There are ongoing debates in the musculoskeletal health care world concerning what type of rehabilitative exercise is the most effective for particular injuries or conditions. After all the research is combed through, there is often no clear-cut answer. That being said, if you zoom out and take in the totality of the evidence it does appear that perhaps one type might outperform all others.
Let’s start to unpack this by looking at exercise options for tendinopathy.
Best Paper of 2021?
In what could be one of the best papers of 2021*, Tendinopathy (Millar et al.), the authors confirm that
exercise regimens, referred to as tendon loading programs, remain the most effective conservative
approach in the treatment of tendinopathy.
*Honourable mention for best paper of 2021 to Beliefs about the body and pain: the critical role in
musculoskeletal pain management (Caneiro et al.).
They go on to explore all the evidence surrounding different types of tendon loading and which may
produce superior results. In the 1990’s eccentric loading was considered the first-choice but much more
evidence has since been produced to show that mixed contraction (concentric + eccentric) types of
exercise provide benefit in the treatment of tendinopathy.
These authors, some of the world’s most prominent clinicians and researchers in the tendinopathy field,
go on to state that, “…the decision as to which is the best tendon loading programme to prescribe
should be an individual decision made between the prescribing health-care professional and the
patient.” This shared decision-making process is also a key component of Evidence-Based Practice and
Person-Centred Care, two foundational principles of modern musculoskeletal health care.
The authors go on to state, “Engaging with patients and presenting treatment options will enhance and
optimize adherence to the selected programme, and this practice may play a large role in the success or
failure of the prescribed loading programme.”
“The optimal program might simply be the one the patient is most likely to perform.” (Millar et al., 2021)
So, after millions of dollars and years of research the most evidence-based and modern advice for
treatment of tendinopathy is prescribing tendon loading that the person will actually perform.
Which leads us to the completion of the teaser title of this blog…
The best exercises are…THE ONES THAT GET DONE.
The same trend can be seen in the evidence base for other musculoskeletal conditions. One such
example is low back pain (LBP), the leading cause of disability worldwide and thus, one of the most
common things that you will see in private clinical practice.
Despite common narratives and practices, the evidence shows that many different types of exercise can
have positive effects on LBP.
Considering that all types of exercise seem to produce positive effects for LBP and are relatively equal in
the long term, my suggestion would be to settle on exercises that the person is going to perform.
The Adherence Challenge
Even though exercise and movement are recommended for the rehabilitation of and recovery from
many musculoskeletal conditions like LBP, Tendinopathy, and OA, it is often very difficult to have people
consistently perform their prescribed exercises.
This also applies when advising changes to activities of daily living (ADLs). It is very challenging for
people to incorporate new things into their lives or change long-term habits even if they are told said
changes will most likely benefit their quality of life!
Strategies To Increase Adherence
- Person-Centred Care → Involve the person in the choosing of the exercise, movement or activity that is to be performed.
- Meaningful Activity → If possible, prescribe meaningful activities that they love.
- Less Is More → 2 exercise that get done are better than 6 that don’t get done. You can always add more later.
- Keep It Simple → If the active management plan and/or the exercises themselves are too complex it can seem daunting and deter people from engaging with it.
- Let people know that they will not have to perform the exercises forever. Some people shy away from doing active rehab because they think they must do it indefinitely or their pain will come back.
- Prescribe exercises that match the person’s life. This could be available time, access to equipment and monetary means.
Practical Tips For The Clinic
- SODOTO → See one, do one, teach one. Demonstrate each exercise, have them perform it and
then have them teach it to you.
o Advise them to perform the exercise a few more times that day without any loads so
that they can ‘cement it’ into their brains.
- ‘Write’ all Rx details down. This would include Frequency, Intensity, Volume and the Exercise
name itself. You can write these on paper, email them, use a digital exercise program like Rehab
- Have the person record a video of you doing the exercise.
There are many reasons that it is so challenging to get people to perform exercise and movement or
make changes to their activities of daily living (ADLs).
Newton’s first law of motion is one hurdle we face from a physics standpoint:
- An object in motion tends to stay in motion and an object at rest tends to stay at rest.
Then there is our incredible ability to disregard common knowledge regarding health and wellness and
do things that are unhealthy for us, or not do things that are healthy for us.
Look at our behaviors around exercise in general. We know, without any doubt, that exercise is
beneficial to humans in many ways, yet these are the behavioral statistics are observed in the Canadian
- Only 16% of Canadian adults are performing the recommended amount of weekly exercise.
Sometimes it is our own fault as health care practitioners. We don’t even give people the chance
because we don’t prescribe exercise, movement or a change to their current way of doing things. We
choose to try and ‘fix’ people solely with our passive modalities.
These are but a few of the challenges we face, but Newton’s first law also gives us hope, “an object in
motion, tends to stay in motion.”
Perhaps one of the best things we can do as MSK practitioners is to get people moving and help them to
keep moving?! This is one of my primary goals in my practice as there are just so many primary and
secondary health benefits to movement.
I hope that this blog helps to decrease some pressure on you. Pressure that you may be feeling to
prescribe the ‘right’ exercise at the ‘right’ intensity and volume with the ‘right’ biomechanics (don’t get
me started on this, it deserves a blog or blogs all to itself). The evidence base seems to show that
perhaps the most important component to an exercise’s effectiveness in producing positive results for
the people you are working with, is if it is getting done!
To that vein, we also covered some practical tips that should help to increase buy-in from people and
result in them performing the exercises, movements or changes to activities of daily living (ADLs) that
you prescribed. I hope that you can incorporate some of them into your practice in order to help people
get moving and keep moving!!!
Caneiro, J., Bunzli, S., & O’Sullivan P. Beliefs about the body and pain: the critical role in musculoskeletal
pain management. Braz J Phys Ther., 25(1):17-29. doi: 10.1016/j.bjpt.2020.06.003.
Millar, N. L., Silbernagel, K. G., Thorborg, K., Kirwan, P. D., Galatz, L. M., Abrams, G. D., Murrell, G.,
McInnes, I. B., & Rodeo, S. A. (2021). Tendinopathy. Nature reviews. Disease primers, 7(1), 1.
Shnayderman, I., & Katz-Leurer, M. (2013). An aerobic walking programme versus muscle strengthening
programme for chronic low back pain: a randomized controlled trial. Clinical Rehabilitation, 27(3),
Smith, B. E., Littlewood, C., & May, S. (2014). An update of stabilisation exercises for low back pain: A
systematic review with meta-analysis. BMC musculoskeletal disorders, 15, 416.