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 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:
  • Adherence to Rehabilitation
  • Adherence to home exercise programmes
  • Exercise adherence in patients with ankylosing spondylitis

Routine Therapeutic Exercise Prescription

Barker K, Eickmeyer S. Therapeutic exercise. Medical Clinics. 2020 Mar 1;104(2):189-98.

Stretching and mobility exercises – daily

Balance – daily

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

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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