Exercise and Back Pain – Hell’s own elephant

It’s getting cramped in here and I can’t work out why. I’m inside a room labelled ‘how to treat low back pain’ and something enormous is taking up all the space.

Exercise is at the heart of the physical therapies in the treatment of back pain. Most forms of therapeutic exercise boast arguably plausible theories and don’t require a belief in magic. Exercise is something that patients can be taught to do, is less likely to breed passive reliance on therapists and so should empower patients. Exercise Rocks! (right?).

Best Practice & Research in Clinical Rheumatology has just published a special edition on back pain research and one paper caught my eye. A very well respected group of researchers from the Netherlands have produced an overview of systematic reviews of exercise therapies for low back pain.[1] This research group have as much expertise at doing this as any in the world. Their findings are not so different from previous reviews but are no less striking for that. Here’s what they found:

Exercise therapy is not effective for acute low back pain. This is no surprise and is strongly reflected in most clinical guidelines. For chronic low back pain exercise is not more effective than no treatment or just leaving people on a waiting list. That is a humdinger of a finding and I want you to remember it when thinking about the next ones.

Exercise is more effective than usual care, not more or less effective than back school/education classes, behavioural therapy, electrotherapy, spinal manipulation or psychotherapy and no type of exercise therapy is clearly more effective than another.

Better than usual care but not in comparison with no treatment? That’s peculiar.  How much better than usual care? On a 0-100 point scale of pain the average difference probably lies between 2 and 16 points with similar results for disability. This estimate is very imprecise but still pretty low and the average hovers around the 10/100 mark. Is it likely to be clinically significant? Recent evidence[2] suggests that the average back pain sufferer would want to see around a 40% improvement to consider physical therapy worthwhile. Whilst change in an individual’s pain is a different thing to a group average, it doesn’t look good.

At least it is having some effect you might argue. Perhaps, but consider that you can’t properly blind trials of exercise – therapists and patients know what treatment they are getting. We have good evidence[3] that in clinical trials that measure subjective outcomes like pain incomplete blinding can artificially increase effect sizes by around 25%.  Many of the studies included in the review suffered from limitations in their methods that introduce a risk of bias. So it seems likely that these tiny effect sizes might actually be exaggerated. Which begs the question – what is left? You might conclude that exercise is hardly (if at all) better than doing little or nothing. That no form of exercise appears superior to another (and it really is a broad church of theories) leaves us with little indication that any specific approach has real merit for this condition.

It has been argued that clinical trials don’t capture the true power of physical therapy.  Trials often apply a one-size fits all treatment approach (although this is not always the case; clinicians can sometimes modify their treatments for different patients) and many believe that there are distinct subgroups of patients within chronic back pain that require different treatment approaches.

This reasonable argument suggests that only some of the people who got the “active” treatment in the trial were suited to that treatment. The real effect is washed away in the averaging by those who shouldn’t have been given that treatment in the first place. But if true it rests on an interesting premise. Where there is little or no effect on average, for every patient that the treatment made significantly better, there must have been one for whom it was not just ineffective, but it actually made them worse. I wonder whether that reflects most therapists’ clinical experience?  There is one more sizeable problem.  Another paper in the same edition[4] points out that we are a long way away from knowing what those subgroups might be, if they exist at all.

It seems hard to believe but the best estimates suggest that specific back exercises may not help back pain. Whenever you read evidence that calls a dearly held belief into question the reflex reaction is to find something wrong with it. This tendency has been called ‘rescue bias‘.[5] This is not so unreasonable as every trial has its flaws but when a bunch of trials that ask a similar question in a different way all find something similar – that’s evidence that shouldn’t be ignored.

In the abstract of the review the authors conclude that exercise is effective based solely on the comparisons with usual care. I find this odd as it doesn’t seem to reflect what we have just seen. That’s  a shame as most readers will probably never make it past the abstract to notice the enormous devil hiding in the detail. And that is why it is so cramped in here.  There is a huge horned elephant with a forked tail sitting next to me that nobody cares to look at. It’s time we noticed it, after all even inconvenient elephants deserve a bit of attention.

WATCH THIS SPACE – COMING UP: Peter O’Sullivan adds his two West Australian dollars (WAUD$1=AUD$1.3) to this. AND THEN….a bio-statistician rounds it off. STAY TUNED…..

Original Article Abstract

Exercise therapy for chronic nonspecific low-back pain

van Middelkoop M, Rubinstein SM, Verhagen AP, Ostelo RW, Koes BW, van Tulder MW.

