It is not all about strength! Rethinking the role of exercise for musculokeletal pain relief with Dr. Jared Powell. EP#585

Welcome to another episode of the BGSM podcast.

My name is Joe Gugomis and I'm a PhD candidate here at Latrobe University in Australia.

And today we are discussing a recent publication in BGSM that is titled, It's Not All About

Strength.

We're thinking mechanistic assumptions in exercise-based rehabilitation for musculoskeletal pain relief.

So today I'm joined by the lead author of this paper, Dr. Jared Powell.

And Jared is a physiotherapist, researcher and educator specializing in shoulder and musculoskeletal pain.

He's also the founder of shoulder-fees of education where he delivers courses and mentorship to clinicians all around the world.

And also runs a telehealth practice specializing in shoulder pain.

His research is pretty diverse.

He works with research groups throughout the world on Rotator cuff related shoulder pain and also frozen shoulder.

And in his own time he likes to write taught provoking editors like this one.

There we're going to discuss today, right, Jared?

So thank you so much for accepting our invite and welcome to the BGSM podcast.

Thank you. It's a pleasure to be here and I'm really looking forward to talking about this because it's a favorite topic of mine.

Yeah, beautiful.

So first of all, congratulations on this amazing piece of work.

And my first question is the reason behind this editor.

So why did you and your co-alters on this side to write about the topic?

And what is the motivation behind this editor?

So this paper is really the culmination of like an eight year Odyssey or adventure in exploring the mechanisms of exercise.

So specifically my PhD was on the mechanisms of exercise for shoulder pain or rotator cuff related shoulder pain.

More specifically.

And so I wrote a similar paper to this one five or six years ago about the mechanisms of exercise for shoulder pain.

And then I finished my PhD a couple of years ago.

And then I started to think that actually I think, you know, the incorrect understanding that we have about the mechanisms of exercise for shoulder pain is actually more broad across across muscular skeletal conditions in general.

So I started looking at the evidence around knee osteoarthritis around patellar femoral pain syndrome around Achilles endopathy around patellar to the nopathy, so on and so forth.

And I noticed it's pretty much the same thing that mechanisms of exercise for broad spectrum musculoskeletal conditions is pretty uncertain.

We don't really know why exercise works.

We don't know who it might work for.

We've got some hypotheses, of course, and I think we're on the right path towards understanding it.

But it's all pretty unclear.

So I thought bringing together all this information that I've been researching over the last nearly decade and putting it into a nice little editorial to summarize the land was a good idea.

And I think it might be helpful for many clinicians.

Yeah, beautiful.

And when I saw your editorial, I thought the same thing because here in La Trobe, we work a lot with patients with our syndrome,

we have a little pain, we've done some trials and results seem to be similar and seem to things are seem to be repeating itself across this musculoskeletal conditions.

So that's why the editor is so interesting.

And I think it's part a lot of discussions like in social media and different platforms.

So that's really cool.

And I think a key takeaway from the editorial, at least like from from me is that patients with chronicle musculoskeletal conditions,

they're going to experience improvements in pain with exercise, but not necessarily because they get stronger, right?

So we were talking about the mechanism.

So why do you think they're improvement?

What are the possible mechanisms behind this treatment effect?

Yeah, so this is the million dollar question.

So like I want to make it very clear at the start that I think exercise is a good thing for people with musculoskeletal pain.

So much of the reaction around this paper has been straw mening the argument and saying,

I don't want people to exercise and it could have been further from the truth.

So I want to get that on record straight away.

Exercise is good.

What I'm interested in in this paper is how and why doesn't work?

Okay, I'm pretty happy that it does work.

That's a first order question, but I want to move beyond that first order question to a second order question,

which is wondering why and how things work.

That's the mechanisms where so we're looking for causal explanations,

because I think in order to understand something and to make it work most efficiently,

we need to go beyond, doesn't work to help work.

