Physiotherapy is the treatment of musculoskeletal conditions, such as persistent pain, through such modalities as exercise rehabilitation, manual therapy, functional restoration, hydrotherapy and acupuncture. During an initial consultation, a Chartered Physiotherapist will ask you a number of questions in order to get to know you as a person and understand your presentation better. The initial interview is vital for us as a therapist as we are able to gain an insight and understanding into your main problems and we are also able to jointly formulate goals and a treatment plan moving forward.
The research within physiotherapy suggests to us very strongly that exercise, over any other treatment modality, will be the most effective and longest lasting method to treating musculoskeletal conditions and persistent pain. The overall aim of exercise rehabilitation is to increase joint mobility, improve muscle strength and capacity and also reduce any fears and anxieties we may have around movement.
Exercise can take many forms. Following the initial consultation a physiotherapist will likely provide you with exercise to perform on a daily basis at home. This could take the form of gentle mobilising or stretching, strengthening exercises for the abdomen, lower back and torso or even some lifting based exercises which may help with functional activities in your everyday life. Exercise such as brisk walking, swimming or cycling may also be recommended.
Physiotherapy will initially take place on a 1:1 basis but you may also be offered the opportunity to attend an exercise group session. This will take place weekly for up 6 weeks and will be with up to 5 other patients at the same time. These sessions will be led by another qualified physiotherapist. These sessions could be based around general exercises for low back pain or they may have a more Pilates base to them. Either way, you will be offered this class based on your suitability.
Hands-on treatment, such as joint mobilisation, manipulation, soft tissue mobilisation or massage, are other excellent methods used to treat musculoskeletal conditions. The existing literature suggests that, for certain groups of people, these treatment techniques can be effective in reducing pain and improving joint range of movement.
As the effects of this type of treatment tends to be quite short lasting, the main aim is to reduce pain temporarily to create a window of opportunity for the patient to exercise more effectively. Manual therapy techniques are excellent adjuncts to exercise but will rarely be used in isolation. If a Physiotherapist uses such techniques, they will also emphasise the importance of continuing or even progressing home-based exercises.
For those patients who need to increase their exercise levels to improve mobility and strength, but find it very difficult to weight bear or have widespread pain, hydrotherapy can be an excellent alternative to land-based exercise. This takes place in the hydrotherapy pool at Worcestershire Royal Hospital. You will be assessed initially on a 1:1 basis but then you will exercise in the water, being led by a physiotherapist, but also alongside other patients. The buoyancy of the water means that our bodies feel lighter in the water, making it easier to weight bear and move around. Exercises are often very effective in the water in this instance. You will also be given exercises to practice at home, to ensure any benefits gained from the pool, are carried over and maintained.
Pain is very complex. Very often, despite multiple investigations such as MRI, it is not possible to precisely identify which structure in the body is generating or causing pain. This has led the medical profession to term pain ‘non-specific’. For example, in the lower back, multiple structures such as the discs, joints and ligaments can all show signs of normal age-related changes on MRI and even in people with no lower back pain. This demonstrates that although a scan can reveal apparent age-related changes, it may well not be causing pain. There are also many other factors which can influence pain, including stress, anxiety, physical workload, inactivity and deconditioning.
Although pain, in the acute stage (less than 6 weeks) is a useful sensation, forcing the body to rest and protect itself, after this stage it becomes maladaptive. Even in this early stage, despite painful sensation, it is still important for the body and affected joints to move. If for example, you suffer an acute onset of lower back pain, this may be due to a sprain, strain or overload of certain structure in the back (hard to know exactly what – pain is complex). This will generate a pain sensation. If this leads to reduced movement, it is a natural bodily response for our joints to become stiff and more painful. Over a period of weeks, if we continue to not move normally, our muscles then become gradually weaker and less flexible. We then find that normal, previously easy activity becomes a great effort and we often experience more pain. This leads to less movement, more stiffness and weakness and subsequently, we fall into a pain and inactivity (persistent pain) cycle.
It is normal to have days with more or less pain. On days when we feel better, it is very easy to try and do too much activity and exercise as we are feeling better. This can lead to an overload and a negative response or flare-up of pain. In the subsequent days, because we are experiencing more pain, we are very likely to adopt movement avoidant behaviours and actually move less. This means that although we felt we were helping ourselves by doing more initially, we probably end up doing less over 3-4 days overall. We often term this the ‘boom-bust’ cycle.
A better way to manage our symptoms is to ensure that we adopt ‘pacing’ strategies. Recognise that on days when we feel more able, it is ok to do more exercise, but do not push far beyond what you have been normally doing on a daily basis over the previous 4-6 weeks. This way, we are able to minimise a flare-up of symptoms and we are more likely to be able to continue exercising over the next 3-4 days, rather than experiencing more pain and therefore doing less overall.
When returning to exercise and movement, physiotherapists will prescribe certain exercises to help mobilise our bodies and strengthen our joints. These movements may be quite unfamiliar to us and even painful on the first few attempts at them. It is critical that we persevere with them and attempt them in a ‘graded’ manner, starting at a low level and gradually increasing the intensity or duration with which we do them. The physiotherapist you work with will be able to progress these exercises in subsequent appointments. It is important to understand that there is no magic cure and that exercise can take a number of months to have a strong effect. The research shows us that it takes at least 6 weeks of regular practice of strengthening exercises, to make true strength improvements. Until these changes occur, it is common for us to not feel any difference in pain or function. This highlights the need for us to be adherent to exercises and persevere over a longer period of time than we might first expect, especially if we have already felt pain for more than 3 months.