Exercise therapy is the most widely used type of conservative treatment for low back pain. Systematic reviews have shown that exercise therapy is effective for chronic but not for acute low back pain. During the past 5 years, many additional trials have been published on chronic low back pain. This articles aims to give an overview on the effectiveness of exercise therapy in patients with low back pain. For this overview, existing Cochrane reviews for the individual interventions were screened for studies fulfilling the inclusion criteria, and the search strategy outlined by the Cochrane Back Review Group (CBRG) was followed. Studies were included if they fulfilled the following criteria: (1) randomised controlled trials,(2) adult (> or =18 years) population with chronic (> or =12 weeks) nonspecific low back pain and (3) evaluation of at least one of the main clinically relevant outcome measures (pain, functional status, perceived recovery or return to work). Two reviewers independently selected studies and extracted data on study characteristics, risk of bias and outcomes at short-term, intermediate and long-term follow-up. The GRADE approach (GRADE, Grading of Recommendations Assessment, Development and Evaluation) was used to determine the quality of evidence. In total, 37 randomised controlled trials met the inclusion criteria and were included in this overview. Compared to usual care, exercise therapy improved post-treatment pain intensity and disability, and long-term function. The authors conclude that evidence from randomised controlled trials demonstrated that exercise therapy is effective at reducing pain and function in the treatment of chronic low back pain. There is no evidence that one particular type of exercise therapy is clearly more effective than others. However, effects are small and it remains unclear which subgroups of patients benefit most from a specific type of treatment.

ResearchBlogging.org[1] van Middelkoop M, Rubinstein SM, Verhagen AP, Ostelo RW, Koes BW, & van Tulder MW (2010). Exercise therapy for chronic nonspecific low-back pain. Best practice & research. Clinical rheumatology, 24 (2), 193-204 PMID: 20227641

[2] Ferreira ML, Ferreira PH, Herbert RD, & Latimer J (2009). People with low back pain typically need to feel ‘much better’ to consider intervention worthwhile: an observational study. The Australian journal of physiotherapy, 55 (2), 123-7 PMID: 19463083

[3] Wood L, Egger M, Gluud LL, Schulz KF, Jüni P, Altman DG, Gluud C, Martin RM, Wood AJ, & Sterne JA (2008). Empirical evidence of bias in treatment effect estimates in controlled trials with different interventions and outcomes: meta-epidemiological study. BMJ (Clinical research ed.), 336 (7644), 601-5 PMID: 18316340

[4] Kamper SJ, Maher CG, Hancock MJ, Koes BW, Croft PR, & Hay E (2010). Treatment-based subgroups of low back pain: a guide to appraisal of research studies and a summary of current evidence. Best practice & research. Clinical rheumatology, 24 (2), 181-91 PMID: 20227640

[5] Kaptchuk TJ (2003). Effect of interpretive bias on research evidence. BMJ (Clinical research ed.), 326 (7404), 1453-5 PMID: 12829562

All blog posts should be attributed to their author, not to BodyInMind. That is, BodyInMind wants authors to say what they really think, not what they think BodyInMind thinks they should think. Think about that!

Comments

  1. Robert Angelo says:

    -Just a quick comment back to Brad – (back in May!) Er – that’s quite a stereotype of Physios you’re lugging about at the moment. Not quite as heavy as the Hells elephant that I’m carrying (I’m a physiotherapist, you see), but big, nonetheless.
    -By the way Neal, this article disturbs me in a scary, kind of good way. Shakes up some of my beliefs. No intelligent answers yet.

    Anonymous Reply:

    Robert,
    Don’t get to much energy built up around it, I bet your one of the good ones.

  2. As a patient who went through many physical therapists due to chronic pain, in different countries, I have my own perspective for this. I would say that my overall success rate with physical therapy was about 30%, with success defined as “noticeably improved function or decreased pain”. So I would say, on the whole, exercise doesn’t work, even for someone like me, who is good at sticking to various exercise programs. But I also had several major successes along the way.

    I think the physical therapist makes a huge difference. Those who stuck to “standard” exercise types were generally not helpful, or no more helpful than the books I already read. But here is an instructive example. I had difficulty recovering after an injury. Exercises prescribed by my PT only made things worse. As a trial, I went to a different one. She looked me over, and said “Let’s try a different program for a while”. She didn’t criticise the other therapist in any way, and in fact I didn’t pick up on what she did until about 6 weeks later. In reality she put me on exercises training the same muscle, but about 2 levels down in complexity/load than the previous PT did. At that time I wasn’t savvy about exercise as I am now, so I didn’t quite realise that this happened. It felt nearly miraculous when my pain levels went down, and doubly miraculous when 6 weeks later she asked me to do the same exercises that the first PT did, and they didn’t hurt anymore and were actually helpful.

