Often after a visit to a medical office for pain, patients are provided with a list of exercises, a pamphlet or brochure or worse, they find a “one size fits all” exercise “cure” on the internet. Many feel these are often sufficient replacements for a skilled physical therapy evaluation and subsequent treatment, with the notion that strengthening or exercising the painful area will improve the pain in function.
The leading experts in the therapy, movement and performance field will tell you that this assumption is incorrect.
Physical therapists, with a foundation of anatomical structure, neurological pathways, and motor control are the recognized functional experts the in healthcare industry. With the proper education and approach they can easily explain to you not only what is hurting, but why it is hurting. With the proper approach, they will look at the entire kinetic chain. Many times, the pain is not the problem; it is a symptom of movement dysfunction elsewhere, putting more stress on the area that is experiencing pain. Direct, “one size fits all” programs for a painful area rarely lead to a decrease in pain and often can make symptoms worse and lead to an unsatisfied patient.
The Problem in Theory:
All too often patients receive a home exercise program with the “one size fits all” approach with the painful area being the sole focus. These programs often disregard an injury with individual characteristics resulting in improper recovery, decreasing their ability to return to prior level of function and often result in reoccurrence. The number one cause of re-injury is a result of insufficient or improper rehabilitation. Generic home exercise programs are not sufficient nor are they proper for comprehensive rehabilitation for an individual with pain.
Here are 5 reasons why a stand-alone Home Exercise Program can be ineffective.
1. A home exercise program is not self-care program; it is a component of one. Many incorrectly assume the terms are one in the same. Often important components such as patient education workplace, and home modification to name a few, are not included, to the detriment of the patient. Just as a grade school homework assignment reinforces what is taught in class:
Home Exercise Programs are NOT synonymous with physical therapy, they are an adjunct.
2. The body is designed to compensate and often does without the knowledge of the person performing the exercise. With a “one size fits all” home exercise program these issues often go unaddressed and result in compensation, decreasing the effectiveness of the exercise. Additionally, improperly performing home programs reinforce incorrect motor patterns resulting in additional stress on structures that are not designed to handle the force. The work of Richard A Schmidt, PhD. tell us that tells us that it takes 300 repetitions to create a bad habit, and 3000 correct repetitions to undo it. That is the human condition. Exercises given without compensation safeguards can quickly have detrimental results to one’s movement patterns and pain.
3. Generic programs are limited to a specific painful area and ignore other affected areas of the body. The “one size fits all” exercise program usually only addresses the site of pain with the assumption that the pain is the problem. In most cases the pain is the symptom of movement dysfunction elsewhere. The entirety of the kinetic chain, which is the interaction of muscle, nerves and joint to create movement, is often ignored. When this occurs, people with foot pain, for example, develop knee, back or hip pain because their functional requirements of other areas have increased, but have gone unaddressed. In this same light, if a non-painful dysfunction at the thoracic spine creates issues at the shoulder blade and in turn shoulder pain, shoulder exercises are not going to address the problem.
4. There is often no progression, increasing the chances of re- injury. Without progression, the structures are improperly prepared for the functional demands of everyday life and the end result is some level of pain, be it reoccurring or new.
5. It is an incorrect assumption that if an individual has a program that addressed the structures involved in a specific movement that motor patterns will take care of themselves. Generic orthopedic programs that do not address movement patterns may improve isolated strength, but will not improve the dysfunction that caused the injury.
The Problem in Practice:
Just this week we had a patient who had been in chronic pain for a while. She performed exercises that was a “one size fits all” and her pain had gotten worse. The patient had shoulder pain, so she was provided the “shoulder exercise program”. The patient’s shoulder was painful, but as a result of rounded shoulders and weak shoulder blade stabilizers, not because of decreased shoulder strength. Yet, repeated the very mechanical issue that caused the pain. This program did not address the tight chest muscles and weak scapular stabilizers which were the primary causes of the painful shoulder.
All too often this occurs, resulting in an unsatisfied patient who remains in pain. There are many limitations to performing a general program. To start, the proprioceptive mechanism, which is what tells am individual where their body is in space, is not well tuned, making it nearly impossible for an individual to self-correct. Good pure movement is often altered in the non-painful population, let alone a painful one. Many won’t correct a problem unless they know there is one in the first place, if they don’t know there is a problem, the correction won’t happen.
The “one size fits all” approach is counterintuitive to all other aspects of medicine, and yet it seems to be the “go to” approach for orthopedic pain. Two people with similar health problems are rarely going to be prescribed the same prescription medicine, with regard to frequency and dosage. People are different; so it stands to reason that many factors should be taken into account. Returning to the scenario above, shoulders are not created equally, and yet, the “one size fits all” approach was the “cure.”
If you have received or given an exercise program, you should ask yourself these questions:
Does it include self-treatment education on proper use of modalities, home and workplace modification?
Does it have safeguards against compensation to protect functional movement from becoming dysfunctional?
Does it focus on multiple areas vs .one?
Does it include motor pattern correction?
Is it being performed correctly? How do I know?
Is it too easy? Is it too difficult? How do I know?
If you do not know the answer to one or more of these questions, a physical therapist will be able to answer them for you or your patient.