Research4Physiotherapists

Saturday, 14 July 2018

The SELF managed exercise programme

A few years back I reported the design, development and evaluation of a SELF managed exercise programme for rotator cuff tendinopathy here, here and here. The programme was based on the work of others, including McKenzie & May, and evolved through learning from systematic reviews (here, here and here) and a whole bunch of other literature summarised in my PhD thesis here.

The SELF managed exercise programme involved prescribing just one exercise in relation to the most painful shoulder movement and progressed over a minimum of a 12-week period guided by the symptom response, i.e. exercise should be acceptable to the patient while doing the exercise, immediately after the exercise, and 24-hours later (no use of visual analogue scales and terms such as 3, 4 or 5/10 and no time frame, i.e. it's ok providing the symptoms settle within 24 to 48 hours etc).

The SELF managed exercise was prescribed in relation to what was described as a self-managed framework including helping the patient to understand their problem along the lines of; 'this is a problem with the muscles and tendons of your shoulder, they're lacking fitness, capacity, strength' (limitations of this explanation recognised but aiming to do no harm and provide an understanding that facilitates engagement with exercise). Time is spent in the clinic with the patient practising their exercise so they feel confident to do this independently (more on this later); exercise prescription is supported with an exercise diary and used as a basis to discuss exercise adherence in subsequent follow-up sessions; goals are set using the Patient Specific Functional Scale as a guide; questions are asked about when the patient will fit the single exercise in to their daily routine before a schedule for further follow-up appointments, if required, is agreed.

Recognising that many people with this type of shoulder pain complain of abduction related pain, abduction was used as an example to guide how the SELF managed exercise would be initially prescribed and progressed in previous reports. But, it seems this has been misinterpreted by some and the SELF managed exercise programme has been seen solely an abduction loading programme; it isn't.

The single exercise programme is initially directed towards the most painful or problematic shoulder movement which could be abduction but could also be reaching up to a shelf, bench pressing, serving at tennis, reaching behind etc etc. In the clinic, clues to the most painful or problematic shoulder movement will be gained while taking the history. In terms of the examination, this begins by asking the patient to demonstrate the shoulder movement that most provokes their problem - this is now termed the baseline functional test. Then, movements of the neck are examined to see if they have an effect on the shoulder pain or movement. If they do, and increase or decrease the pain, then it is probably sensible to spend some time exploring the neck a little more before undertaking further testing of the shoulder. If movements of the neck do not influence the shoulder, then the next step is to exclude shoulder pain with stiffness and a simple lateral rotation test is done for this purpose. To confirm the provisional diagnosis of 'rotator cuff tendinopathy' resistance is then applied to the baseline functional test in the pre-symptomatic range, e.g. inner-range flexion if reaching to a shelf is a problem, with the aim of reproducing the familiar shoulder pain. If this test is positive then the next stage of the examination is initiated which aims to identify the type and dose of exercise to be prescribed.

So, for example, if reaching forward to a shelf over 90 degrees is problematic then the movement is broken down and testing could begin with isometric flexion in a step-stance position (to mimic the functional movement as far as possible). The response to 3 sets of 10 isometric flexions is examined remembering that the symptom response should be acceptable during and after and this will vary between patients. If a pain response is not acceptable to the patient then quite simply you wouldn't provoke it. After 3 sets of 10 isometric flexions, if the symptom response is acceptable the next progression could be to isotonic inner-range flexion using theraband or a hand-weight. Again, the response to 3 sets of 10 repetitions is evaluated and if the response remains acceptable then the exercise is progressed further, for example to mid-range flexion with theraband. The aim is to commence an exercise programme that directly challenges the functional problem, so in this case the aim is to introduce loading at 90 degrees of flexion and beyond.

This process helps to identify the type of exercise; begin with the most painful or problematic movement and if loading of this is unacceptable then commence the training with a different movement and return to the most painful or problematic movement when the threat response has reduced sufficiently. This process also helps to identify the dose of exercise; 3 sets of 10 is used as a starting point for the assessment but does not need to be the exercise prescription in all cases. For some, 3 sets of 10 will result in an unacceptable response so a reduced number might be prescribed. For some their functional demand might require higher repetitions so the exercise prescription would reflect this. For some their functional demand might require sustained loading so the exercise prescription would reflect this. In the previous studies listed above, the exercise was prescribed twice per day. Interestingly we still don't know what the optimal frequency is but I think prescribing a programme of this nature and doing it on most days could be a useful starting point.

One clear advantage of going through this process in the clinic is that the patient develops confidence to exercise and has a clear understanding of how to do this but also they are learning how to progress and regress their exercise. So if they want to push on they can begin to understand the principles but equally if the symptom response becomes unacceptable then they know how to regress their exercise, so hopefully enhancing self-efficacy and reducing reliance on the physiotherapist.

The exercise would be progressed over a minimum of a 12-week period based on the symptom response, and using acceptability as the guide. Patients should not begin the 12-week programme with one exercise and end doing the same exercise; progress is expected.

Consider another example; the patient who complains of pain when serving at tennis. The tennis serve could be broken down and testing could begin with isometric medial rotation with the arm by the side. Then progressed to isotonic medial rotation but still with the arm by the side. Then isotonic medial rotation with the arm in 30 degrees of abduction etc etc. Progress is based on acceptable symptom response with the aim of retraining in the zone which is most problematic. This could commence on day one or might take a number of weeks to achieve through the various progressions.

I hope this adds some clarity; no detailed recipes just some guiding principles.

As I mentioned in a previous blog here, there were methodological limitations with the SELF study which means it is not safe to conclude that this approach is better or worse than other approaches at the moment. However, it is an approach that has been developed using existing evidence and is theoretically informed but further evaluation through high-quality, adequately powered randomised controlled trials comparing against other exercise programmes and/ or wait-and-see approaches might be worthwhile to help develop our understanding.

Thanks for making it this far...
Chris

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