Introduction to Therapeutic Exercise
Top Contributors - Jess Bell, Wanda van Niekerk and Kim Jackson
Introduction[edit | edit source]
When considering exercise prescription in physiotherapy practice, it is important to understand the difference between therapeutic exercise and general exercise. General exercise is essentially a “work out”. It is exercise for wellness, overall health, appearance, fun, leisure etc.
Therapeutic exercise is specifically for individuals who have a physical problem / impairment, which is often painful.
“Therapeutic exercise is distinguishable from other forms of recreation because it is a purposeful, body-building activity, often prescribed by experts [...], drawing on their knowledge of bodily function to engage in a powerful form of anatomo-politics”.
Rehabilitation professionals must be able to assess, analyse, and determine the cause of a client’s pain or impairment. Exercises are then prescribed in order to address deficits in:
- Mobility / flexibility
- Strength and power
- Neuromuscular control
- Muscular endurance
Why Include Therapeutic Exercise in a Treatment Plan?[edit | edit source]
- Research supports the use of exercise interventions for long-term changes when compared to manual therapy alone
- A systematic review by Lin et al. appraised 44 clinical practice guidelines for musculoskeletal pain conditions. They found that exercise was recommended in all guidelines. However, when manual therapy is utilised, it should be used alongside other interventions (i.e. exercise, psychological therapy, information / education, activity advice).
- Exercise is supported over other therapeutic interventions
Terminology[edit | edit source]
Table 1 provides a list of terms that are often used when discussing therapeutic exercise.
|Exercise||Rotating joints in specific ways to challenge muscles|
|Form||A "topography of movement" or a specific manner of performing an exercise to maximise safety and ensure gains in muscle strength|
|Repetition / rep||A cycle consisting of controlled lifting and lowering of a weight|
|Set||Several repetitions performed in a row without a break|
|1 repetition maximum / 1RM||The maximum weight that an individual can lift once|
|Antagonist||Opposite of an agonist, can control rapid movement eccentrically|
|Synergist||Muscle(s) that stabilise(s) a joint around which movement occurs|
|Tempo||The speed at which an exercise is completed; tempo affects both the amount of weight that can be moved and the muscle|
Tissue Damage, Pathogenesis, Pain and Performance[edit | edit source]
Injury and tissue damage cause a disruption in joint biomechanics:
- Pain from an injury or surgery results in a cascade of changes that can cause disruptions to the joint and, potentially, ongoing pain. This pain may last for years. This, in turn, can lead to degenerative changes such as facet arthritis, accelerated annular degeneration, and nerve root irritation.
- Tissue damage occurs when excessive stress / strain is applied to a tissue (i.e. the force exceeds the strength of the tissue). Injury may occur after a single insult or from repeated loads. Tissue damage leads to motor control problems and, subsequently, long-term pain and degenerative changes.
Therefore, the challenge is to train the stabilising system during steady-state activities and during rapid voluntary motions, so that the body can withstand sudden, surprise loads. However, the presence of pain prevents the re-establishment of “healthy” motor patterns. And just as motor patterns are affected by injury, inappropriate motor patterns can also cause injury. Therefore, perturbed motor control systems are both a cause and a consequence of injury.
- Range of motion, flexibility and mobility
- Muscle activation
- Neuromuscular coordination
- Joint stability
- Strength and power
- Muscle endurance
Progression and Regression Design Principles[edit | edit source]
When prescribing exercises, it is important to understand how to progress and regress exercises. If patients are improving, exercises can be progressed. However, if they experience an increase in pain / symptoms, it may be necessary to alter certain parameters, including:
Phases of Exercise[edit | edit source]
- Firstly, it is necessary to determine if the patient can activate the affected muscle - i.e. is there a connection between muscle and brain?
- Tissue healing
- The phase of healing will have a significant impact on which exercises are given
- Joints are stabilised by the muscles
- As stability increases, range can be added
- Muscle performance improvement
- Advanced coordination and skill
- Progressively add difficulty in movement patterns to restore normal functional abilities
Teaching Methods for Exercise[edit | edit source]
- Verbal cues
- Mental imagery
- Visual feedback
- Manual cues
Various cues used to assist motor learning are discussed in more detail here.
