Physiotherapy and Enjoyable Exercise Prescription

Physiotherapists are the health professionals on the job when it comes to advocating the public to lead physically active lifestyles. Our occupation is fortunate to have longer contact time at a face to face level with people of a wide range of health statuses and conditions. The nature of our profession requires that we find out about the physical demands in a client / patients life, tuning into behaviour change talk, and empowering these persons to leave our care more enabled to participate in physical activity / exercise or empowered to make positive health decisions. When it comes to prescribing exercise the physiotherapist is looking to advocate long term engagement and adoption of these health behaviours. What better way of doing this, than to tell them to enjoy it!  Let me explain.

Physios do a great job empowering patients to manage pain, whether it be education about the mechanisms causing pain or strategies to reduce the level of pain whilst promoting movement. When it comes to exercise education and monitoring, we do a lot of things well, like teaching activity pacing for those acutely unwell or supervising exercise of deconditioned persons in the acute care environment. There are some things we don't do as well. Prescribing moderate intensity exercise (particularly continuous exercise like fast paced walking, biking, rowing, swimming.... or burpies) is one of these things. From your own experiences you will be aware that when the cardiovascular  envelope is pushed, much like pain, it can be uncomfortable.You won't be surprised to learn that the same experience is true for the client / patient. 

Typically we ask clients to use a visual rating scale or a numerical rating scale, we simply insert the factor we want to measure "on a scale of 0 to 10 where zero is no ___ and ten is ____..." When it comes to exercise prescription, we either advocate for mild to moderate intensity, a 4 - 6 out of 10 on the scale. Great, they can talk but we don't have to listen to them sing! We know the intensity will achieve a wide range of health outcomes if the duration and frequency of other activities are accumulated to be greater than 150min throughout the week (ACSM guidelines). We would expect the energy systems of the individuals exercising at these intensities are tipping toward the predominant use of the anaerobic energy system. Give the exerciser a few minutes and they will find the physical activity is becoming pretty hard work. There are a number of reasons that this may be the case: deconditioning / poor exercise tolerance, mismatch of perceived 'fitness' and the task, initially over-exerting themselves, poor body awareness, inefficient movement patterns, poor understanding of the rating scales... maybe it's just unsustainable hard work and cognitively or emotionally, the activity is just not pleasurable. 

As a practitioner we can entertain the idea of having the patient enjoy the exercise by throwing them a numerical rating scale, asking them to feel good whilst exercising. Feeling good whilst exercising, only to feel good having exercised sounds like an upward spiral that would promote exercise and healthy lifestyles! Let me introduce a tool that can help us all achieve this!

The Feeling Scale

The feeling scale is a means of mindfulness. The physiotherapist usually aims to achieve a set exercise prescription (e.g. 10min exercycle session, HR 40-60% HHR) however this approach has a change of perspective; it has a process orientation focus rather than an outcome orientation focus. It encourages reflection in action, appraising the enjoyment of the exercise whilst exercising. Intensity is the key variable that can be changed whilst exercising (although not exclusive; you will see that the mode of exercise could be interchanged to achieve a longer duration of exercise too).

This is a modified feeling scale I used with one of my patients. Note, you can adapt it to suit the task e.g. change the word speed to incline / weights / resistance etc. I had a timer that beeped every two minutes which cued the patient to think about how they felt, and modified their intensity to feel more pleasure in completing the exercise.

The Feeling Scale (Hardy & Rejeski, 1989) actually looks like this (below).

• +5 Very Good
• +4
• +3 Good
• +2
• +1 Fairly Good
• 0
• -1 Fairly Bad
• -2
• -3 Bad
• -4
• -5 Very Bad

Hardy, C. J. & Rejeski, W. J. (1989). Not what, buy how one feels: the measurement of affect during exercise. Journal of Sport and Exercise Psychology. 11(3), 304-317. DOI: 10.1123/jsep.11.3.304

It's a promising tool that deserves greater recognition by health professionals, namely physiotherapists. It is recognised that individuals who use the feeling scale will exercise at a sufficient intensity to elicit health gains (1, 2) with exercisers usually achieving the ACSM guidelines for exercise intensity. The clinician will ask the client to exercise at an intensity that makes them feel good (+3) and have the exerciser evaluate how they feel every 2-5 minutes. If the exerciser rates their affective state below (for example) +1 fairly good, then the clinician should ask the exerciser to adjust their own intensity to improve their rating on the feeling scale.

