Accredited Exercise Physiologists (or AEPs) are allied health professionals with a minimum of 4 years tertiary training in exercise prescription for chronic conditions. They work in the private and public sector and are recognised by Medicare, NDIS, Veterans’ Affairs and health funds. Accredited Exercise Physiologists prescribe exercise and deliver education specific to each individual, with an emphasis on self-management and positive behavioural change.
There has been an increasing interest in exercise as medicine (see Exercise is Medicine). This is based on considerable research showing exercise improves physical and psychological wellbeing in a broad range of chronic conditions. Exercise is a primary treatment modality for chronic musculoskeletal pain and can improve pain, function and quality of life.
Chronic musculoskeletal pain refers to ongoing pain felt in the bones, joints and tissues of the body that persists longer than 3 months. While back, neck pain and osteoarthritis are the most prevalent, lesser known conditions include fibromyalgia and rheumatoid arthritis. Musculoskeletal conditions are the leading cause of years lost to disability worldwide, with around 7 million Australians reporting a musculoskeletal condition in 2017.
Low back pain is the most prevalent musculoskeletal condition and around 50-60% of people experience symptoms for longer than 3 months, defined as chronic low back pain (CLBP). Exercise is the first line treatment for CLBP, which is frequently treated by Accredited Exercise Physiologists. This case study provides insight into an Accredited Exercise Physiologist’s treatment of CLBP.
Sam, a 38-year-old male, was referred by his GP to an Accredited Exercise Physiologist after 12 months of non-specific chronic low back pain (CLBP). Non-specific refers to back pain where no known cause can be identified and accounts for around 90% of CLBP. Sam is otherwise healthy. He works as a firefighter and self-employed carpenter. He lives with his wife and two children and is a habitual exerciser.
Sam experienced constant low-level back pain which worsened with trunk movements, in particular forward bending. He avoided trunk movements and maintained his back in a fixed upright position. Sam continued with a gym program but limited this to upper body exercise for fear of increased pain/further injury. He is a passionate surfer but had stopped surfing because it increased his back pain. Sam hadn’t missed any work through injury; however he was very careful and attentive to his symptoms during physical activity. He was anxious about the possibility of longer-term pain and the impact this might have had on his work and daily life. He strongly believed that he needed an MRI to identify the injured area in his spine. Sam had seen multiple therapists who provided conflicting advice. His mood was often depressed and his social interaction, which was largely related to surfing, had reduced.
Treatment with the Accredited Exercise Physiologist commenced with a detailed 60 minute initial assessment to identify the physical and psychosocial factors contributing to Sam’s difficulties. These factors were targeted during a 6-week combined exercise and education intervention involving self-managed and supervised exercise.
Exercise prescription was informed by Sam’s personal goals and exercise preferences. He commenced a general exercise program involving strengthening and walking exercise, which was paced up during treatment. Sam was frequently reassured that it was safe to exercise with manageable/tolerable levels of pain as he had lost the ability to move his spine. Retraining and restoring his trunk movements and confidence commenced with watching and visualising trunk movements. This progressed to gentle lumbar movements in lying that became more demanding prior to commencing trunk movements in standing. The Accredited Exercise Physiologist provided frequent demonstration and feedback including video. As his trunk range of motion improved, more complex and surf specific movements were introduced.
Targeted education by the Accredited Exercise Physiologist addressed: the unreliability of MRIs for identifying pain generators, and in Sam’s case, the lack of evidence of serious spinal pathology warranting an MRI; and the concept of pain as an output of the brain based on perceived threat as opposed to a marker of tissue damage. This education helped Sam to identify and reduce known threats (e.g. fear of movement; the belief that his spine is damaged; anxiety about longer term pain and disability; not being able to surf again; and over attentiveness to his symptoms).
The brain and nervous system become more protective the longer pain persists causing pain to increase and spread. Gradually becoming more active, resuming normal activity and learning about pain can help restore normal brain processing. The Accredited Exercise Physiologist utilised a variety of teaching modalities including discussion, social media, written handouts and worksheets including the Protectometer and other ‘Explain Pain’ resources (see NOI Group).
Treatment outcomes: Sam’s trunk movements were pain free and unrestricted after 6 weeks. He was mostly pain free with occasional low back discomfort he described as manageable. He resumed surfing 8 weeks after commencing treatment, which he was tolerating well. Developing Sam’s confidence with movement, reducing fear and anxiety, and helping Sam understand and make sense of his pain were key to the successful treatment outcomes.
Email from Sam to the Accredited Exercise Physiologist 4 months after completing treatment:
“My back’s coming along amazingly; had at least 20 surfs and although there’s discomfort at times it’s getting better. Wait ‘til you see how I can do the fold of my lower back now. Pretty much no pain out of the water and if I’m totally honest, I don’t think about back pain at all really now.”