Types of Muscle Contraction[edit | edit source]
- Concentric (shortening)
- Eccentric (lengthening)
- Static / holding
- Negative force of a muscle contraction (i.e. negative work)
- Leads to muscle hypertrophy
- Beneficial for tendons
- Causes delayed onset muscle soreness
- Should take no less than 4 seconds
- Muscle contraction without any movement / change in muscle length
- Positive force of a muscle contraction (i.e. positive work)
- Used to build endurance and increase tolerance to exercise
- Should take no longer than 3 seconds
Concentric versus eccentric:
- Eccentric strength must be greater than concentric strength
- The eccentric load must be greater than what an individual can lift concentrically
The following video provides a detailed discussion of concentric, eccentric and isometric muscle contractions.
Overload Principle[edit | edit source]
In order to improve strength, increased load must be applied to a muscle. This will increase the muscle's capability. Progressively adding stress to the system means that it can adapt. It also prepares the body to do more in the future.
The following video provides a brief discussion of the overload principle.
Learn more about some of the basic principles (such as specificity, overload, reversibility and individuality) in exercise physiology here.
Preparing the Patient[edit | edit source]
In order to prepare the patient for therapeutic exercise, please consider the following:
- Educate for success:
- Discuss how to progress
- Encourage patients to keep going once they have finished therapy
- Set expectations:
- What is normal muscle soreness?
- 24-48 hours
- How often should exercises be performed?
- How long will it take to make changes? It is important to note that:
- It takes 4-6 weeks to achieve physiological changes in a muscle
- Early increases in force production are associated with neural adaptations
- A patient may ‘feel’ stronger before 4-6 weeks have passed
- What is normal muscle soreness?
Programme Design[edit | edit source]
Table 2 provides a summary of the traffic light system. This system can be used to determine at what level an individual should exercise.
General Principles[edit | edit source]
It is essential to target an exercise intervention and focus on the impairment (i.e. weakness versus sensorimotor or neuromotor deficit). Consider:
- Irritability and current level of function
- Reps and sets scheme
- Targeted impairment category
- Progressions (necessary to see changes)
Neuromuscular Education[edit | edit source]
Sensorimotor control is defined as "afferent and efferent information streams, as well as the central processing of these two, contributing to joint stability."
- Impairments in the integration and processing of information in various parts of the sensorimotor system (e.g. sensory input, central nervous system, motor output)
- Neural inhibition is associated with pain, swelling, inflammation, joint laxity, and damage to the afferents of joints
- In knee pain, sensorimotor deficiencies have also been found in the non-injured leg:
- This may be due to physical inactivity post-injury, reduced function, and impaired sensory feedback from the injured joint
For a detailed discussion of the sensorimotor system, please see this article, and figure 1 in particular: The sensorimotor system, part I: the physiologic basis of functional joint stability
The video below summarises the sensorimotor system.
Neuromuscular Training[edit | edit source]
Neuromuscular training programmes have been found to be effective in improving function and reducing symptoms for various injuries. To improve sensorimotor control, closed kinetic chain exercises are often performed in a range of positions.
Please note that closed kinetic chain exercises are exercises or movements where the distal body segment is fixed to a stationary object. Open kinetic chain exercises are when the distal body segment (e.g. foot) is free / not fixed to an object.
Progress function through motor learning principles:
Progress function through movement:
- Frequency, intensity, duration (time)
- Single- to multi-joint; closed to open
The following video provides a basic summary of the FITT principles (i.e. frequency, intensity, time, type).
The process is as follows:
- Motor learning
- Functional movement training
- The core musculature is key to the movement of the extremities
- The extremities are tied to the spine
- The spine must be stable
Strength and Conditioning[edit | edit source]
Strength is defined as the amount of force that a specific muscle or muscle group can generate.
Conditioning (endurance) is defined as the ability to “perform repetitive muscular contraction against some resistance for an extended period”.
"Strength does not equal stability".
