Use an expert
If you have pain, exercises should be commenced only after you have been assessed by someone who is qualified to deal with musculoskeletal problems. It’s not a case of one size fits all. If people start exercising inappropriately they can easily make their condition worse. Exercises should be prescribed after a thorough objective and subjective assessment by someone who has knowlege and experience in dealing in conditions which present with pain, movement impairment or malalignment.
A good assessment will determine which exercise is right for each patient. This may involve moving into the pain or avoiding pain depending on the nature of the underlying pathology and medical history. If there is an underlying dysfunction in joints or muscles then exercises will need to be directionally specific. There may be times when exercise is contraindicated altogether, such as when there is acute inflammation, trauma, or suspected serious pathology. The patient’s response to movement gives valuable information used to determine the nature of the underlying condition. It should also determine the type of exercise to be used as a treatment technique, if the assessment is done by a therapist skilled in musculoskeletal dysfunction.
Taken into account should be the needs of the person, the sport they play, the goals they wish to achieve, their lifestyle and personal preferences.
When exercises are used to promote tendon healing, the starting point of the exercise is important. This will usually be the point at which pain is felt (target zone). The healing process is then facilitated by repetitive loading of the tendon at this point. Exercises will then be upgraded over time changing resistance, range, amplitude and frequency.
People suffering from chronic pain benefit more from non directional specific exercises and stretches unless there is specific mechanical dysfunction as well. Pain education often needs to be included if there is underlying sensitization of the central nervous system which can be present in long term pain sufferers.
Systematic review of commonly used treatments in musculoskeletal conditions
The authors Robin McKenzie and Stephen May in their book “The human extremities: mechanical diagnosis and therapy” reveal results from a systematic review of commonly used treatments in musculoskeletal conditions:
The only intervention that consistently appears beneficial across a wide range of spinal and non-spinal musculoskeletal problems is exercise. ( Clarke 1999) states “First and importantly, exercise appears to be the best modality. Strengthening muscles protects the joint”.
“In common with other areas of musculoskeletal rehabilitation, the evidence strongly supports exercise (except possibly in the rare case of true radicular back pain) and a cognitive behavioural approach to pain management” (Haigh and Clarke 1999).
Optimum treatment of many musculoskeletal conditions is founded on patient involvement.
Arthritis
(“Puett and Griffin 1994) “Exercise reduces pain and improves function in patients with osteoarthritis of the knee. ” Maintaining a full range of movement and muscle strength at an affected joint may reduce disease progression as well as greatly decreasing pain and disability.
It is suggested that drugs, often the wrong sort, are overused, whereas biomechanical interventions for the management of OA are underused (Dieppe 1993).
Research has shown that individualized programs involving exercise, relaxation, appropriate use of affected joints and problem-solving resulted in better functional preservation, improved pain, fewer health care visits and less depression.
Tendon strain or overuse injuries
Tendon pathologies are correctly referred to as tendinopathy or tendinosis rather that tendonitis. Histopathological studies do not demonstrate inflammatory cells in persistent tendon problems. This would indicate that steroid injections and anti-inflammatory medication is often used unnecessarily.
There is evidence from trials and systematic review that strengthening exercises have a positive outcome in tendon problems. This is based on the finding that repeated loading of the tendon can facilitate remodeling and repair (mechanotransduction). In physiological terms, regularly repeated movements strengthen and normalize healing tissue, and restore to normal function tissue that is abnormal, over-sensitized or de-conditioned.
The appropriate administration of therapeutic exercise is invaluable when treating and rehabilitating tendon injuries. The reliance on surrounding muscular activity for joint stability and mobility means the physiotherapist can be a major determinant in the recovery outcome of joint injury. In order to maximize speed and degree of recovery following tendon or muscle injury, the exercise program must be specific and prescribed after a thorough objective and subjective assessment.
Later in rehabilitation the retraining becomes more activity specific as determined by the intentions of the patient. Loading, speed of movement, repetitions, rest periods and complexity are manipulated to simulate occupational, recreational or sporting activities for which the patient is being retrained.
knowledge … self-management … prevention