Therapeutic Exercise Prescription

Original Editor - Wanda van Niekerk based on the course by Richard Jackson

Top Contributors - Wanda van Niekerk, Jess Bell and Tarina van der Stockt

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

Appropriate therapeutic exercise prescription requires several considerations. The exercise must be appropriate for a patient on a particular day. While exercise protocols can be useful and used when appropriate, they must be suitable for the patient's current condition and circumstances on the day. The phases of healing play an important role in exercise prescription and recovery. If you'd like to learn more about the phases of healing, there are several pages you can explore: Injury and Healing with Sports Physiotherapy, Soft Tissue Healing and Bone Healing. Another key consideration is the patient's tolerance level. Additionally exercise therapy can serve as an effective tool the 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

Activating trust, motivation and confidence mechanisms can help to enhance patient involvement and engagement in therapeutic exercise.

Ways to develop trust include building a therapeutic alliance and developing a rapport with the patient. This will also help to identify the patient's needs and beliefs and ensure a holistic approach.

Understanding a patient’s goals will help rehabilitation professionals create a tailored exercise programme. When combined with personalised advice and education, the patient’s motivation and adherence may be increased. If you would like to read more about goal setting, please read: SMART Goals and Goal Setting in Rehabilitation.

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

If you are interested, you might like to read the following articles to learn about adherence to exercise prescription: Adherence to Rehabilitation, Adherence to Home Exercise Programmes and Exercise Adherence in Patients with Ankylosing Spondylitis.

Types of Therapeutic Exercises

• Passive
  • performed by the clinician or someone other than the individual OR
  • performed by a mechanical device OR
  • performed using gravity
  • another limb can also be used to perform passive movements without active muscle contraction of the affected area
  • indications for using passive range of motion exercises:
    • an individual is unable to actively move the specific body part
    • muscle activity at the time may cause further damage

• Active-assisted
  • the individual does the exercise with some assistance from:
    • the other limb
    • mechanical devices
    • another person (clinician)
    • gravity
  • can help an individual reach full range of motion when:
    • range of motion is limited by pain or weakness
    • used as a progression during the recovery of an injury when limited muscle force is allowed on structures

• Active
  • performed by the individual without any assistance

• Resisted
  • exercise is performed against some form of resistance such as:
    • gravity
    • external forces, such as free weights, pulley systems, mechanical equipment and manual resistance applied by the clinician

Routine Therapeutic Exercise Prescription

General therapeutic exercises to include in an exercise programme involves several key components. These include daily stretching and mobility exercises along with daily balance exercises. Strengthening exercises should be performed three to five times a week. Cardiovascular and core exercises can also be included.

Phases of Exercise

Below is a short recap of the phases of exercise to consider with therapeutic exercise prescription:

• activation - to determine if the patient can activate the affected muscle
• tissue healing - the phase of healing will have an impact on which exercises are prescribed
• stabilisation - joints are stabilised by the muscles
• mobility - 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

Components of Therapeutic Exercise

Warm-up

The warm-up should consist of cardio-intensive exercise. Incorporating a warm-up in therapeutic exercise offers numerous beneficial physiological effects. In increased ATP (adenosine triphosphate) turnover and muscle cross-bridge cycling rate, which is beneficial to subsequent exercise performance. The increased temperature facilitates important internal changes, such as increased blood flow and metabolic responses.

Additional benefits include improved oxygen delivery, increased blood flow and faster muscle contraction and relaxation. The warm-up also leads to improved force development and reaction time, while decreasing skeletal muscle viscosity and resistance. It also increases the compliance of ligaments and tendons and enhances metabolic reactions. The video below shows an example of a warm-up.

Range of Motion Exercises

Range of motion exercises have several benefits. It increases blood flow and the flow of synovial fluid. These exercises also aid in the removal of waste products (such as metabolic byproducts) in the joint. This waste removal process occurs as the synovial joint moves, causing the synovial fluid to circulate and facilitate the removal of waste products (e.g. lactic acid, carbon dioxide, uric acid) from the joint cavity. Additionally, range of motion exercises help decrease pain.

If you'd like to learn more about the benefits of range of motion exercises, please see: range of motion exercises and stretching.

