This blog is aimed at allied health clinicians, clients and patients, strength coaches, and other medical professionals.
In this article, I will cover the following key points
- Who are Exercise Physiologists and why do we need them?
- How exercise in rehabilitation has been ‘under-dosed’
- Why EP’s are best placed to optimise exercise programs in rehabilitation
- Highlighting examples where Physio & EP’s can collaborate as part of a complimentary & synchronous treatment team
“I haven’t heard about Exercise Physiologist’s, how can they help?”
Physiotherapists have been around for generations – the Australia Physiotherapy Association (APA) coined the term in 1939 and physios have been working in private practice since the 70’s. Other commonly known professions, such as Chiropractors have also had a foothold in Australian private practice for over half a century (1959).
In comparison, Exercise Physiologists (EP) were practicing by the early 1990’s but not formally recognised until the 21st century. So naturally, there can be some confusion from clients and other practitioners about engaging with an Exercise Physiologist for musculoskeletal rehabilitation.
Exercise physiologists (EP) can optimise rehabilitation outcomes as part of an allied health treatment team. EP’s are experts at using exercise as treatment for various conditions but haven’t traditionally been involved in pain and injury. EP’s value in this space is largely due to strong understanding of strength and conditioning principles and how to apply them to the rehabilitation process safely and effectively.
If we already have multi-modal professions that are skilled in both passive and active therapies, why the need for EP in a treatment team?
Some people in our industry believe that the need for exercise physiologists here in Australia was created from an under-prescription of exercise from Physiotherapists, a preference for passive therapies vs active ones. To elaborate on this belief, a quick revision on exercise guidelines and the importance of remaining physical active is needed – especially for those suffering pain and injury.
Here are some key stats around exercise:
- ACSM, WHO, ESSA, NPAG guidelines recommend a minimum of 150 minutes per week of exercise of moderate-high intensity, over 5 or more days a week with at least two sessions of strengthening exercise. (While this amount may be unachievable for the very unwell, generally speaking the guidelines should be treated as an effective ‘dose’ of exercise)
- Less than 1 in 2 Aussie adults were meeting these guidelines, with less than 1 in 4 meeting the strength training guidelines (AIHW, 2018)
- People in pain are 3 times less likely to meet the physical activity guidelines than healthy counterparts (Vancampfort et. al 2017).
- Regular exercise can be protective against onsets of back pain and is considered a ‘cornerstone’ of recovery in all musculoskeletal rehabilitation programs (Smith et. al 2019; Hanna et. al 2019).
The Dosage Issue In Rehabilitation
Under-Prescription – Loading
The definition of ‘exercise’ and ’strength training’ in the rehab space has become murky. I have witnessed entire ‘strength’ exercise programs made up of therabands, activation exercises, 1kg dumbbells and motor control exercises. And sometimes even less.
Lightly loaded, slow-to-start movement will always have a place in musculoskeletal rehabilitation – it is non-threatening, easily tolerated by the patient and may be all an unwell and largely sedentary patient can handle. The problem is that this level of loading should only be prescribed as a starting point, when in reality it is often the only advice on exercise that the patient receives. There is a lack of guidance on progressions, variations and general exercise outside of the targeted program and that patient is left with an under-dosed, sub-optimal exercise routine.
High load is not easily tolerated by the injured or painful area, granted, but there is absolutely no reason why we can’t coach patients to progressively increase load over time to optimise the effectiveness of their program.
Unfortunately, many in the rehab sector just aren’t comfortable doing that – for whatever reason – and that is fine. They don’t have to be. This is where Exercise Physiologists stand out; they have tertiary qualifications in exercise science, which includes detailed study in the areas of exercise programming, strength and conditioning and sport performance.
Additional masters qualifications in exercise physiology helps us apply these principles to clinical populations, and brings a strong understanding of how exercise can impact the pathoanatomical nature of injury and/or pain. Most EP’s should possess a high level of competency in the gym (given they pair this education with experience in the field) which may not come naturally to other allied health professions given differences in academic background and this makes them an asset in a treatment team.
A clinical example: A patient initially presented for some low back pain after a work injury. They have responded well to early interventions of manual therapy and low level exercise, now in mid-end stages of rehabilitation but are finding it difficult to cope with the physical demands of the workplace which is hampering the return to work process. As the patient doesn’t have experience lifting weights and needs to lift heavy loads at work, the physiotherapist recommends engaging with an exercise physiologist to help optimise strength training in order to help improve loading tolerance.
Under Prescription – Non-Specific Exercise
It is easy for both practitioner and patient to focus all treatment efforts on the painful or injured area. Naturally, this makes sense to give specific exercises targeting tissues in and around the site in question. For long-term pain however, there is not yet a clear consensus on whether targeted exercise is any more effective than general exercise (Geneen et. al 2017). This can be taken many ways but I believe this encourages the prescription of exercise to be more comprehensive in the rehabilitation process.