    Since then, I have found the same thing. Exercise worked for me when I had sudden exacerbations of my pain due to overworking certain muscles, and some physical therapists were able to find the affected muscle and figure out an effective way to stretch and strengthen it. Exercise didn’t work if it was used in general “strenghten your core/stretch your hamstrings” fashion, and it certainly wasn’t a magic bullet for my chronic low back pain.

    I still come back to PT to get a combination of massage and exercise when I get into a state where routine pain management does not work. It’s a tool among many that I use to keep myself going, knowing that it will not solve all my problems, but that it can help in some specific circumstances. But detecting and evaluating this in a clinical trial, I probably come out as “unsuccessful” patient.

  3. michael says:

    Neil, your analysis is spot on.

    One minor picky point that doesn’t change your conclusions is that I think you exaggerated the effect of not blinding when you said “in clinical trials that measure subjective outcomes like pain incomplete blinding can artificially increase effect sizes by around 25%”. The study you cited reported effect sizes as odds ratios, and 0.75 for lack of blinding. Odds ratios are not the same as relative risk, and always exaggerate the effect described by relative risk. But, I suspect that OR (and RR) were underestimated in the study you cited.

  4. Alice Fung says:

    Interesting that there are no Exercise Physiologist on this blog. I wonder how they will take it if they read the article.
    Will forward this blogger to an EP friend to see how she response.
    Any EPs out there reading this please write your thoughts on it.

  5. Neil O'Connell says:

    Hey all (it’s busy around here what with all of you, me and the elephant!).

    @ Snippets, I’m in full agreement that the relationship is all important. The other fascinating thing from the studies you cite is that clinical experience had little influence. It is hard to train good communication and empathy skills I guess and perhaps also hard to train people in the art of maximising their non-specific effects.

    @everyone else…

    It is fantastic that you would take a more global view of your patients. But before you dismiss the results it is worth considering this. Several trials have compared individually tailored care based on patient assessment to standardised care and have come up with equivalent effects. See refs below….

    Granted that the individualised care in these trials may not be what you would do but the results bare thinking about. Our therapies evolve all the time but can you remember all those years back when you practised differently thinking at the time that your practice was limited, out of date, not reasoned? In my experience we always think that current practice is effective, perhaps because it is, or perhaps for all of the reasons Barry Beyerstein gives in the link above. Importantly at this moment in time the quality data in back pain gives us little idea what optimal care really should be.

    Anyway great discussion all, thanks for contributing and remember alternative interpretations are on there way right here….

    Refs:

    Critchley DJ, Ratcliffe J, Noonan S, Jones RH, Hurley MV: Effectiveness and cost-effectiveness of three types of physiotherapy used to reduce chronic low back pain disability: a pragmatic randomized trial with economic evaluation. Spine 2007, 15:1474-81.

    Carr JL, Klaber Moffett JA, Howarth E, Richmond SJ, Torgerson DJ,
    Jackson DA, Metcalfe CJ: A randomized trial comparing a group exercise programme for back pain patients with individual physiotherapy in a severely deprived area. Disabil Rehabil 2005, 27:929-937.

    Frost H, Lamb SE, Doll HA, Carver PT, Stewart-Brown S: Randomised controlled trial of physiotherapy compared with advice for low back pain. BMJ 2004, 329:708-711.

    Geisser ME, Wiggert EA, Haig AJ, Colwell MO: A randomized, controlled trial of manual therapy and specific adjuvant exercise for chronic low back pain. Clin J Pain 2005, 21:463-470.

    Hay EM, Mullis R, Lewis M, Vohora K, Main CJ, Watson P, Dziedzic
    KS, Sim J, Minns Lowe C, Croft PR: Comparison of physical treatments versus a brief pain-management programme for back pain in primary care: A randomised clinical trial in physiotherapy practice. Lancet 2005, 365:2024-2030.

    Lewis JS, Hewitt JS, Billington L, Cole S, Byng J, Karayiannis S: A randomized
    clinical trial comparing two physiotherapy interventions for chronic low back pain. Spine 2005, 30:711-721.

