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When Can I Start Exercising?
May 24, 2014 by Dr Matthew D. Long
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When Can I Start Exercising?
May 24, 2014 by Dr Matthew D. Long
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When Can I Start Exercising?
May 24, 2014 by Dr Matthew D. Long
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Whenever ‘best practice’ management of spinal pain is discussed the topic of exercises is never far away. Most patients do expect to be given exercises. Indeed, the prescription of exercises is now considered one of the defining features of an 'evidence-based' approach. But are they truly essential to a good outcome? What effect do they really have? What is the mechanism by which they work?
In a previous blog article we looked at the current thinking about the role of exercise in chronic lower back pain (read the article here), specifically examining the topic of how exercise might exert its positive effects. The consensus does appear to be that exercise is a useful tool for altering the abnormal motor patterns that typically accompany chronic spinal pain. Indeed, there is an ever-growing body of evidence to show that those with chronic spinal pain have impaired cortical drive to their back muscles (1,2), as well as altered representation of the back muscles in the somatosensory cortex (3). The same is true in the cervical spine. According to Falla and colleagues (4);
In a previous blog article we looked at the current thinking about the role of exercise in chronic lower back pain (read the article here), specifically examining the topic of how exercise might exert its positive effects. The consensus does appear to be that exercise is a useful tool for altering the abnormal motor patterns that typically accompany chronic spinal pain. Indeed, there is an ever-growing body of evidence to show that those with chronic spinal pain have impaired cortical drive to their back muscles (1,2), as well as altered representation of the back muscles in the somatosensory cortex (3). The same is true in the cervical spine. According to Falla and colleagues (4);
"Reduced specificity of neck muscle activity in patients with neck pain may be the result of multiple mechanisms including direct effects of nociception on motor neuron output, effects of pain on sympathetic activity and changes in motor planning."
So the old paradigm of ‘strengthening the supporting muscles’ has gradually given way to an appreciation for the more important aspect of muscular control. In other words, the goal of exercise is to act as a catalyst for changing the coordinated control of spinal musculature, not simply its strength. This has been reinforced many times in the literature by studies that demonstrate that simple strength-based training does not have the same rehabilitation success as skilled training (5), with measurable changes in cortical neuroplasticity occurring when motor-skill training is used (6,7). As such, it does seem that exercise is a critical component to achieving a ‘strong’ and stable spine. The question is, when should we prescribe them.
Patients often start asking about the need for exercises early on in their course of treatment. Some even feel that a delay in beginning exercise will hinder their progress. But is this actually true?
Current evidence suggests that the presence of pain will alter motor patterns sufficiently to undermine the effects of exercise. A recent paper in the journal Manual Therapy (8) examined the question of exercise timing, and whether we should start our patients exercising whilst they are still experiencing pain. In this study Rittig-Rasmussen and colleagues investigated the changes in corticomotor excitability and motor learning that occurred in patients prescribed an exercise whilst concurrently experiencing neck pain. The training task involved controlled dynamic concentric/eccentric activation of the right trapezius muscle and they used transcranial magnetic stimulation and electromyography to measure how pain-free patients compared to those suffering from neck pain. Interestingly they observed that neck pain reduced the excitability of the corticomotor pathways for up to 7 days and impeded motor learning. The authors therefore concluded that;
Patients often start asking about the need for exercises early on in their course of treatment. Some even feel that a delay in beginning exercise will hinder their progress. But is this actually true?
Current evidence suggests that the presence of pain will alter motor patterns sufficiently to undermine the effects of exercise. A recent paper in the journal Manual Therapy (8) examined the question of exercise timing, and whether we should start our patients exercising whilst they are still experiencing pain. In this study Rittig-Rasmussen and colleagues investigated the changes in corticomotor excitability and motor learning that occurred in patients prescribed an exercise whilst concurrently experiencing neck pain. The training task involved controlled dynamic concentric/eccentric activation of the right trapezius muscle and they used transcranial magnetic stimulation and electromyography to measure how pain-free patients compared to those suffering from neck pain. Interestingly they observed that neck pain reduced the excitability of the corticomotor pathways for up to 7 days and impeded motor learning. The authors therefore concluded that;
"Our results infer that pain and concomitant training induce an enhanced and sustained inhibition of motor-evoked potential (MEP) amplitudes lasting for one week. The findings suggest that motor training should be conducted in a pain-free manner or with minimal pain, as it seems that pain is an important factor in determining training-induced corticomotor excitability and be a limiting factor for the clinical outcome of neck training in contrast to training with no pain."
So what can we learn from this?
We do know that early activation and maintaining mobility are important in the management of acute spinal pain patients. Indeed, the literature has repeatedly affirmed that those who rest do worse than those who keep moving. But when it comes to the prescription of specific rehabilitation exercises, it seems that good things comes to those who wait.
Something to think about...
