Great blogpost by Luca Maestroni! 🙂
The way you load a patient is important.. he explains why in this post.
In his course, he discusses the combination of neuroscience and mechanotherapy.
Luca Maestroni is a physiotherapist working now in northern Italy after having spent several years in Australia and UK. He has got a special interest in neuroscience and exercise physiology and how the combination of these two fits nicely in the biopsychosocial model.
You can find his website here (www.lucamaestroni.com) and follow him on Twitter: (@lucamae1987)
Being a physiotherapist could be very rewarding but at the same time daunting, considering that we still do not really know “what is this thing called pain” (cit.Woolf). The ability of instilling biopsychosocial pain beliefs and developing independence has been associated with successful outcomes and this requires an “elegant” shift from a mere “tissue based” to a simple person-centred explanation. Explanation together with a clear demonstration may foster this and empower patient’s adherence and compliance.
The main goal of Physiotherapists is to restore a “thoughtless, fearless movement” (L.Gifford). Despite the evidence, suggesting that the language used [1, 2] is a crucial tool able to enhance movement and to decrease pain perception, too many patients still report to have been strongly advised to stop their favourite physical activity or to drastically reduce the physical load by their GP, Physiotherapist or other healthcare professionals. This, in their own theoretical assumptions, supposedly reduces the risk of further injuries and pain flare ups. Is this the reality? Are these claims supported by the scientific evidence in 2016? It does NOT seem so…
Indeed, the discriminating factors that maintain persistent nociceptive pain, apart from possible psychosocial factors, are the so called “maladaptive features”, in other words neuroplastic changes that are able to reduce or to modify specific physical capacities and neurophysiological mechanisms. For example, Rio et. al  found a reduced cortical excitation in subjects presenting with tendinopathies; O’Sullivan et al.  assessed the endurance capability of the lumbar extensor muscles in a specific low back pain cohort and the results showed a reduced performance in the Biering Sorensen Test compared to asymptomatic subjects; recently Andersen et al.  demonstrated a reduced “rate of force development” in chronically painful cervical muscles and so forth. There are also clinical presentations where the “maladaptive features” emerge as an increased co-contraction that presents with an inability to relax the painful area. See for instance the absent flexion-relaxation in specific persistent low back pain profiles [6, 7]. These presentations are however beyond the scope of this brief article.
It appears quite obvious then that the presence of reduced or altered physical capacities due to cortical inhibition or intrinsic weakness, requires an intervention whose aim is to restore their normal function. As recently stated by Professor Jill Cook  outmoded passive therapies cannot deliver positive outcomes. Therefore, in order to normalize the aberrant function, several studies have been conducted and the result clearly shows that the ability to prescribe an effective mechanical load stimulates positive cellular responses . For example Bohm et al.  showed that tendon “stiffness” increases significantly with load greater than 70% of MVC (maximal voluntary contraction); Maffiuletti et al. demonstrated that employing explosive-type resistance exercise or non-explosive albeit heavy training loads (≥75% di 1RM) is highly effective in eliciting marked gains in RFD (rate of force development); Rio et. al  displayed that isometric contractions performed with specific loads, repetitions and sets reduce cortical inhibitions in subjects with patellar tendinopathy.
And what about pain? Although long lasting tissue changes require periods varying from weeks to months , the acute (i.e. immediate) effect of exercise has been documented in several systematic reviews and meta-analysis . Other researchers have instead investigated the effect of different exercise regimes and modalities in disorders where the exercise-induced endogenous analgesia is dysfunctional . The conclusion is however the same: the exercise with the appropriate load, frequency and recovery time has got a beneficial effect on the patient, if the latter has been correctly examined.
Does this mean that a purely mechanical approach is sufficient? No! The scientific literature has repeatedly shown that a positive interaction , a good explanation  and a person-tailored exposure to exercise  have the ability to create an “expectancy violation”, that is a positive mismatch between expectancy and positive experience, thus enhancing the extinction of associatively learned pain memory . For those who may struggle to understand what I am referring to here is a simple practical example:
Mr Brown presents with chronic Achilles tendinopathy. Mr Brown has been advised to reduce the daily load and has been prescribed some passive treatments to cure his tendon. Mr Brown consider this to be a likely plausible solution for his problem. His Physiotherapist, instead, asks Mr Brown to perform heavy isometric exercises after having briefly illustrated how a tendon can be compared to a spring. Springs love load! Mr Brown obtains a sudden decrease of his symptoms which is in disagreement with previous expectations. This “expectancy violation” , together with immediate positive results, hence fosters a better compliance and adherence to the programme prescribed by his Physiotherapist.