    Mannion AF, Müntener M, Taimela S, Dvorak J: A randomized clinical
    trial of three active therapies for chronic low back pain. Spine 1999, 24:2435-2448.

    Petersen T, Kryger P, Ekdahl C, Olsen S, Jacobsen S: The effect of McKenzie therapy as compared with that of intensive strengthening training for the treatment of patients with subacute or chronic low back pain: A randomized controlled trial. Spine 2002, 27:1702-1708.

    The UK BEAM Trial Team: United Kingdom back pain exercise
    and manipulation (UKBEAM) randomised trial: effectiveness
    of physical treatments for back pain in primary care. BMJ
    2004, 11:329(7479):1377

  6. Caitlin says:

    The comments regarding treating the body as a whole are entirely accurate. Furthermore, in reality it is rare (and a poor clinician) to treat with only exercise (even with a little bit of a consult added in). Physio is an art as much as a science, and some of it cannot be measured (though that is why qualitative studies can also be useful).

    With regard to exercise therapy, obviously this systematic review pulls together all different sorts of studies, with all sorts of ‘non-specific LBP’ patients. This category has already been recognised as a major problem in studying efficacy of physiotherapy treatment, and there are a number of teams around the world working on specific classifications. Where an exercise intervention has been targeted at a certain population with excellent clinical reasoning (eg, O’Sullivan’s study on training Multifidus in people with spondylolisthesis) the results are far more interesting and relevant (and positive).

    I can change people’s symptoms within the same treatment using targeted, specific exercise along with clinical reasoning. Sadly, many physios seem to want to get people up doing something….anything….rather than the best thing, and it is easy to see why these patients do poorly (particularly with regard to high level core strength that so many physios etc seem so fond of!).

  7. Kathryn Fidati, PT, LMT says:

    Amen to Brad. I agree most exercise programs target specific body parts in isolation of the whole, doing a disservice to the patient. We are not “a back” or ‘an elbow” but a human kinetic marvel. Therapeutic intervention must address the entire kinetic chain inlcuding sequencing and inefficient patterns of the whole. We must be able to determine where the “kink” is in the chain and reeducate the ease of movement of the whole if we want to make help the patient make real changes.

  8. Neil O'Connell says:

    Good recommended reading Luke. I would also throw in the excellent “Snake Oil Science” by R Barker Bausell. While its about the evidence for complementary therapies it gives some good basics for appraising clinical evidence.

    @Brad, I’m not sure anyone is suggesting that exercise is physio and I would think that many good therapists consider a broader perspective when considering their back pain patients. But exercise is still something of a mainstay in physical therapy for back pain and it is interesting to try to estimate its value. As far as having a detailed working knowledge of “dynamic system function” I am not clear on what that might be or how it might be evidenced.

    Brad Beldner Reply:

    It is a main stay because most PT’s are limited in their training and scope of practice in terms of thinking and working with their patients as a dynamically organizing system, especially in terms of systemic nuerologic events.

    I know many therapists may understand this in a linear way as a concept, but in practice they don’t have the training to know how to put the concept into practice with the patients they work with. I do not doubt that the exercise or “gym” approach may be better than doing nothing at all, but it is a very primitive way of think of and working with a body – and many times tends to fortify habitual patterning with more muscular tonus and heavier synaptic entrenchment.

    Back pain does not arise in a vacuum. With chronic pain, the dysfunctional way the entire human system is responding to the environment is what creates the precariousness in the local area the PT’s are focusing on, and they are usually hindered by the small scope that the insurance companies alot them to work with.

    Pain is most times a symptom, a response to a larger event. And with an acute insult, the response to the event and lack of resiliency is mostly do to lack of neurologic dexterity i.e., inability to efficiently organize the self to adapt to abrupt changes in the body and in the environment.

    You can change the physiologic response to abrupt architectural changes in the inner and outer environment through changing the response of the nervous system and brain. Raise the central nervous systems IQ if you will. Sets, reps, and stretching is the opposite of raising systemic intelligence and takes very simple manual ability on the part of the practitioner who doesn’t have the training needed to palpate, connect, and interact manually with their patients physiologic state in a way that can make a meaningful change for them.

    PT’s unless they have had training in awareness based learning modalities and dealing with psycho/physiologic based trauma’s organization as a nuerologic event, are usually just chasing and bandaging local signs of a whole body event reaction/adaptation formation. Although localization methods are a simplistic way of working, it is covered by insurance so can be helpful in a pinch when a person with chronic pain is low on funds and resources and knowledge of other methods.

