Therapeutic Exercise Prescription

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Top Contributors - Wanda van Niekerk

Exercise Prescription - “A balance between (he)art and science”

Proper therapeutic exercise prescription should consider:

• Appropriate exercise for a specific patient on that specific day
  • exercise protocols can be used when appropriate, but it has to match with the patient on the day

• the phases of healing when prescribing therapeutic exercise
  • if you'd like you can read more about:
    • Injury and healing with sports physiotherapy
    • Soft tissue healing
    • Bone healing
• the patient’s tolerance level

• Exercise therapy is often used as a supplement to maintain the effects of manual therapy.
  • For example in persons with non-specific chronic neck pain, therapeutic and stabilisation exercises after manual therapy have been shown to have more positive effects such as increased range of motion and decreased pain.

Adherence to Therapeutic Exercise Prescription

• The involvement and engagement of patients in therapeutic exercise, their commitment to following the prescribed routines and the the resulting outcomes can be enhanced by activating trust, motivation and confidence mechanisms.
  • Ways to develop trust is by building a therapeutic alliance and developing a rapport with the patient. This will also assist in a holistic approach and identifying the patient’s needs and beliefs.
• Understanding what a patient’s goals are will help rehabilitation professionals create a tailored exercise programme and with personalised advice and education, this may increase the patient’s motivation and adherence. Read more about goal setting:
  • SMART Goals
  • Goal Setting in rehabilitation

• Set goals with your patient based on functional limitations, impairments, activity and participation restrictions. The International Classification of Functioning, Disability and Health (ICF) Framework is a valuable tool to use.

• Select the correct level of exercise for the patient on that specific day and progress as tolerated.
• You can read more about adherence to exercise prescription:
  • Adherence to Rehabilitation
  • Adherence to home exercise programmes
  • Exercise adherence in patients with ankylosing spondylitis

Routine Therapeutic Exercise Prescription

General therapeutic exercises to include are:

• stretching and mobility exercises – daily
• balance exercises – daily
• strengthening exercises– 3 to 5 times a week
• cardiovascular exercise
• core exercises

Components of Therapeutic Exercise

Warm-up

• This should be cardio intensive exercise.
• Benefits of warm-up include:
  • beneficial to subsequent exercise performance via increase in ATP turnover and muscle cross bridge cycling rate
  • increased temperature – this allows internal changes such as increased blood flow and metabolic responses
  • improved oxygen delivery
  • increased blood flow
  • faster muscle contraction and relaxation
  • improved force development
  • improved reaction time
  • decreased skeletal muscle viscosity and resistance
  • increased compliance of ligaments and tendons
  • increased and enhanced metabolic reactions

Range of Motion Exercises

Benefits of range of motion exercises include:

• increased blood flow
• increased flow of synovial fluid
• decreases waste in the joint
• decreased pain

Read more about benefits of range of motion exercises here.

Strength Training Considerations

Some foundations of strength exercise to consider include:

• Sets: 1 to 3 sets
  • 1 set for untrained populations
  • Multiple sets for trained populations and lower extremity exercises
• Establish 1 Repetition Maximum (1 RM)
  • Working weight should be 60 to 80% of this
  • You can read more about 1 RM here

• Repetitions
  • 10 repetitions (maximises increase in strength, endurance and power)
    • 3 X 5 increase in strength
    • 3 X 10 increased in strength, endurance, power
    • 3 x 20 increase in endurance
  • to volitional fatigue
  • More recently loading and dosage recommendations have been prescribed along the "repetition continuum" or the "strength-endurance continuum". This continuum proposes the following:
    • muscle strength - low repetitions with heavy loads: 1 - 5 repetitions per set with 80% - 100% of 1 -repetition max (1RM)
    • muscle hypertrophy – moderate repetitions with moderate loads: 8 - 12 repetitions per set with 60% - 80% of 1RM
    • muscle endurance – high repetitions with light loads: 15 + repetitions per set with loads below 60% of 1RM

• Use superset format
• Rest intervals if not performing supersets
  • 30 to 60 seconds between sequential sets
  • isometric exercises - 1 minute recovery between sets
  • isotonic exercises - 30 seconds to 60 second recovery between sets
  • isokinetic exercises - 2 to 4 minutes recovery between sets
  • You can read more about types of muscle contractions here.
• Frequency: each major muscle group should be trained 2 to 3 times a week

• Duration: minimum of 6 weeks
• Progression: 3 to 10% per week (based on the total volume of work)
• Provide 10 different exercises

You can read in more detail about designing a strength training programme here.