The peak and end rule simply predicts that the person exercising will remember the peak affect during exercise and the peak affect post exercise. The important thing to note here is that self-selected exercise intensity tended to have higher peaks on the feeling scale when compared to prescribed exercise intensity (3). What does this mean for physiotherapists? The exerciser will be more inclined to remember the peak and end affect of their exercise, so if the physio can make it an enjoyable experience then the exerciser is more likely to engage in that activity in the future.


There is a lot of research going on in the exercise psychology field which needs a bit more publicity in the physiotherapy community.

References

1. Hargreaves, E. & Parfitt, G. (2008). Can the feeling scale be used to regulate exercise intensity. Medicine and Science in Sport and Exercise. 40(10), 1852-1860
2. Hamlyn-Williams, C., Tempest, G., Coombs, S. & Parfitt, G. (2015). Can previously sedentary females use the feeling scale to regulate exercise intensity in a gym environment? An observational study. BMC Sports Science, Medicine and Rehabilitation, 7(30), DOI 10.1186/s13102-015-0023-8
3. Parfitt, G. & Hughes, S. (2009). The exercise intensity - affect relationship: evidence and implications for exercise behaviour. Journal of Exercise Science and Fitness 7(2), S34-S41.

Cupping Therapy in Physiotherapy

Cupping therapy doesn't involve filling up your beer glasses

Cupping therapy has been practiced in Traditional Chinese Medicine for many decades (1). From its inception, it has evolved and become popularised by adjunct-junkies in the realms of sports and musculoskeletal physiotherapy. The international sporting stage, the Rio Olympic Games, in 2016 put cupping therapy in the spotlight. Although the evidence for the use of cupping therapy is low level, limited in both quantity and quality, with questionable results showing little benefit (2), it is still used in contemporary physiotherapy practice. There is a notion that 'if high performance athletes use cupping therapy to gain the 1% advantage in performance, it must have its place in the physiotherapy toolkit'.

The world of high performance sport is arguably a special one, where performance variables are managed with a fine-tooth comb by a team of professionals. Gains of 1% in performance on the day can make the difference between first and second place, which in turn may affect the athletes sponsorship (this is often their career after-all). The physiotherapist and athlete will be wanting to do everything possible to prepare the athlete for a peak performance. With clinical reasoning and taking advantage of a placebo effect, I think they are right to consider cupping therapy. For everybody else... should we recommend it as a treatment?

Hopefully I've opened a few cans of worms to let squirm. However, rather than cooking any particular philosophy or opinion, I will simply describe the most appropriate cupping therapy techniques in an attempt to form a guideline for its use based on the literature and suggest a clinical basis for how it might serve a purpose.

Cupping Therapy techniques

Wet Cupping utilises suction with a process of scarification for bloodletting purposes. The theories for this technique have their origins in Traditional Chinese Medicine, and functions similarly to the practice of Eastern acupuncture. This technique is worth knowing about, but would not be used in standard physiotherapy care. For an article that explicitly describes the wet cupping protocol, I guide you to read this article by Kim et al (2011), reference in small print below:

Kim, J., Kim, T., Lee, M. S., Kang, J. W., Kim, K. H., Choi, J., Kang, K., Kim, A., Shin, M., Jung, S. & Choi, S. (2011). Evaluation of wet cupping therapy for non-specific low back pain: a randomised, waiting-list controlled, open-label, parallel-group pilot trial. Trials, 12, 146. DOI 10.1186/1745-6215-12-146

Dry Cupping utilises suction with no scarification performed. There are various modes of suction which inevitably differ depending on the device used: machine, manual pump or fire cupping. Oral suction, like that which would leave a hickey on a patient's neck is not cupping therapy and should never be applied.

