In the rare case of a patient with severe pain an analgesic review with their GP or consultant may be required in order to allow participation in rehabilitation. Many people believe that activities that cause pain must be harmful. Clinicians need to gain a clear understanding of the patient’s pain experience and beliefs about pain (Eccleston and Eccleston, 2004) and counter those which are mal-adaptive. Clinicians should reinforce messages

which reduce fear or anxiety about pain, e.g. that the presence of pain should mTOR inhibitor not prevent most patients from safely participating in therapeutic exercise (Waddell et al., 2004) and may lead to reduction in symptoms (Guzman et al., 2002), improved function and return to work (van

Tulder et al., 2000). Those who participate in regular exercise are also less likely to experience progressive problems (McLean et al., 2007). Patients should be encouraged to start exercise gently and advised to progress to moderate or even high intensity levels of this website exercise over a period of time (Pernold et al., 2005). This evidence could counter the fears held by many pain sufferers that movement could be damaging or lead to re-injury. Low levels of physical activity at baseline (Minor and Brown, 1993, Rejeski et al., 1997, Stenstrom et al., 1997 and Schoo et al., 2005) or in previous weeks (Rejeski et al., 1997 and Oliver

and Cronan, 2002) and low in-treatment adherence with exercise (Alewijnse et al., 2003, Schoo et al., 2005 and Dobkin et al., 2006) were barriers to treatment adherence. Physiotherapists need to recognise and be ready to mitigate the many barriers to initiating and adhering to exercise programmes; these include poor programme aminophylline organisation and leadership, poor education, poor history of exercise, perceived physical frailty, perceived poor health and readiness to change (Duncan and McAuley, 1993, Courneya and McAuley, 1995, Boyette et al., 1997, Hellman, 1997 and Rhodes et al., 1999). Several strategies may be employed to improve patient adherence. Firstly providing explicit verbal instruction, checking the patient’s recall and supporting this with additional written instructions may be effective at improving exercise adherence (Schneiders et al., 1998). Secondly, employing motivational techniques such as counselling sessions, positive feedback, reward, written treatment contracts and exercise diaries may also be helpful (Friedrich et al., 1998). Setting goals and drawing up action plans and coping plans which have been agreed collaboratively between the clinician and patient may be effective with patients who intend to participate in exercise (Bassett and Petrie, 1999, Evans and Hardy, 2002 and Ziegelmann et al., 2006).