Functional restoration for people with patho-anatomy as the primary barrier to recovery

Functional Restoration (FR) is a structured exercise program in conjunction with a behavioural approach addressing non-physical barriers to recovery typically provided for patients with persistent pain non-responsive to standard treatment. Functional Restoration is typically provided by physiotherapists, but is not in the exclusive domain of this discipline. This learning module aims to develop the basic theoretical understanding and practical skills of the practitioner in providing FR for patients with a primary pathoanatomical problem through achieving the following learning objectives:

• Understand how to teach a precise contraction of the lumbar spine core stability muscles
• Be able to develop a functional, graded exercise program of suitable dosage for different patient profiles
• Be able to develop a program leading to independence post FR

After achieving the objectives of this module the practitioner should consistently apply the principles learnt in the clinical setting (± supervision from an experienced practitioner as required) to ensure clinical competency is attained.

An assumption is made that all practitioners engaged in this module will have at least a Bachelor level understanding of human anatomy, biomechanics, physiology and pathology. This module relies on sound basic science knowledge to allow an application to clinical practice. In addition, the practitioner is strongly recommended to complete the learning modules Lumbar Spine Assessment I and II before commencing this module. Knowledge of the content of these modules will be assumed.

The principles of FR presented in this module are applicable to all body parts, however for ease of presentation, the module is written with a focus on low back disorders (LBD).

Standard functional restoration exercise components

Functional Restoration is an effective way of teaching the patient how to self manage their condition so that maximum recovery in the injury and function can occur. The primary principle of FR is to address the pathoanatomical, neurophysiological and psychosocial barriers to recovery with minimal risk of symptom aggravation. Symptom aggravation can be genuinely pathoanatomical based on demand exceeding the capacity of a structure thereby disrupting tissue healing. It can also be due predominantly to psychosocial distress including sudden deterioration in depression/anxiety symptoms, elevated fear avoidance beliefs or heightened pain focus. Both pathoanatomical and psychosocial based aggravation of symptoms have the potential to “wind up” central sensitisation. For this reason, particularly in the early phases of FR, the practitioner should aim to get patients improving their function with minimal increase in their symptoms. As the patient and practitioner gains confidence and understanding of the nature and irritability of the condition, more rapid increases in exercise intensity and dosage can occur.

Increase in exercise and activity can be viewed within a psychosocial and neurophysiological paradigm as having few risks of actual tissue damage.(1) However, experienced practitioners understand that tissue healing of an injury in persistent pain may still be occurring. When combined with a potentially deconditioned patient, there are very real risks of tissue damage due to exercise being too rapidly increased. Finding the balance between these complex array of factors is the skill in setting up and progressing a personalised and effective FR program.

Following are some guidelines for exercises in a “standard” FR program for LBD. Generally a range of parameters are presented allowing practitioners to adapt their program to suit their patient. These exercises are based on the extensive FR literature(2), the interpretation of the literature on mechanisms of FR already discussed, and the clinical experience of the author over 20 years of providing FR in a physiotherapy and multi-disciplinary environment. Discussion of specific behavioural strategies within a FR program will follow the exercise section of the module.

As per the patient explanation section of this module, the information presented relates to a patient with a primary pathoanatomical barrier to recovery with possible secondary other factors. Exercise progression in patients with primary neurophysiological or psychosocial barriers to recovery will be discussed in later sections.