Therapeutic Exercise Prescription
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Introduction[edit | edit source]
Exercise Prescription - “A balance between (he)art and science”[edit | edit source]
Proper therapeutic exercise prescription should consider[1]:
- 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:
- 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.[2]
Adherence to Therapeutic Exercise Prescription[edit | edit source]
- 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.[3]
- 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.[3] Read more about goal setting:
- Set goals with your patient based on functional limitations, impairments and activity 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:
Routine Therapeutic Exercise Prescription[edit | edit source]
General therapeutic exercises to include are[1]:
- stretching and mobility exercises – daily
- balance exercises – daily
- strengthening exercises– 3 to 5 times a week
- cardiovascular exercise
- core exercises
Components of Therapeutic Exercise[edit | edit source]
Warm-up[edit | edit source]
- 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[4]
- increased temperature – this allows internal changes such as increased blood flow and metabolic responses[5]
- improved oxygen delivery[6]
- increased blood flow[6]
- faster muscle contraction and relaxation[6]
- improved force development[6]
- improved reaction time[6]
- decreased skeletal muscle viscosity and resistance[6]
- increased compliance of ligaments and tendons[6]
- increased and enhanced metabolic reactions[6]
Range of Motion Exercises[edit | edit source]
Benefits of range of motion exercises include:
- increased blood flow
- increased flow of synovial fluid[7]
- decreases waste in the joint[8]
- decreased pain[9]
Read more about benefits of range of motion exercises here.
Strength Training Considerations[edit | edit source]
Sets: 1 to 3 sets
1 set for untrained populuations
Multiple sets for trained populations and lower extremity exercises
Repetitions
10 repetitions (maximises increase in strength, endurance and power
Establish 1 Repetition Maximum
Working weight should be 60 to 80 % of this
Use superset format
Rest intervals 30 to 60 seconds
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
Single versus Multiple sets
Single set programmes for an initial training period in untrained individuals result in similar strength gains as multiple set programmes
Trained individuals performing multiple sets generated significantly greater increases in strength and were superior to single sets Wolfe et al 2004
Why 10 repetitions
3 X 5 increase in strength
3 X 10 increased in strength, endurance, power
3 x 20 increase in endurance
Davies 1986
Why super sets Kelleher 2010
Super set: sets proceed from one muscle group to another without rest
Super set sets increase the following compared to traditional exercise:
increased energy expenditure
Greater post-exercise oxygen consumption
Supersets increase energy expenditure and have a fixed exercise volume with limited exercise time available
Dosage
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
10 different exercises
Immediate cardio shortens recovery???
Rest Intervals
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
Resting between sets is therapeutic - 50% of ATP/CP stores are replenished after 30 seconds of rest
Inadequate rest intervals during exercises causes:
Increased lactic acid accumulation
fatigue
decreased neuromuscular control
decreased force production
decreased motor unit recruitement
Lactic acid
Excess accumulation signals CNS
Brain responds by sending weaker nerve impulses to working muscles
Results in decreased proprioception and kinesthesia
Decreased performance
Injury
Flexibility
Painful, irritable, hypertonic tissue - 5 to 10 second stretch
Stay less than 4 out of 10 pain
Muscle, a little tight (after exercise)
3 x 30 seconds , 2 to 3 times a day
Very limited muscle length
stretches more than 1 minute long
stay less than 4 out of 10 pain
Joint capsule
20 x 5 seconds or sustained stretch
Creep principle
Cardiovascular training
5 to 7 days a week
Recommendation: 150 minutes of moderate intensity/ week
Aerobic exercise
3 to 5 days a week for 20 to 60 minutes at an intensity that achieves 55 yo 90 % of the maximum heart rate (220 - age)
Risk Assessment
Patient risk is your risk
Low
Medium
High
Vital Signs
Vitals should always be taken before, during and after exercise
Pre-exercise BP greater than 200mmHg systolic or 120mmHg diastolic is a contraindication to exercise
Normal for systolic blood pressure to rise between 160 and 200 mm Hg during exercise
Diastolic should remain the same or slightly drop.
Increase of 10mm = stop
Hypertension
Stage 1 - systolic 140 - 159 Diastolic 90 - 99
Stage 2 - systolic 160 - 179 Diastolic 100 - 109
Stage 3- systolic over 180 Diastolic over 110
Low Risk
No angina
no unusual shortness of breath
No light-headedness
No dizziness
BP 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)
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Resources[edit | edit source]
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References[edit | edit source]
- ↑ 1.0 1.1 Jackson, R. Exercise Prescription. Plus. Course. 2024
- ↑ Demir O, Atıcı E, Torlak MS. Therapeutic and stabilization exercises after manual therapy in patients with non-specific chronic neck pain: a randomised clinical trial. International Journal of Osteopathic Medicine. 2023 Mar 1;47:100639.
- ↑ 3.0 3.1 Wood L, Foster NE, Dean SG, Booth V, Hayden JA, Booth A. Contexts, behavioural mechanisms and outcomes to optimise therapeutic exercise prescription for persistent low back pain: a realist review. British Journal of Sports Medicine. 2024 Feb 1;58(4):222-30.
- ↑ McGowan CJ, Pyne DB, Thompson KG, Rattray B. Warm-up strategies for sport and exercise: mechanisms and applications. Sports medicine. 2015 Nov;45:1523-46.
- ↑ Silva LM, Neiva HP, Marques MC, Izquierdo M, Marinho DA. Effects of warm-up, post-warm-up, and re-warm-up strategies on explosive efforts in team sports: A systematic review. Sports Medicine. 2018 Oct;48:2285-99.
- ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 Bushman BA. The Value of Warm-Up and Cool-Down. ACSM's Health & Fitness Journal. 2024 Mar 1;28(2):6-9.
- ↑ Neves M, de Freitas Tavares AL, Barbosa Retameiro AC, Reginato A, da Silva Leal TS, de Fátima Chasko Ribeiro L, Flor Bertolini GR. Effects of Exercise on The Knee Joint in an Experimental Rheumatoid Arthritis Model. Journal of Morphological Sciences. 2021 Jan 1;38.
- ↑ Roberts HM, Law RJ, Thom JM. The time course and mechanisms of change in biomarkers of joint metabolism in response to acute exercise and chronic training in physiologic and pathological conditions. European Journal of Applied Physiology. 2019 Dec;119:2401-20.
- ↑ Rocha TC, Ramos PD, Dias AG, Martins EA. The effects of physical exercise on pain management in patients with knee osteoarthritis: A systematic review with metanalysis. Revista brasileira de ortopedia. 2020 Dec 2;55:509-17.