    You can’t put localized studies and systemic system studies side by side to measure outcomes because the are completely different sets of ideology and practice. Localization/mechanistic ideology is a very small subset of a whole person. They can’t be fully understood by a smaller subset of parts.

    There are many trainings a PT can take to get up to speed with awareness and brain based methods like Feldenkrais.

    Neil O'Connell Reply:

    Thanks for your response Brad. Innovative approaches to managing back pain are welcome but I suspect we need to exercise caution in expressing how and if they might work.

    A quick search for “Feldenkrais” or “awareness back pain trial” in pubmed and the Cochrane library returns no RCTs, except one comparing breathing exercise with physical therapy (no difference found).
    So while in your clinical practice this approach may seem very effective we cannot assume this with confidence yet.

    I am afraid that I don’t clearly understand what you mean by training to ” palpate, connect, and interact manually with their patients physiologic state in a way that can make a meaningful change for them.” and also I am not sure we can say with confidence that conventional exercises “fortify habitual patterning with more muscular tonus and heavier synaptic entrenchment.”

    All approaches come with their own background philosophy and we individually wouldn’t use them if we didn’t think that was solid. Unfortunately where the theory outpaces or exists without scientific evidence we are essentially left with an “argument from authority”, which is a kind of logical fallacy: http://en.wikipedia.org/wiki/Argument_from_authority

    I guess we are all scratching around trying to make sense of back pain…

    Brad Beldner Reply:

    Weigh the exercise strategy against developmental learning.That is a huge difference. One is very conscious and uses the entire body in a meaningful functional way. The other does not.

  9. This is a debate that comes up when PT’s have a limited idea of dynamic system function. ” Back Pain” is usually just a symptom of a entire disorganized nervous system and disorganized dynamic system. “Exercise” is a a funny solution that is usually just fortifying “Muscling up” and stretching the overly habituated state that is created the precariousness in the structures of the back. The clients that come to my practice with back pain, the problem most of the time is coming from the dysfunctional use of their whole self that is reflected in the low back. Exercise and stretching is an unfortunate “gymnasium” mentality that lives on because most PT’s don’t have adequate knowledge of dynamic system functioning in human structure. Many PT’s look at the low back pain myopically and focus only on the back. And even then they treat function very mechanically and don’t know how to make the connect to the entire system. The low back cannot be isolated and doesn’t function by a few muscle groups only. I hope the APTA will work on raising the standards for PT education to understand what it means to organize a body for functional movement. Then I think these debates over exercise will end because they have zero relevance to how a body via intention engages with it’s environment as it moves through space. You have to work on humans like humans, not furniture.
    Ciao.

    Anonymous Reply:

    Dear Brad
    What do you mean by “dysfunctional use of their whole self that is reflected in their low back pain”? What is your evidence for this opinion?

    Brad Beldner Reply:

    Anonymous, email me at: bradbeldener@yahoo.com and I will send you the full article on systemic neuralogic dysfunction. This reply box wont let me post my full text.
    Brad

    Brad Beldner Reply:

    Most of the evidence comes from over sixty years of practitioners using this method of systemic neuro organization to obtain out comes as well as many books and studies on the method. My observations are from my own clinical experience. Beyond that does the explanation of a dynamic systems theory not resonate in your world? Is all PT education based on isolation intervention? I am thinking this is the case because nobody has been curious about a dialogue around the approach other than where is the empirical evidence. You cant compare a dynamic systems approach with a myopic leaning approach because the they are two systems that are looking for completely different indicators that point to injury resolution. The two approaches also have totally different indicators that would be considered moving towards resolution.

    The interesting conversation would be a around those indicators and how an entire system organizes to produce a chronic condition or how it organizes around an injury from an out side source. This was a similarly interesting conversation a few years ago when physical therapists realized “Tummy Time” was a bad idea to apply on infants and turned towards working with enhancing developmental movement to resolve slow movement towards rolling, crawling and weight bearing and developmental goals.

  10. Neil O'Connell says:

    Thanks to all for your thoughts on this. I don’t want to say too much as we haven’t seen the other perspectives yet (keep watching!).

    I agree that exercise is not used in isolation in the clinic but its worth noting that in many of these trials patients would have been given advice and there would have been a therapist interaction. Also regardless of other factors if exercise confers a specific and substabtial unique benefit in back treatment it would be reasonable to expect to see it reflected in bigger effect sizes. No style of exercise was clearly superior in this analysis including motor control based exercise.

