It doesn’t matter if you come in with shoulder pain, knee pain, or back pain. I make all my pain clients exercise. I build a successful practice doing just that. Find out how a Singapore chiropractor is changing the local musculoskeletal pain industry.

It is difficult for my clients to explain to others what I do in practice. Yes, I am a chiropractor but no, I don’t offer chiropractic adjustment as a service. In fact, we offer almost exclusively exercise. While that may sound strange for most of us, we do get super good results!

Singapore is a very manual therapy centric society. If you were to do a quick Google on massage (or any form of manual therapy), you’ll get a whole bunch of results showing people who are masseuse to personal trainers to physiotherapists to osteopaths and of course chiropractors. Literally anyone can do massage after a weekend training program and EVERYONE (except us) offers it. Why? It’s good for money. Singaporeans love manual therapy.

#1 Manual therapy can worsen your pain

We have already talked about it many times. Manual therapy simply doesn’t work. There is no research showing its efficacy and in some instances, we have data showing that IASTM worsen pain outcomes when compared against control. It’s literally worse for you.

Yes, it is true not all manual therapy are created equal. To be fair, chiropractic adjustments sit in the grey area because we know it does have some short-term benefits.

#2 Exercise = less visits, longer term solution

Manual therapy almost always equates to more treatment because of the nature of how they work (i.e. pain modulation). We previously blogged that massage therapy has some positive effects at four weeks for Achilles tendon pain. The caveat? Twice a week message for four weeks.

Legitimate, forward-thinking chiropractors do a little better because if you do visit a good chiropractor, you wouldn’t need a lot of sessions. Check out how often do I need to see a chiropractor?

Exercise? Cognitive functional therapy had a positive effect even three years after and all it took was seven to eight visits across a 12-week period. If you are willing to accept a treatment that doesn’t involve manual therapy at all, we have the solution for you! What we do at Square One closely mirrors cognitive functional therapy. Since we started implemented a predominantly exercise approach to managing musculoskeletal pain, we are getting better results! Over 80% of our clients will leave our care, pain-free with full function, within four to seven visits. Pretty neat huh? We talked about this in Why We Choose Exercise.

Fun fact: Do you know chronic pain affect over a 100 million people in the US alone? For perspective, that is more than diabetes, cancer, and heart diseases COMBINED! 

#3 Exercise does help with pain

We already know exercise helps with pain for a very, very long time. Perhaps the one of the most high profile papers to support exercise for pain is the paper published by Alfredson et al in 1998. We have decided to compile a list of papers (that we know of) by year to show you how much research there is supporting exercise.

(If you are already already convinced, scroll on.)

1998: Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis

After the 12-week training period, all 15 patients were back at their pre-injury levels with full running activity. There was a significant improvement in pain during activity and the calf muscle strength on the injured side had also increased significantly.

2002: Therapeutic exercise for people with osteoarthritis of the hip or knee

Land-based therapeutic exercise was shown to decrease pain and improve physical function for people with osteoarthritis of the knee.

2005: Exercise therapy for treatment of non-specific low back pain

Exercise therapy appears to be slightly effective at decreasing pain and improving function in adults with chronic lower back pain.

2007: Exercise for treating fibromyalgia syndrome

There is ‘gold’ level evidence (www.cochranemsk.org) that supervised aerobic exercise training has beneficial effects on physical capacity and fibromyalgia symptoms. Strength training may also have benefits on some fibromyalgia symptoms.

2008: Dose response of isometric contractions on pain perception in healthy adults

High-intensity and long-duration, low-intensity isometric contractions produced an analgesic response. The greatest change in pain threshold and pain ratings, when pressure was applied to the contralateral finger, was after the long-duration, low-intensity contraction sustained until failure.

2009: Dynamic exercise programs (aerobic capacity and/or muscle strength training) in patients with rheumatoid arthritis

This is a bit of a complicated review to summarise but let’s just say exercise helps with patients with rheumatoid arthritis.

2014: Exercise for intermittent claudication

Exercise programmes are of significant benefit compared with placebo or usual care in improving walking time and distance in people with leg pain from intermittent claudication who were considered to be fit for exercise intervention.

2015: Exercise for treating patellofemoral pain syndrome

This review has found very low quality but consistent evidence that exercise therapy for PFPS may result in clinically important reduction in pain and improvement in functional ability, as well as enhancing long-term recovery.

2019: Motor control using cranio-cervical flexion exercises versus other treatments for non-specific chronic neck pain

Motor control interventions for non-specific chronic neck pain patients reduces pain and disability. Motor control seems to be more effective to reduce pain and disability than other treatments.

Is this enough proof?

#4 Even if you’re in pain, exercising may be better

People think I am crazy when I make them exercise while they are in pain. That is because we associate pain to damage or harm. As a result of this belief, we intuitively rest when we injure ourselves or when we experience pain. The criteria to return to sport or to start rehabilitative exercise is usually based on if we are still in pain. This is a flawed approach. 1) Pain is not an indication of damage, and vice versa 2) It is okay to exercise while you are currently in pain.

In some cases, it might be better for you if your exercises hurt a little. A 2017 study looking at 385 participants found treatments using painful exercises offer a small advantage over pain-free ones! How’s that?

The question really shouldn’t be if it is safe to exercise while you are in pain but more of what exercises should you do to get you out of pain. As discussed in our earlier point, lots of studies have shown that exercises help.

#5 Exercises target your exact problem

We do get people asking what’s so special about our exercises. There is a connotation that we only get good results because we know something others don’t. Um, that’s not true. We are very open with what we do and how we practise. We even link most of what we share directly to their sources. I mean, there’s really no secret here!

If there’s any one thing that we are doing differently from other chiropractors in Singapore, it is probably our approach. We are a big believer of evidence-based practice. Check out this commentary published 10 years ago: Why do ineffective treatments seem helpful?

Having said that, that doesn’t mean our exercise prescription is generic. Research tells us tendinopathy responds well to eccentric exercises and slow, heavy resistance at different stages of recovery. In the case of neck pain, the latest research suggest that motor control exercises may be superior to other treatments.

So, no. It does take some clinical experience to know what to do with exercises at any given time. But yes, the exercises themselves are not one of a kind. My job is to know when to do what to make you better!

Are you already exercising but still in pain?

Perhaps you do already work out a lot but your shoulder pain is still persisting. Well, that happens! While exercises for fitness and exercises for recovery may look exactly the same, the intent is different.

When exercising for fitness or general health reasons, the program is designed towards increasing power, strength, endurance, hypertrophy, VO2 max, or weight loss. Exercises for recovery, are geared towards addressing pain, function, freedom of movement, fear of movement.

Also, the dosage matters. Modern practice prefers higher loading and dosage for exercise while the traditional approach seem to play it safe by going light and easy. It is possible to exercise too much where your current symptoms are aggravated and it is just as possible for you to exercise too little so that there are no perceivable improvement!

This is why seeing an evidence-based chiropractor (or even physiotherapist or osteopath) is important.

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