Strength and endurance training have many benefits:
- Increased tissue vascularisation
- Increased structural integrity of connective tissue
- Improved lean muscle mass
- Increased metabolic rate
- Decreased body fat
- Every individual has a tolerance for work
- Tissues are damaged if their load tolerance is exceeded
- Tolerance is lower in tissues that are already weakened by injury
- Understanding each individual’s tolerance will assist in choosing the appropriate dosage / load for each stage of training
- Every individual has a capacity for work
- Capacity is defined as “the sum total of all activities over a period of time” (i.e. the maximum physical exertion that an individual can sustain)
- People use up a portion of their daily capacity with every task they perform, including warm-up activities, poor posture (sitting or standing)
- Ideal training occurs when capacity and tolerance are increased together
Read more on: Neuromuscular Adaptations to Exercise
Principles of Conditioning[edit | edit source]
- Warm up / cool down
- Overload (see below)
- Minimise stress
SAID Principle[edit | edit source]
The Specific Adaptation to Imposed Demands (SAID) principle is a framework on which strength and conditioning programmes can be designed.
- All training is specific to a particular task
- Specific skills or training may not be easily generalised or transferred to distinct activities
The following video includes a discussion of the SAID principle and other principles of exercise training.
Principles of Progression[edit | edit source]
- Increase or decrease difficulty with:
- Complexity of exercise
- Closed versus open chain
- Best results come from including both open and closed chain exercises
- Open to closed, closed to functional
Exercises can also be progressed by challenging the balance system:
- Unstable surfaces
- Eyes closed
- Visual distraction
More information on balance training is available here.
Additional Resource[edit | edit source]
References[edit | edit source]
- Jackson R. Therapeutic Exercise Course. Plus. 2022.
- Nicholls D, Jachyra P, Gibson BE, Fusco C, Setchell J. Keep fit: marginal ideas in contemporary therapeutic exercise. Qualitative Research in Sport, Exercise and Health. 2018;10(4):400-11.
- Maestroni L, Read P, Bishop C, Papadopoulos K, Suchomel TJ, Comfort P et al. The benefits of strength training on musculoskeletal system health: practical applications for interdisciplinary care. Sports Med. 2020;50(8):1431-50.
- Prall J, Ross M. The management of work-related musculoskeletal injuries in an occupational health setting: the role of the physical therapist. J Exerc Rehabil. 2019;15(2):193-9.
- Bielecki JE, Tadi P. Therapeutic Exercise. [Updated 2021 Sep 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK555914/
- Lin I, Wiles L, Waller R, Goucke R, Nagree Y, Gibberd M et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med. 2020;54(2):79-86.
- Wikipedia. Strength training. Available from: https://en.wikipedia.org/wiki/Strength_training (accessed 14 March 2022).
- Kalkhoven JT, Watsford ML, Impellizzeri FM. A conceptual model and detailed framework for stress-related, strain-related, and overuse athletic injury. Journal of Science and Medicine in Sport. 2020;23(8):726-34.
- Van Dieën JH, Reeves NP, Kawchuk G, van Dillen LR, Hodges PW. Motor control changes in low back pain: divergence in presentations and mechanisms. J Orthop Sports Phys Ther. 2019;49(6):370-379.
- Meier ML, Vrana A, Schweinhardt P. Low back pain: the potential contribution of supraspinal motor control and proprioception. Neuroscientist. 2019;25(6):583-96.
- Bailey DL, Holden MA, Foster NE, Quicke JG, Haywood KL, Bishop A. Defining adherence to therapeutic exercise for musculoskeletal pain: a systematic review. Br J Sports Med. 2020;54(6):326-31.
- Babatunde OO, Jordan JL, Van der Windt DA, Hill JC, Foster NE, Protheroe J. Effective treatment options for musculoskeletal pain in primary care: A systematic overview of current evidence. PLoS One. 2017;12(6):e0178621.
- Padulo J, Laffaye G, Chamari K, Concu A. Concentric and eccentric: muscle contraction or exercise? Sports Health. 2013;5(4):306.
- Hody S, Croisier JL, Bury T, Rogister B, Leprince P. Eccentric muscle contractions: risks and benefits. Front Physiol. 2019;10:536.