So this is the whole point of this paper.

So the short answer to that question is I don't really know how exercise works,

but I think we're sort of directly on the right path.

I'd break the mechanisms down into three broad categories.

We've got biomechanical mechanisms, we've got psychological mechanisms,

and we've got, I think, physiological mechanisms.

So biomechanical, psychological and physiological.

On the biomechanical side, we don't really have a ton of evidence

that biomechanical variables explain improvements in pain.

So strength is just one example of these biomechanical mechanisms

that our profession is really built on.

You know, like our profession is built on changing biomechanical variables,

which are then assumed to be associated with a change in pain.

And we've only really just started testing this over the last 10 to 15 years

with proper statistical methods like mediation analysis.

We do have a little bit of evidence from osteoarthritis

that strength changes may explain a small fraction of overall improvement in knee pain,

but most of it is probably related or explained by other variables.

Psychological variables appear to be promising.

When we look at mediation data analysis, things like pain self-efficacy,

pain catastrophizing, kinesiophobia, often come up as valid mechanisms of recovery.

And this seems to hold regardless of the type of exercise intervention.

So strength training, motor control training, whatever you want to do,

these are the psychological mechanisms that appear to hold

irrespective of the exercise intervention that you want to give to your patient.

And then there are physiological variables.

And I think this is a really promising area of research actually.

So does exercise change our local and systemic physiological environment

in a way that is helpful for reducing pain?

I think so, where we're in the process of more rigorously researching this at the moment.

We don't have any strong causal evidence for it, but it's plausible.

It makes mechanistic sense.

I think that exercise may make us more healthy

and does making us more healthy change our pain.

And I think that's really valid hypothesis.

So in summary, there's biomechanical, physiological and psychological reasons

that probably explain the vast majority of pain reduction that we see through exercise.

And I think it's also important to note that these mechanisms are probably context-dependent

and may be unique to each individual.

And they may even interact with each other to produce an aggregate,

helpful or detrimental effect.

So even though we only might see a very small change in pain self-efficacy,

that small change in pain self-efficacy or confidence to move may actually add up

to produce this really strong effect in a reduction of pain.

And the same thing may even go for strength or for whatever other variable

we're researching.

So unfortunately, or unfortunately, pain is a really complex area of human beings,

very complex organisms.

And so I don't think we're ever going to arrive at one simple answer

that explains why exercise is important for every single individual.

But I think we're on the right path towards understanding it.

And we're certainly far more advanced than we were five to ten years ago

when we were barely thinking about these things.

Yeah, exactly, it's not a simple answer right to deliver.

Yeah, and I think it's complex as you said.

And to help you to support your sentence that you said

that you're not against exercise-based treatments

and some people may think of that because what they saw in the tutorial.

So I separated here one of the sentences of the tutorial that I really enjoyed.

So this is going to help you probably too.

And this says that the sentence from the editor says

that clinicians should absolutely continue to champion exercise.

But with a updated narrative, one that highlights strength gains

as a marker of improved physical robustness and health,

rather than a prerequisite for being pain-free.

So regarding this sentence, my first question is,

why do you think it's important for patients to understand this?

And if you think that's, it's important.

For example, that pain improvements often don't happen simply

because they get stronger.

And how would you phrase this for a patient?

So what are you saying clinical practice?

What words do you use with your patients to help them to understand this message?

And also maintaining them engaged with this exercise

and strength-based interventions.

Yeah, so I think it's very important that we

be open, honest, and transparent with patients about what we know

and what we don't know.

And I think this is about being intellectually humble

and practicing with humility and not pretending

that we have all the answers.

So this is why I think we should be honest

about really what we don't know specifically

about how exercise works.

And I tend to tell patients that exercise

is an evidence-based treatment for helping

various musculoskeletal conditions.

It works.

It's accessible.

It's cost-effective.

It's generally responsible in its use of resources,

especially when we compare it to injections and imaging and surgery.

