“Don’t Do That Or You Will Hurt Yourself”

I think it’s important to consider that the original position for many people partaking in physical activity is one that is fearful.

Instilled is perhaps a parental figure reminding them to “be careful when picking up that weight” or “be careful pushing yourself, you will get hurt”. Prompting caution at every turn. Or perhaps even due to outdated societal beliefs “girls shouldn’t lift heavy weights it’s dangerous”, or due to previous negative experiences. Exercise feedback is then framed around negative emotional elements such as incorrect exercise form causing harm, and potential harmful outcomes due to concerns of ‘overdoing it’. Why some of these positions are held is also part of human existence. Self preservation. The problems that afflict us simply by virtue of being human.

To state the obvious here, healthcare practitioners are not immune from this. It creates this paternalistic leaning. Only to be reinforced by principles of ethics like nonmaleficence (first and foremost I must do no harm). I think this can help understand some of the backdrop in the debate around the implementation (or lack of) exercise as an intervention for those with musculoskeletal pain.

“Fear avoidance beliefs from practitioners reinforces a cautionary and passive approach to pain and may lead to long-term passivity, unhelpful beliefs about activity, and disengagement from a patient-focused self-management approach”

All the while...

“…many physiotherapists (and many other healthcare practitioners) lack preparedness to prescribe physical activity, aerobic exercise and resistance training following guidelines to people with musculoskeletal pain”

This is a problem that I often come across in practice.

The combination of lack of preparedness / expertise / experience in exercise prescription for those with musculoskeletal pain, and concern of causing unnecessary harm with exercise, I think drives practitioners to be passive, defensive and overprotective. It biases our decision making towards a paternalistic model of care. It favours an intervention that promotes avoidance of activity, or passive interventions to help treat. Or potentially provides an active intervention that underestimates the capability of an individual, perhaps undermining self efficacy.

Don’t get me wrong though, it can be wildly in the other extreme too, where the demands way exceed an individuals capacity, but I don’t see it as much.

*Perhaps it’s also fair to say here though that exercise interventions don’t often meet patient expectations when in pain. It might exacerbate the feelings of fear and discomfort for some, due to the aforementioned. There is also perhaps a medico-legal component too. The terrain in general is difficult to navigate.

Secondly, not everyone needs an exercise intervention when presenting with musculoskeletal pain. Strength coaches probably overstate the importance of strength training in improving pain outcomes. It can be equally reductionist (e.g. KOT). You could also argue if an intervention that helps modulate or reduce pain, then simply, it has utility for that individual. But I often ask to what end? Do we all stop and wrap ourselves up in bubble wrap until it resolves? Over the years people have come to me after being told to not walk up stairs because they have a painful arthritic hip... or to quit there job and find a new profession.

My opinion - Whilst exercise may not be a ‘fix’ for musculoskeletal pain, every other facet of wellbeing can be improved with its consistent application, and so it should be primary for the majority. If we consider it from a consequentialist perspective, there is more utility when you look at health and function from a macro lens POV rather than attempting to ‘fix’ pain. Ironically, the by product of that is probably the thing that helps most. Antoine Béchamp’s Terrain theory: don’t just attempt to isolate and treat the fish, clean up the fish tank.

You would hope a multi-faceted approach in pain management should see an attempt to maximise functionality providing some immediate pain relief, whilst also pursuing further investigations to try and ‘fix the cause’... If only it can all be resolved so easily. Instead, perhaps also due to our desire to provide solutions and our bias to cause and effect, interventions are are often combined with narratives of fragility, fear of movement, and biomechanical & biomedical explanations of pain which often result in pathologising normal movements. The bar is low, very low. If a patient has pre-existing concerns and it’s confirmed by negative beliefs / fear avoidance regarding specific movements / condition from a healthcare practitioner, then you end up with the perfect storm.

The challenging component to this is that avoidance and removal due to these explanations (e.g. flexion is bad for your back, it’s weak because your discs are crumbling) may well alleviate symptoms, and therefore confirm culpability to a specific activity or movement lasting till the end of time. In addition, a proposed treatment might be positioned to help fix the issue that is causing pain e.g. realigning your spine with a manipulation. Someone might receive this treatment and feel better, which is great, but absorbing potentially negative perceptions of self along the way. All the while, regression to the mean may well occur, meaning over time pain has improved due to our potential to heal. Often regression to the mean happens despite what intervention has taken place, and what constitutes as harm (and usually far more problematic) is the lingering perception of fragility attributed to movement/exercise based on language used. Sadly, I have come across countless examples of this.

It is suggested healthcare professionals with a biomedical treatment focus and high fear avoidance beliefs around exercise interventions are more likely to contribute to poor adherence with exercise. No shit. The less cynical side of me chooses to give the benefit of the doubt, and not to think this is because practitioners look to take advantage of fear and create dependency on their treatment for £. It does happen, but it’s too prevalent for that to be the case IMO, even though it’s one of a few professions (in the private sector) where there is financial incentive to not be good at your job.

Instead, a more balanced opinion is that I think it’s just a by-product of the human condition. And in order to go against the grain in decision making you

a) Have to be well skilled as a practitioner / have a critical mind

b) Heavily invested in your own training (practitioners who train more are more likely to advocate for that as an intervention and truly understand the cost of their recommendations)

c) View the human body as more resilient than it is fragile. Ask your practitioner if they read much philosophy.

Both perspectives will be true at some point in your lifetime. I’d just argue there is far more utility in one perspective over the other in the majority of cases.