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Exercise & education 
Exercise & education have emerged as shining knights of rehab
Good for SRs, guidelines & saying 'evidence based' but are they just buzz words?
There are 3 issues IMO
How to implement?
Is it good for MY patient?
Efficacy vs effectivness1/
The first challenge is what to do?
Majority of MSK conditions advocate exercise to treat, but is there a pathway to doing so. LBP is an example. Everything has potential effect but not a guaranteed one
Maybe why don't get so much change in practice?
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7563797/
2/
Majority of MSK conditions advocate exercise to treat, but is there a pathway to doing so. LBP is an example. Everything has potential effect but not a guaranteed one
Maybe why don't get so much change in practice?
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7563797/
2/
It can be almost impossible to find out what is actually done in many studies & involves searching through 3-4 papers and supplementary attachments that still don't enable clinical application
Many times the headline does not fit the program
https://www.sciencedirect.com/science/article/pii/S1526590020300390
3/
Many times the headline does not fit the program
https://www.sciencedirect.com/science/article/pii/S1526590020300390
3/
Does that mean any old exercise will work? I don't think so. Many times we have to change or adjust things because they have not achieved what we wanted them too. This might be the under discussed part of exercise in MSK
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Is it good for my patient? Thats the tough bit! Research into isometrics has shown how variable outcomes can be to the same intervention/dosage.
A group mean may not represent what happens for MY patient with a standardised exercise protocol
https://onlinelibrary.wiley.com/doi/abs/10.1111/sms.13296
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A group mean may not represent what happens for MY patient with a standardised exercise protocol
https://onlinelibrary.wiley.com/doi/abs/10.1111/sms.13296
5/
People with pain respond DIFFERENTLY to exercise than those without. EIH does not appear to be consistent across the board
https://www.sciencedirect.com/science/article/pii/S1526590018304565
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https://www.sciencedirect.com/science/article/pii/S1526590018304565
6/
"Unlike asymptomatic individuals, participants with LBP lacked EIH over the lumbar erector spinae muscles following repeated lifting"
https://pubmed.ncbi.nlm.nih.gov/31187932/
7/
https://pubmed.ncbi.nlm.nih.gov/31187932/
7/
So although exercise is 'evidence based'. Can we expect people to get an average outcome? How does this fit in with peoples expectations of treatment & recovery? Especially if they get an outcome that they did not sign up for
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8/
We also have the issue of efficacy vs effectiveness
A clinical trial that is used to inform guidelines may not suit the ability/lifestyle/motivation level of the person in front of us
What response can we expect once adjusted to the person?
https://bjsm.bmj.com/content/50/6/323
9/
A clinical trial that is used to inform guidelines may not suit the ability/lifestyle/motivation level of the person in front of us
What response can we expect once adjusted to the person?
https://bjsm.bmj.com/content/50/6/323
9/
Guidelines & exercise literature rarely discusses the real world application & this is where the real problems can lie
Successful implementation may be as much about application & the person applying it as the dosage. Often neither are apparent
https://pubmed.ncbi.nlm.nih.gov/19995464/
10/
Successful implementation may be as much about application & the person applying it as the dosage. Often neither are apparent
https://pubmed.ncbi.nlm.nih.gov/19995464/
10/
So do we have more guidelines then guidance? Like patients, clinicians also need a path to change not just information to do so.
Behaviour change is not an issue just on one side of the desk
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Behaviour change is not an issue just on one side of the desk
11/
Maybe we need to lose the prescriptive mindset with exercise for painful conditions? It works for fitness, less so for pain and rehabilitation. Especially in more complex scenarios that involve more than just physical change
https://cor-kinetic.com/the-myth-of-exercise-prescriptions-its-probably-more-trial-and-error-than-we-care-to-admit/
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https://cor-kinetic.com/the-myth-of-exercise-prescriptions-its-probably-more-trial-and-error-than-we-care-to-admit/
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