Dr Matthew D. Long
BSc (Syd) M.Chiro (Macq)
We do know that early activation and maintaining mobility are important in the management of acute spinal pain patients. Indeed, the literature has repeatedly affirmed that those who rest do worse than those who keep moving. But when it comes to the prescription of specific rehabilitation exercises, it seems that good things comes to those who wait.
Something to think about...
Dr Matthew D. Long
BSc (Syd) M.Chiro (Macq)
References:
1. Chiou, S. Y., Shih, Y. F., Chou, L. W., McGregor, A. H., & Strutton, P. H. (2013). Impaired neural drive in patients with low back pain. European Journal of Pain, n/a–n/a. doi:10.1002/j.1532-2149.2013.00428.x
2. Strutton, P. H., Theodorou, S., Catley, M., McGregor, A. H., & Davey, N. J. (2005). Corticospinal excitability in patients with chronic low back pain. Journal of Spinal Disorders & Techniques, 18(5), 420–424.
3. Flor H, Braun C, Elbert T, Birbaumer N. Extensive reorganization of primary somatosensory cortex in chronic back pain patients. Neuroscience Letters 1997;224(1):5e8.
4. Falla, D., Lindstrøm, R., Rechter, L., Boudreau, S., & Petzke, F. (2013). Effectiveness of an 8-week exercise programme on pain and specificity of neck muscle activity in patients with chronic neck pain: A randomized controlled study. European Journal of Pain, n/a–n/a. doi:10.1002/j.1532-2149.2013.00321.x
5. Boudreau, S. A., Farina, D., & Falla, D. (2010). The role of motor learning and neuroplasticity in designing rehabilitation approaches for musculoskeletal pain disorders. Manual Therapy, 15(5), 410–414. doi:10.1016/j.math.2010.05.008
6. Rittig-Rasmussen, B., Kasch, H., Fuglsang-Frederiksen, A., Jensen, T. S., & Svensson, P. (2013). Specific Neck Training Induces Sustained Corticomotor Hyperexcitability as Assessed by Motor Evoked Potentials. Spine, 38(16), E979–E984. doi:10.1097/BRS.0b013e3182975310
7. Rittig-Rasmussen, B., Kasch, H., Fuglsang-Frederiksen, A., Svensson, P., & Jensen, T. S. (2014). Effect of training on corticomotor excitability in clinical neck pain. European Journal of Pain (London, England). doi:10.1002/j.1532-2149.2014.487.x
8. Rittig-Rasmussen, B., Kasch, H., Fuglsang-Frederiksen, A., Svensson, P., & Jensen, T. S. (2014). The role of neuroplasticity in experimental neck pain: A study of potential mechanisms impeding clinical outcomes of training. Manual Therapy. doi:10.1016/j.math.2014.04.010
1. Chiou, S. Y., Shih, Y. F., Chou, L. W., McGregor, A. H., & Strutton, P. H. (2013). Impaired neural drive in patients with low back pain. European Journal of Pain, n/a–n/a. doi:10.1002/j.1532-2149.2013.00428.x
2. Strutton, P. H., Theodorou, S., Catley, M., McGregor, A. H., & Davey, N. J. (2005). Corticospinal excitability in patients with chronic low back pain. Journal of Spinal Disorders & Techniques, 18(5), 420–424.
3. Flor H, Braun C, Elbert T, Birbaumer N. Extensive reorganization of primary somatosensory cortex in chronic back pain patients. Neuroscience Letters 1997;224(1):5e8.
4. Falla, D., Lindstrøm, R., Rechter, L., Boudreau, S., & Petzke, F. (2013). Effectiveness of an 8-week exercise programme on pain and specificity of neck muscle activity in patients with chronic neck pain: A randomized controlled study. European Journal of Pain, n/a–n/a. doi:10.1002/j.1532-2149.2013.00321.x
5. Boudreau, S. A., Farina, D., & Falla, D. (2010). The role of motor learning and neuroplasticity in designing rehabilitation approaches for musculoskeletal pain disorders. Manual Therapy, 15(5), 410–414. doi:10.1016/j.math.2010.05.008
6. Rittig-Rasmussen, B., Kasch, H., Fuglsang-Frederiksen, A., Jensen, T. S., & Svensson, P. (2013). Specific Neck Training Induces Sustained Corticomotor Hyperexcitability as Assessed by Motor Evoked Potentials. Spine, 38(16), E979–E984. doi:10.1097/BRS.0b013e3182975310
7. Rittig-Rasmussen, B., Kasch, H., Fuglsang-Frederiksen, A., Svensson, P., & Jensen, T. S. (2014). Effect of training on corticomotor excitability in clinical neck pain. European Journal of Pain (London, England). doi:10.1002/j.1532-2149.2014.487.x
8. Rittig-Rasmussen, B., Kasch, H., Fuglsang-Frederiksen, A., Svensson, P., & Jensen, T. S. (2014). The role of neuroplasticity in experimental neck pain: A study of potential mechanisms impeding clinical outcomes of training. Manual Therapy. doi:10.1016/j.math.2014.04.010