    In terms of the qualitative/quantitative thing I think clinical experience is important but ulitmately should be treated with caution. For a fantastic account of all the reasons why see this essay by the late (great) Barry Beyerstein: http://www.csicop.org/SI/show/why_bogus_therapies_seem_to_work/

    Treatment effects can be quantified and while no method is perfect, the trial method is more perfect than most. Reviews of reviews do sacrifice precision somewhat but my feeling is that the overarching message from this data is not very supportive of exercise.

    Luke Parkitny Reply:

    I would also recommend (as less specific reads but very very related) “Bad Science” by Ben Goldacre AND “Irrationality” by Stuart Sutherland. At least one of those should be mandatory to all clinicians (methinks).

    SnippetPhysTher Reply:

    Oops, sorry Neil. I guess I wasn’t communicating very well.

    I am a fan of Jensen and colleagues and their work on “expert.” The qualitative aspect of their findings I think is helpful. I think they bring to the table the relevance of the interactions that occur during physical therapy sessions. Somewhat recently there were two articles published back to back: one study with a focus on determining physical therapist experts treating low back pain AND then a qualitative study of a sampling of those physical therapists. It’s kind of neat to learn that not only is what a physical therapist does clinically relevant but also the engagement of the patient and how the physical therapist interacts and thinks. The majority of physical therapists all had some commonalities, but the “experts” were different. This was the first literature to discount clinical experience as being the key factor in clinical expertise.

    Resnik and Jensen on the differences between an “average” physical therapist and an “expert” physical therapist: http://ptjournal.apta.org/cgi/reprint/83/12/1090

    The original work by Resnik and Hart that determined the “expert” and “average” physical therapists in treating low back pain: http://ptjournal.apta.org/cgi/reprint/83/11/990

  11. Katie Piraino, PT says:

    Did they include the Movement Impairment approach? When I was back in Britain not many PTs had heard of it. It is the most effective approach I have found in my career of 21 years (trained in the UK, residency in the US).
    I find postural re-education and biomechanics key to success. Did they include this?
    You can exercise all you want but if you sit, stand and move badly it will not be effective!

    Anonymous Reply:

    I agree fully with the importance of posture and body mechanics in daily activities. The core should stay strong if posture and body mechanics are optimal, and one is reasonably active. It takes time to educate patients on this topic, but benefits pay off when they get the concepts. Plus, they will learn concepts for preventing future episodes of back pain. (Yes I teach exercises based on evalution results.)

    Alfred Ball, Kinesiologist Reply:

    It doesn’t take much thought to know that exercise is not appropriate for acute low-back pain. I agree with a Jason and Katie that effective treatment for chronic low-back pain has to be qualitative and patient centered, because there are so many different -“causes” for low-back pain.

    Are we chasing the pain? Or trying to figure what is aggravating the pain? Exercise is one component, but re-education the patient on movement and being aware of how they move outside of the clinic are important as well.

    Movement re-education and patient involvement are critical in seeing improvement and pain reduction. We can not just prescribe the same set of exercises for every patient. Instead consider – who, what, when and why.

    Did these studies look at posture or flexibility? Effective treatment I find in a clinical setting includes stretches, exercises, movement education and posture education. Chronic low-back pain usually involves trigger points as well. Have these been examined?

  12. Most studies are quantitative in nature. When I think of back pain and in particular the group of patients with chronic back pain, “exercise” generally does have a role. What patient, what exercise, what intensity, what duration, how is it progressed, who was responsible for determining the parameters of exercise … those are all relevant questions that aren’t always addressed in reviews. Granted, I understand you are sharing that reality may be different than what I think.

    I tend to believe the qualitative aspect is just as important in understanding the full picture of what physical therapists do. How patient-centered was the relationship? What education was provided? How involved was the patient in the process of making decisions? In my opinion, the experience with physical therapy is more than just the provision of “exercise.”

  13. Jason L. Harris, PT, DPT says:

    Maybe this is more evidence that exercise itself isn’t helpful, but attempting to treat treat chronic pain with one specific intervention is not helpful. If it was really just as simple as a weak muscle (PT), bone out of alignment (DC), or degenerating disc (surgeons) life would be great. However, when pain is an interpretation of the mind – and not wholly a chemical signal from an “injured” tissue – ignoring it to only treat the back will almost never provide a “40% improvement”.

    Great post. Keep challenging our most closely held beliefs and make us think!