The same principle can be applied to all persistent musculoskeletal disorders. This requires a deep understanding of the “maladaptive features” of the disorder, a simple and comprehensible explanation, technical competencies regarding exercise and load prescription as well as a careful assessment of the patient’s biopsychosocial profile.
In conclusion, it appears that the new horizons are linking Neuroscience with Mechanotherapy: this recently explored bond has the potentials not only to improve clinical outcomes but also to foster self -efficacy, active coping strategies and a healthy lifestyle.
Are we all going to apply these principles for our patients’ health and well-being?
- Lupyan, G. and A. Clark, Words and the World: Predictive Coding and the Language-Perception-Cognition Interface. Current Directions in Psychological Science, 2015. 24(4): p. 279-284.
- Barker, K.L., M. Reid, and C.J. Minns Lowe, Divided by a lack of common language? A qualitative study exploring the use of language by health professionals treating back pain. BMC Musculoskelet Disord, 2009. 10: p. 123.
- Rio, E., et al., Tendon neuroplastic training: changing the way we think about tendon rehabilitation: a narrative review. 2016. 50(4): p. 209-15.
- O’Sullivan, P.B., et al., The relationship beween posture and back muscle endurance in industrial workers with flexion-related low back pain. Man Ther, 2006. 11(4): p. 264-71.
- Andersen, L.L., et al., Effect of contrasting physical exercise interventions on rapid force capacity of chronically painful muscles. J Appl Physiol (1985), 2009. 107(5): p. 1413-9.
- Karayannis, N.V., et al., Fear of Movement Is Related to Trunk Stiffness in Low Back Pain. PLoS One, 2013. 8(6): p. e67779.
- Dankaerts, W., et al., Discriminating healthy controls and two clinical subgroups of nonspecific chronic low back pain patients using trunk muscle activation and lumbosacral kinematics of postures and movements: a statistical classification model. Spine (Phila Pa 1976), 2009. 34(15): p. 1610-8.
- Cook, J.L. and S.I. Docking, “Rehabilitation will increase the ‘capacity’ of your …insert musculoskeletal tissue here….” Defining ’tissue capacity’: a core concept for clinicians. Br J Sports Med, 2015. 49(23): p. 1484-5.
- Khan, K.M. and A. Scott, Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair. British Journal of Sports Medicine, 2009. 43(4): p. 247-252.
- Bohm, S., F. Mersmann, and A. Arampatzis, Human tendon adaptation in response to mechanical loading: a systematic review and meta-analysis of exercise intervention studies on healthy adults. Sports Medicine – Open, 2015. 1(1): p. 7.
- Maffiuletti, N.A., et al., Rate of force development: physiological and methodological considerations. Eur J Appl Physiol, 2016. 116(6): p. 1091-116.
- Rio, E., et al., Isometric Contractions Are More Analgesic Than Isotonic Contractions for Patellar Tendon Pain: An In-Season Randomized Clinical Trial. Clin J Sport Med, 2016.
- Naugle, K.M., R.B. Fillingim, and J.L. Riley Iii, A Meta-Analytic Review of the Hypoalgesic Effects of Exercise. The Journal of Pain, 2012. 13(12): p. 1139-1150.
- Daenen, L., et al., Exercise, not to exercise, or how to exercise in patients with chronic pain? Applying science to practice. Clin J Pain, 2015. 31(2): p. 108-14.
- Ferreira, P.H., et al., The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain. Phys Ther, 2013. 93(4): p. 470-8.
- Louw, A., et al., The clinical application of teaching people about pain. Physiother Theory Pract, 2016. 32(5): p. 385-395.
- Craske, M.G., et al., Maximizing exposure therapy: an inhibitory learning approach. Behav Res Ther, 2014. 58: p. 10-23.
- Zusman, M., Associative memory for movement-evoked chronic back pain and its extinction with musculoskeletal physiotherapy. Physical Therapy Reviews, 2008. 13(1): p. 57-68.