By Adam Meakins, BSc (Hons), Physiotherapy

It’s been a tough few weeks for exercise in healthcare, both on social media and in the literature. A recent systematic review¹ has shown it provides little to no benefit for acute low back pain. Then a popular blogger called it ‘snake oil’ and a ‘dirty word.’² And finally, a discussion on twitter questioned my favorite slogan of ‘you can’t go wrong getting strong.’

It’s fair to say that exercise, as a treatment for pain and disability, has a lot of critics, questions, and uncertainties around its efficacy and effectiveness. And although I am, and always will be, a very ‘strong’ advocate for exercise within all aspects of healthcare, I have to reflect and ask myself why do I use it as a treatment so much?

If I am being brutally honest, I use exercise with most of my patients because I am biased toward it, but also because it’s expected and assumed that’s what physical therapists (PTs) should do. There is a very strong tradition and culture that PTs give out exercises for pains and problems, just like doctors give out tablets, and chiros give out back cracks.

And although I love exercise and use it a lot with my patients, I don’t think it’s sufficient to help many pains and disabilities and I also don’t think many actually ‘need’ it as a treatment for their pain or disability. Now before you call me a hypocrite, or express your disgust or disappointment, please let me explain.

I think we all agree that all pain and disability is individual, complex, and multifactorial, from the enigma that is non-specific low back pain, to something as ‘simple’ as an Achilles tendinopathy. Regardless of the believed cause of the pain or disability, we really don’t know what needs to be addressed to help each specific patient.

For example, when someone has low back or Achilles pain and disability, do we need to ask them to move more or less? Do we need to increase their strength, power, or endurance? Do we need to improve their knowledge, confidence, or pain self-efficacy? Maybe they just need to lose some weight, stop smoking, sleep a bit better, use different shoes, and relax more? The factors to consider are almost endless.

Now there are some conditions where we have a better understanding of what needs to be addressed more to help someone improve, for example, after an anterior cruciate ligament repair (ACLR) ‘it’s the quad,’ as my mate Erik Meira would immediately say. But for many other pains and disabilities, the list of factors and variables is long and complex.

To think that addressing just one factor will be sufficient is both naive and ignorant; even Erik reluctantly admits that it is actually more than just addressing the quad for return to play after an ACLR. I think many clinicians and therapists are failing with exercise in their limited and reductionist way of thinking about it and in their use of it.

Using any type of exercise to increase someone’s strength, power, or even confidence when they have complex, variable issues is bound to fail or at least only partially help. Working with patients with pain and disability we can NOT use exercise like strength and conditioning (S&C) coaches working with athletes who often only have simple single factors to address, such as strength, power, or endurance.

Don’t get me wrong. I think it’s great to try and get as many patients as strong as possible using simple S&C principles. But if you think it’s only about increasing strength for pain and disability then you and your patients are going to be disappointed.

As I said earlier, I think many PTs give out exercises because it’s expected that’s what they should do, and often they tend to do this without involving the patients into the process because it’s 1) believed they should know best, 2) justifies their existence and fees, and 3) helps with the illusion of being more skilled and specific.

This is a mistake and something that I think needs a monumental shift in culture and training. To make exercise more successful, we need a joint and collaborative approach working alongside patients’ expectations, beliefs, and abilities, and helping to guide and motivate them accordingly.

However, as much as I and most others hate to admit this, the uncomfortable truth is that most things we see tend to have a favorable natural history and a tendency to regress to the mean. In other words, they get better on their own with time, no matter what exercises we give or what other treatments we do or don’t do with them.^3,4,5

This is a hard pill to swallow for many clinicians and therapists, especially after spending years of hard work and dedicated study learning about the complexity of human anatomy, physiology, and pathology and its treatment. To be told that it doesn’t really matter what you do with your patients because they will get better, or won’t regardless, is both a slap in the face and kick in the ego.

However, although I have been quite critical of exercise, highlighting its small effects on pain, how it doesn’t outperform placebo, and how I think most patients with pain and pathology don’t actually ‘need it’ to get better. I still strongly advocate and recommend it with all the patients I see.

Yeah, I know:  What a hypocrite! But hear me out. Although I don’t think formal specific exercise is needed for many pains and disability, I do think formal specific exercise is needed for general health and well-being.

Now I have seen a lot of debate and discussion recently on this topic with some saying healthcare clinicians shouldn’t be so dogmatic, prescriptive, or harsh with their exercise recommendations. That they need to understand and appreciate not everyone enjoys or likes exercise and instead prefers general activity and other types of movement, and these are just as important for health and well-being.

But I think these discussions are confusing two very different things: exercise and activity. And although these words are used interchangeably, they are not the same. It’s also not that one is better than another, it’s that BOTH are essential for an individual’s health and well-being, and BOTH should be encouraged and advocated more.

General recreational or leisure activity and other lower-intensity movements are great and important and fundamental. But no matter how much you wriggle, worm, contort or twist it you just can not escape from the harsh facts that regular intense, robust, difficult, awkward, even painful exercise is also essential for health and well-being.^6,7

As much as movement matters, so does intensity, and to think you can go through life at a constant low intensity without needing to challenge your body and mind hard and often is both misguided and mistaken.⁸ Our bodies and minds respond to the stresses and pressures they are exposed to, toughening and hardening them. Without stress and pressure, there is no robustness or resilience.

Now, I have also seen some comments lately from some clinicians who think that this is not our role and that we should only be focusing on treating an individual’s pain and disability, not on exercise for health, well-being, robustness, and resilience. They also claim that using the secondary benefits of exercise as a justification for its treatment for pain and disability is an excuse.

It is true that exercise doesn’t demonstrate strong effects for most pains or disabilities, but that doesn’t mean it doesn’t reduce pain at all. Exercise has been shown to reduce pain via various different mechanisms, such as endogenous opioid analgesia, diffuse noxious inhibitory control, habituation, conditioned pain modulation, and expectancy violation. The issue is that most studies are small, with a high risk of bias, and normally done on healthy individuals.⁹

So I am well aware that exercise for pain is not a panacea and its effects on pain can be similar to most other treatments such as analgesia, injections, acupuncture, manipulations, massage, etc.

However, if I am going to choose a treatment for someone’s pain and or disability out of all those that are available that all have similar effects, then I am far more comfortable choosing one that has some well-known, well-researched, positive secondary effects on an individual’s health and well-being. This is not ‘excuse based practice’, this is ‘evidence-based exercise practice’.

Adam Meakins, BSc (Hons) Physiotherapy, is an extended scope practitioner and specialist sports physiotherapist as well as a qualified strength & conditioning specialist in the National Health Service and private practice in and around Hertfordshire, England. This article is based on his blog post of the same name, which appeared on his website, The Sports Physio (thesports.physio).