The last thing we want is for patients to become sedentary due to an injury, yet total cessation of other exercise is a common reaction. For patients with shoulder pain, what’s to stop them getting on a bike, performing squats, lunges, trunk work? For patients with knee pain, why can’t they bench press, seated row, lat pulldown and box? The EP skillset is well suited to adjusting exercise programs to work with and around pain and injury, aimed at improving not just the injury itself, but a holistic whole person health and fitness approach. There are a multitude of benefits, both physical and mentally, for remaining active during this process even if targeted exercise to sites of pain is limited.
A clinical example: a patient presents to physiotherapy with some shoulder pain, but has been cleared of all red flags. Patient’s main goal is to reduce pain and improve function of the shoulder. The physiotherapist identifies some specific tissues to target with both active and passive treatment but through questioning discovers patient is largely sedentary, not comfortable in a gym environment and has ceased working due to injury. Knowing the benefits of breaking this cycle of physical inactivity, stiffness and pain, the physiotherapist recommends their patient see an exercise physiologist to help engage them in regular physical activity, improve their understanding of exercise and enhance exercise tolerance. This is not a transition or discharge but an ADDITION of complementary service to create a treatment team.
How can Exercise Physiologists be effective when patient prefers not to exercise?
A qualitative paper looking at patient preferences from physiotherapy treatment described a subgroup of patients that expressed preferences for passive therapies including acupuncture, massage and TENS because it was more pleasurable and less effort than exercise (Bernhardsson et.al 2017). This is understandable, as exercise can be intimidating, uncomfortable and unenjoyable at first with pain and injury.
The paper notes that treatment preferences came from the client’s previous experiences and expectations of the service. A positive experience in the past with passive treatment, or a negative one with active treatments, may mean a patient has their mind made up about what treatment is best for them.
It is important that the client’s preferences, challenges and potential barriers are heard, understood, and addressed in order to establish a therapeutic alliance. Listening to their story may uncover a negative experience that is the foundation of this distaste for exercise and a solution can be outlined to create a more positive experience in future. A key part of this therapeutic alliance is education. The practitioner needs to provide evidence-based advice about effective treatments for their presenting symptoms.
As practitioners, we know exercise is critical in the recovery and prevention of most injury and disease states. Getting people to buy in to this idea can be difficult and for time-pressed clinicians, it may be easier to ‘shelve’ the inclusion of exercise until the patient changes their stance. Including a second ‘voice’ into the treatment conversation (in form of an Exercise Physiologist) will help challenge the client’s beliefs and expectations in order to create an evidence-based recovery plan. To put it simply, not prescribing exercise because ‘patient didn’t want it’ is no excuse and low-value care.
Summary
Regular exercise should no longer be viewed as an optional extra for the young and fit; it is a legitimate, non-pharmaceutical medical intervention for many chronic musculoskeletal conditions.
It is clear that we need healthcare professionals in Australia that are experts at promoting physical activity, particularly for those people burdened with musculoskeletal injury and disability and give them strategies to incorporate it into their lifestyles. This is why we need EP’s.
The Takeaway:
- Exercise Physiologists can be effective in achieving positive outcomes for patients in pain without diagnosing or performing manual therapy
- Patients in pain need exercise (whether they like it or not) because they are at highest risk of physical inactivity, so not prescribing exercise is not good enough
- EP’s are specialists at optimising exercise programs, with the skillset to help patients engage in strength training and progress past initial stages of rehab
Written by Sean Van Velsen, Accredited Exercise Physiologist (AEP) & Exercise Scientist at Absolute Armadale.
References:
- Geneen, L., Moore, R., Clarke, C., Martin, D., Colvin, L. and Smith, B. (2017). Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database of Systematic Reviews.
- int. (2020). WHO | Physical Activity and Adults. [online] Available at: https://www.who.int/dietphysicalactivity/factsheet_adults/en/ [Accessed 18 Feb. 2020].
- Australian Institute of Health and Welfare. (2018). Physical activity Overview – Australian Institute of Health and Welfare. [online] Available at: https://www.aihw.gov.au/reports-data/behaviours-risk-factors/physical-activity/overview [Accessed 18 Feb. 2020].
- Hanna, F., Daas, R., El-Shareif, T., Al-Marridi, H., Al-Rojoub, Z. and Adegboye, O. (2019). The Relationship Between Sedentary Behavior, Back Pain, and Psychosocial Correlates Among University Employees. Frontiers in Public Health, 7.
- Smith, B., Hendrick, P., Bateman, M., Holden, S., Littlewood, C., Smith, T. and Logan, P. (2018). Musculoskeletal pain and exercise—challenging existing paradigms and introducing new. British Journal of Sports Medicine, 53(14), pp.907-912.
- Bernhardsson, S., Larsson, M., Johansson, K. and Öberg, B. (2017). “In the physio we trust”: A qualitative study on patients’ preferences for physiotherapy. Physiotherapy Theory and Practice, 33(7), pp.535-549.
- Vancampfort, D., Stubbs, B. and Koyanagi, A. (2017). Physical chronic conditions, multimorbidity and sedentary behavior amongst middle-aged and older adults in six low- and middle-income countries. International Journal of Behavioral Nutrition and Physical Activity, 14(1).