The machine cupping modality was used in the treatment of osteoarthritis of the knee (4) with significantly improved WOMAC global score and the physical component of the SF-36 for n=40 participants aged 40-80 years. In this study a cups produced a pulsitile suction force. The cups encased the whole affected knee for 10min, and two cups were placed on the lower back for 5min. Participants received two treatments for four weeks, however scores for pain and stiffness were no longer significant at 12 weeks. The pressure was set to 100 - 200mbar, and pulsed at intervals of 2s. This was the only study I could find that used a machine cupping modality. Arguably an inferential machine is also a form of cupping therapy for soft tissues. 

Manual pump cupping uses valves manufactured in the cup design and a pump device to create a suction force. Fire cupping uses combustion to create suction; a flame is lit inside the cup then quickly placed carefully on the treatment site... it carries a risk of burns and hair removal! Both pump and fire cupping modes follow either 'retained cupping' or 'movement cupping' techniques. Cup size selection should be as large as the treated area can accommodate, with the suggestion that smaller cup sizes may not produce sufficient suction to stimulate deep fascia or trigger points (5).

 Manual Pump Cupping Therapy Devices (above)

 Fire Cupping Therapy Devices (above)

Retained Cupping

Retained cupping reportedly affects trigger points or facilitates an increase in blood flow to a region of soft tissue by placing suction over the treatment site. The cups remain static for the duration of the treatment. A contact medium, like sports massage gel, may help to seal the vacuum when placed near a bony prominence. 

Duration and intensity is commonly guided by discolouration. Stopping a treatment before deep discolouration occurs, as this is, in essence, a bruise and has no benefit to the patient and its appearance on the patient's skin may last for weeks. If ignored and suction is continued, the discolouration may lead to ulceration of the skin (a treatment injury). The amount of suction is somewhat controllable with a manual pump device, and is not controllable with fire cupping (unless the glass cup has a valve to release the pressure). Simply put, the greater the suction, the deeper the treatment effect. The depth of suction should feel comfortable for the patient however a physiotherapist could note the amount of skin lifted within the cup.

Frequency of treatments should be guided by clinical reasoning: what tissues or mechanisms are you trying to affect? Why would what you're doing with the cups achieve the effect you're after?

The beauty of retained cupping is that it allows you to treat multiple areas at one time; the greater number of cups, the greater number of treatment sites... don't get carried away though, you will still need to list and detail the treatment to these sites in your patient notes!

Variations: 

• AcuCupping: placement of the cup is guided by the knowledge of acupuncture/acupressure points.
• Medicated cupping and moxibustion: placement of the cup is guided by the intent to treat underlying tissue with a topical medication. Note: prescribing medications fall outside the scope of physiotherapy practice in most countries. 

Movement Cupping

Movement cupping replicates the application and effects of massage, and a contact medium, like massage oil, can facilitate a glide to minimalise irritation / friction of the cup on the skin.

The duration and frequency is applied similarly to retained cupping however less suction is recommended in order to maintain patient comfort and for ease of gliding. Manual pump devices are best designed for this.

Variation:

• Vibrations / shaking of the cup with a perpendicular lift of the cup off the treated site.

The beauty of movement cupping is that as a massage tool, you protect your own joints of the hand.

Cupping Therapy in Physiotherapy

Whether you thought cupping therapy was a treatment that works in mysterious ways or you believed it was an adjunct destined for the junkyard; your thoughts should meet somewhere in the middle. It's a treatment a-kin to massage, it's as simple as that. It is a physiotherapy adjunct that can work similarly to myofascial release / triggerpoint therapy / relaxation massage / remedial massage - it all depends on how the techniques are applied. 

The circular bruises left behind post-treatment won't give you magical performance abilities... Just like k-tape doesn't (...new can of worms!) 

• Could the technique be used to desensitise soft tissue or negate pain? Potentially.
• Could it replace foam rolling? Potentially.
• Should it be limited to high-performance athletes? I don't think so.
• Should it be a stand-a-lone treatment? Absolutely not. Education and higher level of evidence interventions should be given higher prioritisation.
• Would I use it in my clinical career? Absolutely, from time to time when clinically appropriate.
• Will I stick it on my legs and pretend I've been attacked by an octopus? Absolutely!

Biomechanical Mechanism:
Tham, L. M., Lee, H. P. & Lu, C. (2006). Cupping: From a biomechanical perspective. Journal of Biomechanics, 39, 2183-2193.