Strength Training Considerations

Some foundations to consider include:

Sets: 1 to 3 sets

• 1 set for untrained populations
• multiple sets for trained populations and lower extremity exercises

Establish a patient's 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 are often encouraged as a starting point to maximise increases in strength, endurance and power, but various combinations of repetitions and sets can achieve different goals:
  • 3 x 5 repetitions can increase strength
  • 3 x 10 repetitions can increase strength, endurance and power
  • 3 x 20 repetitions can increase endurance
• aim to work 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 requires low repetitions with heavy loads: 1 to 5 repetitions per set at 80 to 100% of 1-repetition max (1RM)
• muscle hypertrophy requires moderate repetitions with moderate loads: 8 to 12 repetitions per set at 60 to 80% of 1RM
• muscle endurance requires high repetitions with light loads: 15+ repetitions per set with loads below 60% of 1RM

• use superset format
  • in this format, a set of exercises is done back-to-back with little rest in between
  • for example: a set of bench presses, immediately followed by a set of barbell rows, extension with little rest in between, and then repeating this set
  • the video below shows an example of a superset

• if not performing supersets, rest intervals can be structured as follows:
  • sequential sets: 30 to 60 seconds rest
  • isometric exercises: 1 minute recovery between sets
  • isotonic exercises: 30 to 60 seconds 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 per week

• duration: minimum of 6 weeks
• progression: 3 to 10% per week (based on the total volume of work)
• provide 10 different exercises

More information on designing a strength training programme is available here.

Flexibility

Table 1 highlights approaches often used by clinicians to improve the flexibility of different types of tissue.

Table 1. Improving flexibility

Type of Tissue	Recommended Dosage
Painful, irritable, hypertonic tissue	5 to 10 second stretch Stay at a pain level of less than 4/10
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 a pain level of less than 4/10
Joint capsule (please note that active range of motion exercises are recommended before stretching the joint capsule)	20 x 5 seconds or a sustained stretch

The American College of Sports Medicine recommends the following for stretching and flexibility:

Table 2. ACSM Stretching and Flexibility Guidelines

Frequency	2 to 3 times per week, but daily stretching is more effective
Intensity	Stretch to the point of feeling tightness or slight discomfort
Time	Hold static stretches for 10 to 30 seconds (recommended for most adults) In older individuals, holding a stretch for 30 to 60 seconds may provide more benefits for flexibility

Notes on Static Stretching

Table 3 provides information on the latest research to consider when prescribing static stretches.

Table 3. 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 an immediate increase in range of motion, hold for between 15 and 60 seconds Stretch times of 6 x 6 seconds improve 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. More information is available on creep here.

If you are interested in learning more, please see: Flexibility and Stretching.

In-Clinic Cardiovascular Training

The World Health Organization's physical activity guidelines for adults aged 18 to 64 years old recommend at least 150 to 3oo minutes of moderate-intensity aerobic physical activity or at least 75 to 150 minutes of vigorous-intensity aerobic physical activity (or a combination of both) per week. In addition, the organisation advises performing muscle strengthening exercises that involve all major muscle groups at least twice a week. For more information on the physical activity guidelines for different age groups, please see Physical activity.

How Hard Should a Patient Work?

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

Measures	Description
Resting heart rate	The "heart rate of an individual whenever they are inactive"
Maximum heart rate (HRmax )	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. However, it is important to note that a large standard error of estimate is 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 this method has a standard deviation of between 10 and 12 beats per minute, and that maximum heart rate can be over- or under-estimated in younger and older populations HRmax = 208 - (0.7 x age in years) - this is a more precise formula, adjusted for people older than 40 years HRmax = 211 - (0.64 x age in years) - this is 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	In healthy individuals, the target heart rate can often 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 + HRR = ... 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 When testing this with a patient in the clinic, measure at rest and then during exercise at various intervals - the RPP should have a steady, linear rise

Examples

Resting heart and percentage of maximum capacity at rest

Example 1: 80-year-old female with a resting heart rate of 100

• Maximum heart rate: 220 - 80 = 140
• Percent of maximum capacity: resting heart / maximum heart = 100/140 = 71%
• At rest, this individual is already using 71% of their maximum capacity
• How hard can this individual work if there is only 29% left to work with?