Flexibility

Table 1. Improving Flexibility

Type of Tissue	Recommended dosage
Painful, irritable, hypertonic tissue	5 to 10 second stretch stay at less than 4 out of 10 pain level
Muscle, a little tight (after exercise)	3 x 30 seconds 2 to 3 times / day
Muscle, very limited muscle length	hold stretch for longer than 1 minute stay at less than 4 out of 10 pain level
Joint capsule	20 x 5 seconds or sustained stretch

Notes on Stretching

Table 2. Considerations for static stretching (adapted from Placzek and Boyce)

Optimal number of static stretch repetitions	4 repetitions	more than 5 repetitions of passive stretching of the hamstrings showed insignificant gains in muscle length.
Optimal amount of time to hold a static stretch	6 to 30 seconds	for immediate increase in range of motion - between 15 to 60 seconds shorter stretch times (< 30 seconds) result in the least impairment on performance stretch times of 6 x 6 seconds improve e of motion and reduce the negative impairment effect of static stretching
Optimal intensity of static stretching	remain under the point of discomfort	research shows that stretching to the point of discomfort can lead to a decrease in performance measures such as jump height, force production and balance whereas stretching intensities below a person's point of discomfort have less negative effects on performance and improve range of motion

The creep principle of soft tissue refers to the gradual stretching and lengthening of soft tissue over time when it is under a sustained load or tension. Read more about creep here.

If you'd like you can read more about flexibility and stretching.

Cardiovascular Training of Patients in the Clinic

The World Health Organization's physical activity guidelines recommend the following for adults aged 18 to 64 years old:

• do at least 150 - 3oo minutes of moderate intensity aerobic physical activity or at least 75 - 150 minutes of vigorous intensity aerobic physical activity (or a combination of both) per week
• muscle strengthening exercises that involve all major muscle groups at least twice a week

For more detail about the physical activity guidelines for different age groups read here.

How Hard Should a Patient Work?

Table 3. Guidelines on how hard a patient should work during therapeutic exercise

Resting heart rate	"the heart rate of an individual whenever they are inactive"
Maximum heart rate	the highest heart rate value an individual can achieve during an all-out effort to the point of exhaustion HRmax can be estimated through age-based prediction equations, but note that there is a large standard error of estimate associated with these methods. It is also recommended that these equations should be applied to similar populations as the populations used when the equation was derived. HRmax = 220 - age in years (this is the most common and widely used formula) This formula is still used in clinical settings. However, it has been reported that there are deviations and over- and under-estimation of maximum heart rate in younger and older populations. HRmax = 208 - (o.7 x age in years) - this is a more precise formula, adjusted for people older than 40 years HRmax = 211 - (o.64 x age in years) - an even more precise formula, adjusted for generally active people
Percentage of maximum capacity at rest	calculated as resting heart rate (RHR) / maximum heart rate (HRmax)x 100 = ...%
Heart rate reserve	calculated as maximum heart rate (HRmax) - resting heart rate (RHR) = ... bpm (beats per minute)
Target heart rate	often in healthy individuals target heart rate can be calculated as 60% to 80% of the maximum heart rate (e.g. 60% of HRmax) in the clinic, the target heart rate may be between 50%(minimum) to 70% (maximum) of the heart rate reserve (HRR) (e.g. raise resting HR by 50% of HRR = (HRmax - RHR) x 50% = ... bpm; then, RHR + (HRmax - RHR) x 50% = ... bpm)
Mean arterial pressure (MAP)	calculated as [(diastolic blood pressure x 2) + systolic blood pressure] / 3 = ... mmHg Normal MAP = 70 to 100 mmHg
Rate pressure product (RPP)	calculated as resting heart rate x systolic blood pressure normal RPP = 10 000 or less at rest trained individuals RPP = 5 000 maximum RPP during exercise should be 36 000

Risk Assessment

Patient risk is your risk

Table 4. Risk assessment of patients doing therapeutic exercise

Level of Risk	Signs and Sypmtoms
Low Risk	no angina no unusual shortness of breath no light-headedness no dizziness blood pressure must be below 200/90 to exercise stop exercise if systolic drops 10 mmHg with activity diastolic can increase 10mmHg with activity
Moderate Risk	presence of angina light-headedness unusual shortness of breath dizziness occuring at high levels of exertion vitals are slightly outside of norms (under 200 diastolic 90) remain constant during exercise
High Risk	dizziness at low levels of exertion vitals are outside of norms and fluctuate during treatment (over 200 or diastolic over 100 is a contraindication)

Vital Signs

• Vitals should always be taken before, during and after exercise
• Pre-exercise blood pressure greater than 200 mm Hg systolic or 120 mm Hg diastolic is a contraindication to exercise
• Diastolic should remain the same or slightly drop
  • Increase of 10mm Hg = stop
• New blood pressure categories
  • Normal: systolic < 120 mm Hg and diastolic < 80 mm Hg
  • Elevated: systolic 120 - 129 mm Hg and diastolic < 80 mm Hg
  • Stage 1: systolic 130 - 139 mm Hg or diastolic 80 - 89 mm Hg
  • Stage 2: systolic ≥ 140 mm Hg or ≥ 90 mm Hg
• Heart rate recovery
  • After stopping peak exercise - a 30 bpm drop after the first minute
  • Less than 12 bpm drop in heart rate = sign of heart weakness