Neurophysiological Mechanism: 

Rozenfeld, E. & Kalichman, L. (2016). New is the well-forgotten old: the use of dry cupping in musculoskeletal medicine. Journal of Bodywork & Movement Therapies, 20, 173-178.

--------------------------------------------------

References

1. Cao, H., Li, X. & Liu, J. (2012). An update review on the efficacy of cupping therapy. PLoS ONE, 7(2), 1-14 
2. Cao, H., Li, X., Yan, X., Wang, N. S. Bensoussan, A. & Liu, J. (2014). Cupping for pain management: a systematic review of randomised clinical trials. Journal of Traditional Chinese Medical Sciences, 1, 49-61.
3. Cao, H., Han, M., Zhu, X. & Liu, J. (2015). An overview of systematic reviews of clinical evidence for cupping therapy. Journal of Traditional Chinese Medical Sciences, 2, 3-10. 
4. Tuet, M., Kaiser, S., Ortiz, M., Roll, S., Binting, S., Willich, S. N. & Brinkhaus, B. (2012). Pulsatile dry cupping in patients with osteoarthritis of the knee: a randomized controlled exploratory trial. BMC Complementary and Alternative Medicine, 12, 184.
5. Tham, L. M., Lee, H. P. & Lu, C. (2006). Cupping: From a biomechanical perspective. Journal of Biomechanics, 39, 2183-2193.

Additional articles/publications published after 2010

• Chi, L., Lin, L., Chen, C., Wang, S., Lai, H. & Peng, T. (2016). The effectiveness of cupping therapy on relieving chronic neck and shoulder pain: a randomised controlled trial. Evidence-Based Complementary and Alternative Medicine. 2016, DOI: 10.1155/2016/7358918 
• Chirali, I. Z. (2014). Traditional Chinese Medicine Cupping Therapy. 3^rd ed. London: Elsevier Health Sciences UK. ISBN 0-7020-4352-4  
•  De-li, S., Yan, Z., Da-long, C., A-bao, Z., Ming, X., Zhi-jun, L., Xun-sheng, Z., He-xin, J. & Wang-shen, H. (2012). Effect of moxibustion therapy plus cupping on exercise-induced fatigue in athletes. Journal of Acupuncture and Tuina Science, 9(1), 282-286.  
• Lee-Mei, S., Kim, J. & Ernst, E. (2011). Is cupping therapy an effective treatment? An overview of systematic reviews. Journal of Acupuncture Meridian Studies, 4(1), 1-4.  
• Lauche, R., Cramer, H., Choi, K, Rampp, T., Saha, F. J., Dobos, G. J. & Musial, F. (2011). The influence of a series of five dry cupping treatments on pain and mechanical thresholds in patients with chronic non-specific neck pain: a randomised controlled pilot study. BMC Complementary and Alternative Medicine, 11, 63. 
• Louche, R., Materdey, S., Cramer, H., Haller, H., Strange, R., Dobos, G. & Rampp, T. (2013). Effectiveness of home-based cupping massage compared to progressive muscle relaxation in patients with chronic neck pain: a randomized controlled trial. PLOS ONE, 8(6), e65378- 
• Lui, W., Paio, S., Meng, X. & Wei, L. (2013). Effects of cupping on blood flow under skin of back in health human. World Journal of Acupunture-Moxibustion, 23(3), 50-52.  
• Markowski, A., Sanford, S., Pikowski, J., Fauvell, D., Cimino, D. & Caplan, S. (2014). A pilot study analysing the effects of Chinese cupping as an adjunct treatment for patients with subacute low back pain on relieving pain, improving range of motion, and improving function. The Journal of Alternative and Complementary Medicine, 20(2), 113-117. DOI 10.1089/acm.2012.0769  
• Nannan, Y., Bo, C., Zelin, C. & Yi, G. (2011). Basic techniques and applications of three-layer moving cupping method. Journal of Acupuncture and Tunia Science, 9(4), 257-264. DOI 10.1007/s11726-011-0527-z  
• Rozenfeld, E. & Kalichman, L. (2016). New is the well-forgotten old: the use of dry cupping in musculoskeletal medicine. Journal of Bodywork & Movement Therapies, 20, 173-178