scared of making the problem worse that may drive me to, well, simply not do it. It may then be key to help people make sense of what they feel and how they can manage that.
For a lot of people the science of both pain and exercise are pretty alien subjects. What’s the difference between exercise induced discomfort and actual pain? For someone who has never experienced the former then perhaps not a lot! I have been pretty sore from training before and found some activities really quite painful.
The likelihood of getting some DOMS from prescribed exercises for someone with no real history of exercise and a low ‘zone of homeostasis’ could be pretty high, so it is vital we can put these sensations into perspective, allay fears and help people to SELF manage their rehab.
A useful phrase I picked up a long time ago is “go to the P in Pain not the Y in Agony” which is a really nice way to say go into some discomfort, which of course is normal, but try to avoid rip roaring pain. We still don’t know if painful exercise is actually bad for outcomes but certainly it may dissuade someone from carrying on with it.
Things can and will go wrong and set backs are normal. These setbacks can be influenced by a whole bunch of factors including stress and lifestyle that can negatively affect recovery, and no rehab plan will ever follow a linear upwards trajectory, especially if we are attempting to push the envelope and ‘vaccinate’ against future reoccurrences.
*HERE* we see psychological stress actually impairs recovery from exercise so we must be mindful of this. It may not be the intensity of the sensation that some struggle with but how LONG it goes on for. Desired adaptations such as strength might also be affected by stress too. *HERE*
Pain is often accompanied by worry and stress and could be both a cause and an effect of the current state of the individual. This is why we must be aware that our rehab programs carry the possibility that they could cause an adverse reaction in times of stress.
Equipping people with the knowledge to both understand AND address these factors is vital for self-efficacy, another key player in the COMMITMENT to a rehab program.
Analogy is a fantastic way of helping people understand subjects that they have very little background in and for many folk both pain and exercise fall neatly into this bracket. One of my favourite analogies for exercise discomfort AND pain is SUNBURN. The reason for this is it (hopefully) places the pain or discomfort into perspective and allows it to be seen as a temporary thing and one that can be easily modified.
Rather than viewing an exercise as simply being WRONG, a comparison to sunburn allows it to be viewed more as an issue with the dosage applied and the bodies response. We generally don’t see the sun as a BAD thing, of course some do but we could put that on the spectrum of fear avoidance! Most people will get sunburn at some point in their lives and just see it is a little bit to much of a GOOD thing!
So what do we do if we overdose on the sun? Generally just ALTER the dosage, simply get less sun the next day by sitting under the umbrella or covering up my burnt bits with a towel, we may have just tried to rush the natural adaptation.
The negative physical reaction is only temporary, often just like the pain triggered from overdosing on exercise, the angry red skin and spiky feeling when in the shower will of course go away if I just alter the dose and let nature run its course. What we do see if dosed correctly is a slow natural adaptation that leaves us positively glowing.
What do you usually do next after burning? Well just be more careful when re-exposing yourself. Spend less time in the sun or apply a higher factor. We don’t freak out, in fact often we berate ourselves for being stupid! We know this happens after all. We can do the same with our exercises, just take a little time off or reduce the amount we do before building up again.
Why might we overdose? Perhaps we have been previously been under dosed. Just like coming of a long sunless winter, not having exercised for while probably reduces the amount I can tolerate and hence potential adverse reactions. This may explain why just a few sets could leave me pretty sore.
If we have previously been good at a sport we tend to be able to play at a much higher intensity than perhaps we can CURRENTLY handle. In fact being good at something could actually be a risk factor for some! Our skill level may far out weigh our tolerance for the level of intensity we can play at. The same is true of tanning, we tend to remember the lazy long days at the END of a holiday applying Hawaiian tropic rather than the blotchy days at the beginning on factor 30.
Some people can exercise till the cows come home and never feel a thing, a bit like those really annoying people who go an amazing shade of brown by just looking at the sun! We maybe predisposed genetically to being LESS tolerant to physical activity. We see discussion of the role of genetics in sensitivity *HERE*
People with fair skin and red hair are often less tolerant of the sun by nature of their Celtic heritage and those of Mediterranean or African origin far better genetically equipped to handle a greater dosage of the sun.
Now no analogy is free from a negative misinterpretation. Whilst the sun could be seen as having dangerous consequences such as skin cancer from extreme overdosing we also see problems with under dosing such as depression from reduced serotonin. Like all things it has an OPTIMAL dosage, after all too much or little water or oxygen can also kill you too!
How can we alter the dosage?
- Frequency – How often. More is not always better.
- Intensity – How heavy or how fast.
- Volume - How much. Sets, reps and rest.
Read more here about dosage *HERE*
- People don't just fit neatly into science
- Increasing pain is a real worry with rehab exercises
- Arm people with information about what to expect and what they are feeling
- Be smart in the first place – Less can be more.
- Self management. Give them the tools to manage the dosage.
- Give support. If it does go wrong to help people get back on track
Ben Cormack owns and runs Cor-Kinetic. He is a musculoskeletal therapist with a clinical background in sports therapy, rehabilitation, pain science & exercise stretching back 15 years. He specialises in a movement & exercise based approach with a strong education component and patient centred focus.
Ben is a popular international presenter who has delivered conferences presentations and courses all over the world.