- Hollander DB, Kraemer RR, Kilpatrick MW, Ramadan ZG, Reeves GV, Francois M et al. Maximal eccentric and concentric strength discrepancies between young men and women for dynamic resistance exercise. J Strength Cond Res. 2007;21(1):34-40.
- Corporis. Easiest Way to Remember Contraction Types: Concentric vs Eccentric vs Isometric | Corporis. Available from: https://www.youtube.com/watch?v=gCyNj-Upbe4 [last accessed 14/03/2022]
- National Council on Strength and Fitness. What is Overload, Progression & Specificity. Available from: https://www.youtube.com/watch?v=TocsLwo7l9A [last accessed 14/03/2022]
- Škarabot J, Brownstein CG, Casolo A, Del Vecchio A, Ansdell P. The knowns and unknowns of neural adaptations to resistance training. Eur J Appl Physiol. 2021;121(3):675-85.
- De Zoete RMJ, Osmotherly PG, Rivett DA, Snodgrass SJ. Seven cervical sensorimotor control tests measure different skills in individuals with chronic idiopathic neck pain. Braz J Phys Ther. 2020;24(1):69-78.
- Röijezon U, Faleij R, Karvelis P, Georgoulas G, Nikolakopoulos G. A new clinical test for sensorimotor function of the hand – development and preliminary validation. BMC Musculoskelet Disord. 2017;18:407.
- Goossens N, Rummens S, Janssens L, Caeyenberghs K, Brumagne S. Association between sensorimotor impairments and functional brain changes in patients with low back pain: a critical review. Am J Phys Med Rehabil. 2018;97(3):200-11.
- Ageberg E, Roos EM. Neuromuscular exercise as treatment of degenerative knee disease. Exerc Sport Sci Rev. 2015;43(1):14-22.
- Rice DA, McNair PJ. Quadriceps arthrogenic muscle inhibition: neural mechanisms and treatment perspectives. Semin Arthritis Rheum. 2010;40(3):250-66.
- Riemann BL, Lephart SM. The sensorimotor system, part I: the physiologic basis of functional joint stability. J Athl Train. 2002;37(1):71-9.
- Professor Dave Explains. The Sensorimotor System and Human Reflexes. Available from: https://www.youtube.com/watch?v=M0PEXquyhA4 [last accessed 14/03/2022]
- Zech A, Hubscher M, Vogt L, Banzer W, Hansel F, Pfeifer K. Neuromuscular training for rehabilitation of sports injuries: a systematic review. Med Sci Sports Exerc. 2009;41(10):1831-41.
- Taulaniemi A, Kankaanpää M, Tokola K, Parkkari J, Suni JH. Neuromuscular exercise reduces low back pain intensity and improves physical functioning in nursing duties among female healthcare workers; secondary analysis of a randomised controlled trial. BMC Musculoskelet Disord. 2019;20(1):328.
- Physiopedia. Closed chain exercise.
- Physiopedia. Open chain exercise.
- PE Buddy. Learn the FITT Training Principles! Available from: https://www.youtube.com/watch?v=Qss0afEmQiY [last accessed 18/03/2022]
- Prentice WE. Regaining muscular strength, endurance, and power [Internet]. Musculoskeletal Key. 2021 [cited 13 March 2022]. Available from: https://musculoskeletalkey.com/regaining-muscular-strength-endurance-and-power/
- Goldstein RE. Exercise Capacity. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 8. Available from: https://www.ncbi.nlm.nih.gov/books/NBK404/
- Johnson AM, Sandage MJ. Exercise science and the vocalist. J Voice. 2021;35(4):668-77.
- Dr. Jacob Goodin. Scientific Training Principles for Strength & Conditioning. Available from: https://www.youtube.com/watch?v=X-zQ5hKB_G8 [last accessed 14/03/2022]
- The Principles of Exercise Therapy (PET). Lecture 4 - The Principles of Exercise Therapy. Available from: https://www.youtube.com/watch?v=wMbp1ZVUNKc [last accessed 18/03/2022]