Example 2: 40-year-old male with a resting heart rate of 80

• Maximum heart rate: 220 - 40 = 180
• Percent of maximum capacity: resting heart rate/maximum heart rate = 80/180 = 44%
• At rest this individual is using 44% of their maximum capacity
• Can work harder because there is still 56% "left in the tank"

Example 3: 74-year-old male with a resting heart rate of 70

• Maximum heart rate: 220 - 74 = 146
• Percent of maximum capacity: resting heart rate / maximum heart rate = 70 / 146 = 48%
• At rest this individual is using 48% of their maximum capacity
• Notice that the 40-year-old and 74-year-old have similar percentage of maximum capacity. Key to this is the lower resting heart rate of the 74-year-old (as you get fitter, heart rate goes down)

Heart rate reserve

Heart rate reserve: Maximum heart rate - resting heart rate

Example 1: 80-year-old female with a resting heart rate of 100

• Heart rate reserve: 140 - 100 = 40

Example 2: 40-year-old male with a resting heart rate of 80

• Heart rate reserve: 180 - 80 = 100

Example 3: 74-year-old male with a resting heart rate of 70

• Heart rate reserve: 146 - 70 = 76

The individuals in examples 2 and 3 can be worked much harder than the individual in example 1.

Target heart rate

Target heart rate = the heart rate at which your patient needs to be exercising at.

Comparison of two methods

Method 1: 60% to 80% of maximum heart rate (works well with younger people, with no comorbidities)

Method 2: raise resting heart rate by 50% to 70% (this method may be more beneficial in clinical scenarios where the patients are sometimes older or with injuries)

The table below compares the target heart rate calculations based on these two methods. From example 1 you can see that if using the first method, the patient's target heart rate (60% of max HR) is only 85 bpm, but the patient's resting heart rate is 100 bpm, so exercising at less than resting heart rate will have no effect. In example 1, it would be better to use method 2 and to calculate target heart rate using heart rate reserve, and having 12obpm as the lower end of the target heart rate.

	Example 1 80-year-old female with a resting heart rate of 100	Example 2 40-year-old male with a resting heart rate of 80	Example 3 74-year-old male with a resting heart rate of 70
Method 1	60% of max HR Max HR x 0.6 =(220 - 80) x 0.6 = 140 x 0.6 = 85 bpm	60% of max HR Max HR x 0.6 = (220 - 40) x 0.6 = 180 x 0.6 = 108 bpm	60% of max HR Max HR x 0.6 = (220 -74) x 0.6) = 146 x 0.6 = 88 bpm
Method 2	50% of HRR = (max HR - resting HR) x 0.5 = ((220 - 80) - 100) x 0.5 = 20 bpm Resting HR + 20 bpm = 100 + 20 =120 bpm	50% of HRR = (max HR - resting HR) x 0.5 = ((220 - 40) - 80) x 0.5 = 50 bpm Resting HR + 50bpm = 80 + 50 =130bpm	50% of HRR = (max HR - resting HR) x 0.5 =(220 - 74) - 70) x 0.5 =38 bpm Resting HR + 38bpm = 70 + 38 = 108 bpm

Mean arterial pressure (MAP)

MAP = [(diastolic blood pressure x 2) + systolic blood pressure] / 3

Example 1: 74-year-old patient with blood pressure (BP) of 130 / 85

• MAP = [(85 x 2) + 130] / 3= 100 mmHg (normal)

Example 2: 35-year-old patient with BP of 120 / 80

• MAP = [(80 x 2) + 120] / 3 = 93.3 mmHg (normal)

Example 3: 60-year-old patient with BP of 140 / 90

• MAP = [(90 x 20) + 140] / 3 = 106 mmHg(hypertensive)

Example of putting it all together

Example: 68-year-old with a resting heart rate of 87 bpm and BP of 138/90

• Max HR = 220 - 68 (age) = 152 bpm

• Percentage of maximum capacity = 87 / 152 x 100% = 57%

• Heart rate reserve (HRR) = 152 - 87 = 65 bpm

• MAP = [(90 x 20) + 138] / 3 = 106 mmHg (hypertensive)

• Rate pressure product = 87 x 138 = 12,006

The clinician needs to watch this patient carefully with exercise as there are signs of hypertension (BP and MAP) and RPP of more than 10 000. If the patient keeps on exercising in the clinic, the clinician needs to check the RPP at regular intervals and a linear rise should be noticed, also if RPP reaches 36,000 patient needs to stop exercising.

• Target heart rate (50% of HRR) = (HRR x 0.5) + resting HR =(65 x 0.5) + 87= 120 bpm (minimum)

• Target heart rate (70% of HRR)

= (HRR x 0.7) + resting HR

= (65 x 0.7) + 87

= 132 bpm maximum

Range patient can exercise within = heart rate of 120 bpm to 132 bpm

Risk Assessment

Patient risk is your risk

Before starting your patient on a cardiovascular exercise programme as part of therapeutic exercise prescription, it is important to do an exercise preparticipation health screening.

