Therapeutic Exercise Prescription: Difference between revisions

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== Introduction ==
== Introduction ==
Exercise prescription


“A balance between (he)art and science”
== Exercise Prescription - “A balance between (he)art and science” ==
Proper therapeutic exercise prescription should consider<ref name=":1">Jackson, R. Exercise Prescription. Plus. Course. 2024</ref>:


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


Appropriate exercise for a specific patient on a specific day
* the phases of healing when prescribing therapeutic exercise
** if you'd like you can read more about:
*** [[Injury and Healing Within Sports Physiotherapy|Injury and healing with sports physiotherapy]]
*** [[Soft Tissue Healing|Soft tissue healing]]
*** [[Bone Healing|Bone healing]]
* the patient’s tolerance level


Exercise protocols can be used when appropriate, but it has to match with the patient on the day
* 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.<ref>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.</ref>


the phases of healing when prescribing therapeutic exercise
=== Adherence to Therapeutic Exercise Prescription ===


the patient’s tolerance level
* 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.<ref name=":0">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.</ref>
** Ways to develop trust is by building a [[Therapeutic Alliance|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.<ref name=":0" /> Read more about goal setting:
** [[SMART Goals]]
** [[Goal Setting in Rehabilitation|Goal Setting in rehabilitation]]


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


Adherence to Therapeutic Exercise Prescription
* 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:
** [[Insights into Rehabilitation in Sport#Adherence to Rehabilitation|Adherence to Rehabilitation]]
** [[Adherence to Home Exercise Programs|Adherence to home exercise programmes]]
** [[Exercise Adherence in Patients With Ankylosing Spondylitis|Exercise adherence in patients with ankylosing spondylitis]]


Patients' engagement with therapeutic exercise, their adherence to the prescribed exercises and the outcomes can be strengthened when “the mechanisms of trust, motivation and confidence are activated.” 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. 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. 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.
=== Routine Therapeutic Exercise Prescription ===
General therapeutic exercises to include are<ref name=":1" />:


Read more about goal setting: SMART Goals and Goal Setting in Rehabilitation
* stretching and mobility exercises – daily
* balance exercises – daily
* strengthening exercises– 3 to 5 times a week
* cardiovascular exercise
* core exercises


Set goals with your patient based on functional limitations, impairments and activity restrictions. The International Classification of Functioning, Disability and Health Framework is a valuable tool.
=== Components of Therapeutic Exercise ===


Select the correct level of exercise for the patient on that specific day and progress as tolerated.
==== Warm-up ====


Routine Therapeutic Exercise Prescription Barker K, Eickmeyer S. Therapeutic exercise. Medical Clinics. 2020 Mar 1;104(2):189-98.
* 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<ref>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.</ref>
** increased temperature – this allows internal changes such as increased blood flow and metabolic responses<ref>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.</ref>
** improved oxygen delivery<ref name=":2">Bushman BA. [https://journals.lww.com/acsm-healthfitness/fulltext/2024/03000/the_value_of_warm_up_and_cool_down.4.aspx The Value of Warm-Up and Cool-Down.] ACSM's Health & Fitness Journal. 2024 Mar 1;28(2):6-9.</ref>
** increased blood flow<ref name=":2" />
** faster muscle contraction and relaxation<ref name=":2" />
** improved force development<ref name=":2" />
** improved reaction time<ref name=":2" />
** decreased skeletal muscle viscosity and resistance<ref name=":2" />
** increased compliance of ligaments and tendons<ref name=":2" />
** increased and enhanced metabolic reactions<ref name=":2" />


Stretching and mobility exercises – daily
==== Range of Motion Exercises ====
Benefits of range of motion exercises include:
* increased blood flow
* increased flow of synovial fluid<ref>Neves M, de Freitas Tavares AL, Barbosa Retameiro AC, Reginato A, da Silva Leal TS, de Fátima Chasko Ribeiro L, Flor Bertolini GR. [https://www.researchgate.net/publication/356771791_Effects_of_Exercise_on_The_Knee_Joint_in_an_Experimental_Rheumatoid_Arthritis_Model Effects of Exercise on The Knee Joint in an Experimental Rheumatoid Arthritis Model.] Journal of Morphological Sciences. 2021 Jan 1;38.</ref>
* decreases waste in the joint<ref>Roberts HM, Law RJ, Thom JM. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6858392/pdf/421_2019_Article_4232.pdf 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.</ref>
* decreased pain<ref>Rocha TC, Ramos PD, Dias AG, Martins EA. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7575366/pdf/10-1055-s-0039-1696681.pdf 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.</ref>


Balance – daily
Read more about benefits of range of motion exercises [[Range of Motion#Range of Motion Exercises & Stretching|here]].
 
Strengthening – 3 to 5 times a week
 
Cardiovascular
 
Core exercises
 
Read more about Physical Activity Guidelines:
 
Warm-up
 
This should be cardio intensive exercise
 
Why warm-up:
 
Beneficial to performance
 
increased temperature – this allows internal changes such as increased blood flow and metabolic responses 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.
 
Increase heart rate
 
Breathing rate
 
Range of Motion
 
Increases blood flow
 
Increased flow of synovial fluid
 
Decreases waste in the joint
 
Decreases pain
 
Read more about benefits of Range of Motion here: Pp page
 
Strength Training Considerations


==== Strength Training Considerations ====
Sets: 1 to 3 sets
Sets: 1 to 3 sets


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Immediate cardio shortens recovery???
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)


== Sub Heading 2 ==
== Sub Heading 2 ==

Latest revision as of 17:26, 25 March 2024

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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
  • 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:

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)


Sub Heading 2[edit | edit source]

Sub Heading 3[edit | edit source]

Resources[edit | edit source]

  • bulleted list
  • x

or

  1. numbered list
  2. x

References[edit | edit source]

  1. ↑ 1.0 1.1 Jackson, R. Exercise Prescription. Plus. Course. 2024
  2. ↑ 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. ↑ 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.
  4. ↑ 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.
  5. ↑ 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. ↑ 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.
  7. ↑ 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.
  8. ↑ 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.
  9. ↑ 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.
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