Exercise is an essential part of any rehabilitation approach to chronic pain. Our clinical experience as well as the literature tells us that it works 1,2. Further to this, there doesn’t seem to be much evidence to tell us which exercise works best – whether we choose motor control type exercises, graded strength based approaches or even aerobic exercises. Regardless of what exercise you choose, you are likely to see improvement in pain and function 3.
When we are setting someone up with an exercise program as part of a management program, it is incredibly important that we put a lot of effort into making sure that the program is going to be ongoing. In the event that they don’t stick with the exercise program and stop doing it before it can start to have the anticipated positive effects, the take home message for the patient is “exercise doesn’t work for my pain”. It becomes for them yet another failed treatment and can feed into the cycle of hopelessness that many chronic pain suffers experience. By having a half-hearted go at exercise and failing, it may have inadvertently done more harm than good.
Research tells us that adherence to home exercise programs on the whole is an uphill battle, with up to 70% of patient not engaging in prescribed home exercises 4. Efforts to increase compliance such as involving the patient in the planning and goal setting process, formally establishing motivation and compliance, exploring the patient’s beliefs about exercise and pain, planning for and troubleshooting obstacles and setbacks and regular follow ups to check compliance have been shown to dramatically improve adherence to exercise programs 4.
For people who haven’t got a strong exercise history, starting out with a high level of support is going to mean better adherence in both the short and long term. Telling someone to start exercising, without much guidance or support is likely to last about two weeks – until the rain, cold, dark, sickness, increased pain or countless other obstacles rear their ugly head. Specifically, to increase your chances of getting an exercise program to stick the following can be helpful:
- Establish motivation – why are you here? What do you want to get out of this?
- What do you enjoy doing? What fits in with your lifestyle? What are you likely to stick with?
- What do you understand about your pain and how exercise effects it and vice versa?
- Try to make sure the exercise is scheduled, especially for the first few months. This might mean that the person attends a class, personal training session, clinical pilates, small group training, bootcamp, crossfit etc. When it is scheduled into their diary and they are expected to attend, the chances of them turning up are greater. This is often even further evident when there is a financial commitment attached to that session (ie. they still pay for the session in the event they don’t turn up!). If the sessions are not as individualised as something like a personal training session, getting them to create a diary entry for something like a gym class is the next best thing.
- Having a high level of supervision, particularly in the early phases can be really helpful in building confidence. This is particularly important when there is a level of fear avoidance. If there is someone qualified who can confidently say to the client that the exercise they are doing is safe and won’t be causing damage, they are more likely to engage in the exercise even if there is some pain associated. There is also greater chance that the exercises will be appropriately progressed and therefore you will see better results.
- For people who are struggling to see the value in, or are unable to afford these types of highly supervised sessions on an ongoing basis, I often suggest that they start with a period of 8-12 weeks on such a program and then review it. More often than not, when the review time comes around, they have seen the value in the sessions and the results that are happening. They will often be happy to continue because they are enjoying the progress they are making. If they choose not to keep going, you have at least got a level of habit, some confidence and success, to keep going on a slightly less supervised program.
- Making a fairly direct referral to the exercise practitioner also helps with the uptake of your suggestion. If you are referring to someone that you know and trust, and can help the person to facilitate contact with that person, you can help smooth the way to the start of their journey. When they are aware that you trust the practitioner, they will have a greater level of confidence in them too. This works particularly well when you have your rehab options “in-house” but can also work with some well established local networks.
- Van Middelkoop, M., Rubinstein, S., Verhagen, A., Ostelo, R., Koes, B., & van Tulder, M. (2010). Exercise therapy for chronic nonspecific low back pain. Best Practice and Research Clinical Rheumatology, 24, 193-204
- Hayden, J., van Tulder, M., Malmivaara, A., et al. (2005) Exercise therapy for treatment of non-specific low back pain. Cochrane Database Syst Rev, (3). CD000335
- Gazzi Macedo, L., Latimer, J., Maher, C., et al.(2012). Effect of motor control exercises versus graded activity in patients with nonspecific low back pain: A randomized controlled trial. Physical Therapy, 92 (3), 363-377.
- Beinart, N., Goodchild, C., Weinman, J., Ayis, S., & Godfrey, (2013). Individual and intervention-related factors associated with adherence to home exercise in chronic low back pain: a systematic review. The Spine Journal, 13, 1940-1950.