The American College of Sports Medicine's updated preparticipation health screening algorithm can be used to systematically determine if an individual needs medical clearance before starting an exercise programme. The need for medical clearance before starting an exercise programme is based on:

• the individual's current exercise participation
• history of cardiovascular, metabolic or renal disease
• signs and symptoms that may suggest cardiovascular, metabolic or renal issues
  • these can be at rest or during activity:
    • pain, discomfort in the chest, neck, jaw or other areas that may result from ischaemia
    • angina
    • shortness of breath at rest or with mild exertion
    • dizziness or syncope
    • orthopnoea or paroxysmal nocturnal dyspnoea
    • ankle oedema
    • palpitations or tachycardia
    • intermittent claudication
    • known heart murmur
    • unusual fatigue or shortness of breath with usual activities
• the desired exercise intensity

Below are some examples of health screening recommendations:

• American College of Sports Medicine: Exercise preparticipation health screening recommendations
• You can see the full algorithm in Figure 1 of the following article: Applying the ACSM Preparticipation Screening Algorithm to U.S. adults, NHANES 2001 - 04
• Exercise and Sports Science Australia: Pre-Exercise Screening System (downloadable documents for screening tools and user guides)
• Professionals working with patients with known cardiovascular disease should consult more in-depth risk stratification procedures such as the American Association of Cardiovascular and Pulmonary Rehabilitation's stratification criteria

Table 4. Characteristics of patients at risk for exercise participation (adapted from the AACPR stratification criteria - note this does not include the non-exercise testing findings)

Low level	Absence of angina No shortness of breath No light-headedness No dizziness Normal haemodynamics (appropriate increase and decrease in heart rate and systolic blood pressure)
Moderate risk	Presence of angina Presence of other significant symptoms, such as unusual shortness of breath, light-headedness, dizziness occurring at high levels of exertion
High risk	Presence of complex ventricular dysrhythmias during exercise or recovery Presence of angina Presence of other significant symptoms, such as unusual shortness of breath, light-headedness, dizziness at low levels of exertion Presence of abnormal haemodynamics with exercise, such as decreasing systolic blood pressure with increasing workloads

Blood Pressure Guidelines Before Commencing Exercise

Table 5 provides an overview of blood pressure ranges when considering an exercise programme.

Table 5. Blood pressure levels and ability to safely start exercise (adapted from Blood Pressure UK)

Blood pressure levels	Safe to start with exercise
Below 90/ 60 mm Hg	Hypotensive, consult with a medical professional before starting new exercise
90 / 60 mm Hg to 140 / 90 mm Hg	Safe to be active
140 / 90 mm Hg to 179 / 99 mm Hg	This is high, but it is still safe to be active to help lower blood pressure levels
180 / 100 mm Hg to 199 / 109 mm Hg	High reading! Consult with a medical professional before starting new exercise
200 / 110 mm Hg or above	See a medical professional as soon as possible and do not start with any new activity

Vital Signs

Vital signs should always be taken before, during and after exercise:

• blood pressure during exercise or on exercise testing
  • aerobic exercise and incremental exercise testing cause an increase in systolic blood pressure (SBP) as the exercise intensity increases
    • a normal response is considered a rise of 10 ± 2 mm Hg per metabolic equivalent (MET) to each increase in exercise intensity; it may plateau at peak exercise
  • the 10th edition of the ACSM's Guidelines for Exercise Testing and Prescription defined the upper limit of exercise SBP (achieved at individual maximal workloads) as > 250 mm Hg and the upper limit of DBP as > 115 mm Hg; these levels are regarded as indications to terminate an exercise test. However, "there is little clarity in the literature as to what may constitute normal submaximal or maximal intensity exercise blood pressure, although maximal responses are commonly cited as being SBP <210 mm Hg (men) and SBP <190 mm Hg (women) with DBP <110 mm Hg (both sexes)"
  • a drop in systolic blood pressure of > 10 mm Hg, despite an increase in workload, is an indication to stop exercise
  • diastolic blood pressure should remain the same or slightly drop on exercise
    • an increase of 10 mm Hg = stop exercise
  • the University of Delaware Physical Therapy Clinic provides a blood pressure algorithm, which you can view here. Remember to always apply your clinical judgement and modify measures to meet the needs of the specific patient
• blood pressure categories (measured at rest):
  • 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
  • hypertensive crisis systolic > 180 mm Hg and / or diastolic > 120 mm Hg
• heart rate recovery
  • after stopping peak exercise, there should be a drop of 30 bpm after the first minute
  • a drop of less than 12 bpm in heart rate = sign of heart weakness