Providing Self-Efficacy: The key to appropriate exercise selection

A patient arrives at my office.  She is about 20 minutes early and appears a little uncomfortable as I come up where she sits in the lobby.   She is clearly in pain as she stands and follows me back to my office.

We go through the usual pleasantries and talk about how she heard of our small place, what keeps her busy, and how her morning has been. She starts to move uncomfortably again while sitting, constantly repositioning one way then another.

I ask what brings her in.

She quickly answers with “it’s my back.”

She has seen numerous people ranging from chiropractic care and physical therapy to more recently consultations with neuro surgeons.  To her, it is a hopeless case. At least 4 medical professionals have cautioned her to limit her activity and to avoid any unnecessary sitting or standing or movement.

There is an MRI report detailing a significant lumbar pathology.  “It is clearly pressing on a nerve.”

I ask if she has numbness, tingling, muscle weakness or issues with going to the bathroom.  She says no.  With more talking, is was clear she had no idea why the hell her back hurts when she is otherwise healthy.  She was even seeing the most highly recommended people for her issues with minimal improvement.

When I first started to practice, this would lead into an exam where I tried to pin down what is hurting, then manual therapy to reduce pain, followed by exercises to target sensorimotor control, then progress until the patient returned to full health.

The results were good if a little long to achieve.

With practice and reflection, I grew my initial discussion delved more into the processes of the other professionals before me.

Its a key question – “have any of your medical professionals given you a way to manage pain?”

And then a follow up, “do you feel like you can manage your pain?”

I have yet to see a patient in this situation that answers with a yes (which is why they are in my office).

When I hear her say no, my entire focus of the session is to clearly identify why she has pain and how she can reduce it by HERSELF.

In this example, she had discogenic low back pain. It was exacerbated by sitting and transitioning. Transitional positions seem easy, but with pain and lack of clear cause, moving from lying down to standing, or standing to sitting, or sitting to standing can be a nightmare.

She learned a technique, volitional preemptive abdominal contraction, to reduce pain while moving combined with better recovery postures during the day.

A week later, her entire demeanor had changed because she was no longer afraid of her pain. She knew that if she did an activity and now her back felt worse, she had tools to make it go away.  This is the power of self-efficacy and it is the best tool in pain management.