It's good for the environment.

And it is clinically effective as well.

It does help people.

It's certainly not a panacea.

It's not a miracle.

It doesn't take your pain from seven out of 10

to zero out of 10 into weeks, nothing does.

So I tend to tell people that exercise works.

It's a good thing we should do.

Exercise and general movement therapy can be used

in many ways to help your pain.

It can change your thoughts.

It can change your feelings.

It can change your beliefs about your body and how it may work.

It can promote various positive, systemic,

and general health changes.

It can get you back to doing the things that you love.

And I think this is how we need to re-frame.

Exercise, we don't need to just reduce all of the complexity of it

to, hey, let's get you strong.

And that's going to be the reason that you get better.

I think there's a lot more nuance there

that we need to pass on to patients.

Because I also think it's quite constraining.

If somebody comes in and they don't really have a good relationship

with exercise or the gym, and we say, hey,

you must get strong in order to get better,

you're marginalizing that person straight away.

So in order to reduce that constraint,

we're liberating clinicians and patients by saying,

hey, there's many ways in which we can help your pain

with exercise here.

It's not just about getting strong.

Maybe we could just go for a walk for 30 minutes a day,

every other day of the week.

Maybe that might even help your shoulder pain.

The shoulder pain is related to metabolic syndrome

that does seem to be a broad general health issue there.

So maybe just generally exercising can be helpful.

So we don't need to limit clinicians and patients

to this oversimplified narrative or heuristic or slogan

that you just have to get strong to get better.

So that's where I think the real value of exercising is.

It's because it's so context-dependent.

It's individualized.

Getting moving is such a positive thing to do.

And another thing is that I really

have exercised for exploring movement,

exploring how the body feels with certain loads, directions

and speeds.

It can actually be a really great way

to interrogate how the body feels.

And also that information that is then sort of fed back

or presented to the patient, that information

can then be used by themselves to perhaps update their beliefs

or their perception about their body.

Because many people come in, they

feel like they're broken, they're fragile,

they can't lift away or they can't move

because it's going to cause some sort of injury.

Perhaps they've read something on the internet.

Exercise and movement is such a powerful tool,

in my opinion, that can really challenge

and update some of those beliefs.

And that's where I think strength training

can be really helpful as well.

Actually just exposing somebody to a load

that gets them to interrogate or scrutinize their own,

but perhaps erroneous beliefs.

So I'm not against strength training.

It's actually like, I give strength training

and resistance exercise to almost 100% of my patients.

I'm just not under the illusion that them getting stronger

is changing their pain.

I'm aware of the complexity that surrounds

that whole interaction.

Yeah, beautiful.

And that's a great answer.

And I think having different options of exercise,

it's only good for us as physios

and also for the patient, especially thinking now

that we have research showing that patient's preferences,

all of the exercise are important for rehabilitation,

patient's expectations,

so how they feel about a certain intervention

or a certain certain type of exercise.

So I think this only give us the ability

to have more flexibility in the rehabilitation

and adapting to the context, as you said before.

So yeah, really, really great take away.

So now talking more about on a research perspective,

so we have several studies clinical trials

showing that exercise, as we are talking here,

is effective for many musculoskeletic conditions.

But at the same time, we know that some patients,

they do not respond well to exercise

or strength-based treatments.

So for this specific profile of patient, for this patients,

are there different types of conservative treatments

that we should be testing in clinical trials,

things that may be using your clinical practice

or you're looking forward to explore your research?

And for example, if you have the designer trial

for this specific group of patients that do not respond well

to exercise-based interventions,

but still wanting to provide something conservative

to these patients, what that might look like.

And this is a really good question.

So exercise will help maybe 60, 70% of people,

and those people would typically have,

like without being too reductionist here,

a very typical and no-seaseptive type sort of pain presentations.

The non-responders to exercise in my experience

are often those with a more no-seep plastic type pain presentation.

