Exercise medicine: train the brain and treat the body

This year’s ACPSEM symposium heard about advances in mindfulness, virtual reality and sleep strategies. 

From the traditional ‘load the tendon’ approach to exercising the brain to create psychological change, a theme of this year’s Association of Chartered Physiotherapists in Sport and Exercise Medicine autumn symposium was that physio practice needs to adapt.

The Sporting Mind event, at the Imperial War Museum in London, focused on the practical application of advances in neurophysiology, pain and exercise science. Specialist pain physiotherapist Richmond Stace warned that chronic pain was a ‘health pandemic’ affecting 28 million UK adults, including athletes. 

He called on physios to use motor imagery: ‘It’s awesome. There’s no magic or mystery to it. Just understand that the brain is a predictor, not a responder.’

He said it was important to prime the patient for treatment and exercise by using touch and by choosing empowering language. Mindfulness was important because ‘a wandering mind is an unhappy mind’.

Psychologist Cathy Craig said she wanted to persuade physios of the huge potential of virtual reality in rehabilitation. The technology has moved on rapidly and was great for testing athletes in real time while under pressure, she said. ‘It can be a tool to help players stay match sharp and return from injury without the risk of coming back too early.’

She added that using technology should not be confined to elite athletes as ‘even 80-year-olds can be competitive’.

Sleep

Another speaker, physiotherapist Michelle Biggins, described sleep’s essential role in recovery, health and performance. She said exercise is often recommended to improve sleep, yet studies suggest that 38-50 per cent of athletes have poor sleep, averaging between 5.4 and 7.9 hours a night when they need between eight and 10 hours. 

Ms Biggins said that gruelling training regimes, such as insisting swimmers are in the pool at 6am, were as unhelpful as overuse of caffeine. She criticised the lack of awareness of sleep strategies (in one study, 59 per cent of team athletes did not have one). A sleep diary can help, as can naps and ‘sleep banking’ in the run-up to competition.

She added that wearable technology, such as Fitbits, was not accurate enough for measuring sleep. ‘Tell people not to look at their watches but focus on how they felt their sleep was.’

She did not recommend a ‘nappuccino’, in which people drink coffee before a nap so they wake up alert. ‘It’s better to focus on teaching them to nap as they are probably getting enough caffeine anyway.’

Dr Adam Gledhill, lecturer at Leeds Beckett University, said he wanted to adapt Benjamin Franklin’s quote about prevention: ‘For me, an ounce of prevention is not as good as a pound of cure – it’s better.’

He called for more emphasis on the role of psychology in reducing sports injury and said it was not ‘pink and fluffy’ as some suggested.

Fitness anxiety

Adrian Mallows, lecturer at Essex University, said the closer an injured athlete gets to returning to sport, the greater the anxiety, with 40 per cent reporting fear. He described the ebb and flow of psychological responses throughout rehabilitation and urged physios to focus on this.

He quoted the example of Scott Baldwin, the Welsh rugby union international, who almost quit the sport following a foot injury, who said: ‘I was told I would have dark days, but probably didn’t understand how dark they could get.’

Mallows explained: ‘He expected to make solid progress between 12 or 16 weeks after the injury and was unprepared for setbacks along the way.’ A key message to take home was that adding psychological interventions to current physical rehabilitation programmes could help many more athletes return to sport successfully. 

Getting the language right

Physios need to mind their language when dealing with patients because words like ‘tear’ and ‘tendonitis’ frighten people and mean they won’t exercise with load.  Australian researcher and sports physiotherapist Ebonie Rio said the key was to ensure patients did not underload as it leads to lost capacity. ‘Use the term tendinopathy so your patients are on board with loading,’ she said. ‘Be careful with the word “tear” and avoid “degeneration”. And don’t let anyone get away with the term “tendonitis”… not your medical colleagues, not the patient and not your physio colleagues. If you use it, the patient won’t load.’

Ms Rio added: ‘We must get the message across that pathology does not equal pain. The body can adapt to pathology so you can reassure people they can load the tendon.’

Pain diaries were a pet hate as they made people focus on pain all the time. Better to ask patients to think about it once a day. ‘My other tip is “don’t poke the tendon” and stop other people poking it. But do you put your hands on patients? Of course you do.’

She said too many physios had the attitude ‘I need to fix you’ when it should be ‘I need to get your load right.’

‘I see people when they’ve tried everything else. But the only way we get to see improvement is through progressive load.’

She cited strong evidence that auditory stimulus lead to a change in the motor cortex and so she recommended patients use a metronome while exercising.

Her joint presenter, Jo Gibson, specialist physiotherapist at Liverpool Upper Limb Unit, part of the Royal Liverpool and Broadgreen University Hospitals Trust, told the symposium: ‘Let’s make our rehab as “brain rich” as possible.

‘Make exercise dynamic and sensory by using a yellow resistance band or a metronome and the results will be better. 

‘The brain needs to be interested or it switches off.’

She said studies suggested physiotherapy was as effective as surgery. But the greatest indicator of whether someone had surgery or not was patient expectation and whether they ‘believed in physiotherapy’. 

An operation meant that the patient was in pain for a shorter time but post-surgery, the chance of getting back to their previous level of performance was only 55 per cent. ‘So don’t operate,’ she said.

She urged physiotherapists to ‘go back to basics’. ‘We need to go back to the biology as we’ve swung too far towards the psychosocial … We are in a bit of chaos and we’re all looking for a magic bullet for the patient in front of us … but it doesn’t exist.’

Author : Janet Snell