They also may have numerous comorbidities as well.

So I don't know if this is class,

there's a conservative intervention or not,

but I think the rise of GLP-1 medications

are going to be interesting.

We know that there's already pretty good evidence

that GLP-1 medications work politely

for knee osteoarthritis pain.

I think it's only a matter of time

before these medications start getting tested

in other conditions that are associated

with metabolic syndrome and metabolic markers as well.

Every single non-traumatic musculoskeletal condition

seems to be associated with metabolic syndrome

or metabolic issues as well.

So I think that's going to be tested.

It's also, I broadly think for these people

that like some sort of pharmacological breakthrough

is going to be the answer or the solution,

maybe not the solution,

but it's going to advance the field.

If you listen to some people,

they think that we're on the cutting edge

or on the edge of a breakthrough

in terms of various medications that can dampen

the an overactive,

no-seceptive upper apparatus

that might be constantly firing in individuals

due to some sort of dysfunction in their nervous system.

And some people seem to believe

that we're on the edge of the breakthrough there.

I'm not so sure.

I think the whole,

the experience of pain is far more involved

and complex than a simple input from our nervous system.

But perhaps it's worth treating

and perhaps it's worth taking seriously.

I do tend to think that.

And then I don't know,

like if we look at non-specific low back pain,

there's a lot of emerging evidence

for cognitive functional therapy,

pain reprocessing therapy

and all these types of interventions.

That seems very promising

that they're associated with pretty good effect sizes

that seems to be sustained over many years.

In terms of being better than usual care

and that's the cognitive functional therapy trial

led by Peter Kent and Peter O'Sullivan.

So there seems to be something there.

We don't really have any evidence

for beyond the lumbar spine as far as I'm aware.

But I don't see why we shouldn't be testing it

in non-specific shoulder pain

or non-specific knee pain or other areas of the body as well.

So I think we've got a ton of research to do there as well.

So I think it's really promising.

We are really at the frontier of this.

We've got a long way to go towards understanding it.

And I'm excited about what the next 10 to 20 years holds,

especially with the rise of AI and large language models.

And are we gonna come up with some sort of breakthrough?

I don't know.

I think it's exciting.

I'm a little bit cynical about it

because I think pain is such a personal,

subjective and complex experience shaped by culture

and social determinants of health and individual beliefs

that perhaps expecting a cure for all

is a little bit naive and reductionist.

But anyway, I'm excited to see what it holds

over the next couple of decades.

Yeah, amazing.

We have some exciting future research.

And if we have some researchers,

PhD students listen to its podcasts,

here we have some great PhD projects ideas.

So absolutely.

Just go for it.

Still talking about studies on the effect of treatment

and you mentioned this.

Today, we have some other studies showing that,

for example, with people with hiposteratitis,

kneeosteratitis, the effects of exercise,

their modest, right?

So it's not a big treatment effect.

And because of that,

some people say that maybe offering

this kind of intervention for these patients

can be a waste of resources.

So what do you thought on this,

like how you feel about the balance,

about implementing this exercise,

offering this to patients when we have modest treatment effects?

So what do you think about it?

Yeah, it's a really good question.

And exercise has rightly come under

a little bit of scrutiny recently.

And I think it deserves to be scrutinized.

Often, exercise has been held up on a pedestal

that means you can't challenge it.

Because it's exercise and our profession,

physical therapy is built upon exercise and physical movement.

So for a long time, I just received a pass mark

that it was above and beyond scrutiny.

And I think that's wrong.

I think we need to scrutinize it.

But having said that,

I definitely don't think that it's a waste of resources.

Every treatment that we have basically

for musculoskeletal pain,

especially non-traumatic musculoskeletal pain,

has modest treatment effects.

And so it depends on what we're studying.

If we're looking at severe hip osteoarthritis versus exercise,

and we compare,

sorry, if we're looking at severe hip osteoarthritis

and we compare exercise to hip replacement, for example,

hip replacement is far better there.

But in 25% of people that exercise may still be helpful

and it may ward off a hip replacement

for many years down the line.

So exercise in that use point is still quite valuable

because it's kicking the can down the line a little bit

and it's giving people an extra five years

of good quality of life before needing to undergo surgery.

And having said that,

if we're just comparing exercise with surgery

for shoulder pain, specifically rotating cuff tears,

we know that 75% of individuals

who undergo a three month exercise program

don't go on to have surgery for the next 10 years

for their rotating cuff tear.

So that's huge impact on economic spending

in terms of the whole socioeconomic impact

of muscular skeletal pain.

So if simply just doing a three month exercise program

can prevent people from getting surgery for the next decade,

that's huge.

And if we're just gonna throw that away,

and I think that's fraught with danger.

So I did mention earlier as well

that exercise is clinically effective.

It's cost effective.

It's responsible in its use of resources.

It's accessible.

You can give it to somebody to do in their own home.

You can give it to them over the internet

in a telehealth appointment

that don't need to travel to see you.

There are so many positives for exercise

above and beyond its simple effect size.

And so this is really an important point

because exercise outperforms almost all other comparators

when we compare it to the full criteria

of effectiveness, cost effectiveness, accessibility,

responsible in its use of resources, et cetera, et cetera.

So I still am a huge fan of exercise.

It should be the starting point

for most nonchalomatic muscular skeletal conditions.

If you try it for three months, six months,

even a year, and you're not getting better,

then we can absolutely start to investigate

some alternative conditions.

However, I just wanna reiterate,

if you come to me with advanced and staying

just the arthritis of the knee of the hip,

a joint arthroplasticity is probably a very good treatment there.

If you come to me with like leg weakness

due to some sort of sciatic presentation,

you probably need to go and get that sort of

rather than just doing planks.

So there are always nuances that we need to consider here.

We shouldn't just say,

let's always try exercise.

Think about the condition, think about the patient,

think about the prognosis

but they likely to just improve over time, et cetera, et cetera.

There's a lot to think about

rather than just saying exercise works.

Just do it, three sets of 10, just load it,

can't go wrong getting strong

or whatever slogan that we wanna show out there.

So that's all I'm advocating for, think about it,

and I really don't think it's too controversial

when we think about it.

Yeah.

Yeah, as you said before,

like depends on the context,

but in the majority of situations and contexts,

probably it's not going to be a waste of resources.

Great, so this is great,

but we're running out of time.

And so my last question to you

is if you had to leave one key takeaway message

for all the clinicians,

physios, listen us today,

that treat patients with chronic muscular conditions,

what would that be?

What would you say to them?

Exercise is a valuable intervention.

Do it, give it to your patients,

don't stop doing it.

It compares favorably to surgical interventions,

injection therapy, it costs less,

and is less invasive.

It also helps general health,

if done well, and for long enough,

exercise is great,

and we should continue to use it in our practice.

I only caution against overly simplistic causal explanations

of how exercise has its effect,

getting stronger, fixing posture,

improving soft tissue length,

or whatever else we wanna say.

These are reductive explanations

with no real evidence to support them.

So we should treat our patients with respect,

and tell them what we know,

and what we don't know.

We shouldn't lie to them.

We should be open, honest, and transparent.

That's my key takeaway from this paper.

Amazing, love it.

I think after today,

no one can say that you're against exercise

or exercise-based interventions.

Jared, thank you so much for your insights today.

Learned a lot from you.

Learned a lot from you.

It's our really amazing work.

And thank you for accepting your invite

and joining us today.

Thank you for having me.

It's been really fun.

Amazing.

So to our listeners,

thank you for joining us for another episode

of the BGSM Podcast.

Feel free to connect with us across all the BGSM

social media platforms, read Jared's editorial,

and see you next time.

Thanks for joining us today.