By Jesse Elis PT, DPT, CSCS, FAAOMPT
Exercise…. the therapeutic tool that slowly has faded into obscurity. Not only have we lost respect for the value it provides, but we have also forgotten the proper application. The irony of our current practice standards is the skill that made our profession unique has been willfully and knowingly surrendered to care extenders. The fact that we surrender this tool and still expect to be considered expert is both foolish and imprudent. In worst cases, it can even be used strategically to account for lost clinical time and allow the PT to catch up with documentation or other patient treatments. In either instance, the application of exercise feels more like a meaningless commercial than the featured show. Consistency across the spectrum of the profession is significantly lacking. Genuinely therapeutic exercise should be based on the foundational sciences of physics, biomechanics, anatomy, and physiology, but instead many PTs get lost in overly complicated and sometimes fabricated systems or algorithms. After reflecting on my own formal education from PT school, the principles of exercise science were barely addressed and there was poor carryover from the mentioned foundational sciences. In most cases, the fate of early “development” of exercise was up to the selected clinical rotation placement or… hours of Youtube viewing. Either option is pitiable knowing the clinical importance it provides in restoring function. A robust education on proper exercise principles would be an ideal foundation allowing students to feel confident walking into their clinical rotations. I decided to provide some clinical insight on the art of exercise prescription. I do this understanding that it is an extensive topic with many different opinions and I’m sharing my view from a few selected factors within the rehabilitation setting.
3 sets x 7 reps said no PT…ever
The first sign of clinical laziness…. 3 x 10 reps. I am not sure how this even worked it’s way into physical therapy. In the 1940’s DeLorme did a study for the army where he determined that a 10 repetition maximum load was optimal for strength development. This was defined as a level where temporary failure of the targeted muscle(s) was reached, such that the subject could not perform an additional repetition. However he also determined that the muscles needed to be warmed up prior to this maximal exertion and indeed settled on 3 sets of 10 but with the 1st set at 50% maximum, the 2nd at 75%, and the final at maximal load. Now the 3 x10 is a mainstay to exercise prescription, but isn’t even done accurately. When deciding appropriate volume, there are many different principles to address but here are a few to follow: (1) functional capacity, (2) required muscular demand, and (3) kinesthetic awareness.
Functional capacity is the figurative “battery power” of a muscle. If a muscle is extremely deconditioned or in an excessively lengthened or shortened position, the muscle’s capacity to continuously fire will be diminished. When training functional capacity, set and rep totals should be low to allow the muscle group to build foundational neurological “strength” while minimizing compensation patterns. Many times, the patient will need to have modified positioning either to challenge gravity or neutralize its effect.
Muscular demand is related to the extent of work required for a specific muscle group and adaptation to lifestyle. Certain muscle groups such as rotator cuff/rhomboids/lower trap have a demand of constant activation at a very low firing intensity. With the noted specificity, sets should be moderate to high with higher rep totals and less resistance. To make it more practical and easy for the patient, I will recommend an exercise be performed until it’s fatigued or form is no longer sustainable. I usually relate it to an example of bench pressing and you stop on the last rep that you know you can successful push up without a spot, or if they’re algebra fans I use the equation (x – 1).
Kinesthetic awareness is related to proper sequencing and is responsible for movement quality. At times, there is an underlying dyskinesia that needs to be addressed and cueing is essential to help provide the needed feedback to be successful. When a dyskinesia is present, I usually will keep the reps and sets at a lower volume but really focus on a higher frequency variable. Patients need to be consistently focusing on improving the dysfunctional motor pattern throughout the day, so I try to prescribe an exercise that can be completed in any setting, at any time.
Cueing is critical
A point to stress when instructing on an exercise, especially for a home program, is the importance of focus. An exercise is addressing the physical capacity but should also require mental participation. It is all too common to see patients completing exercises with little attention. If done with that level of commitment, there’s a good chance that the purpose of the exercise isn’t understood, or that the execution of the maneuver isn’t challenging enough as both mental and physical stimulus should provide engagement. Visual/tactile/verbal cues are essential, not only for correction but facilitation. Recapping with the patient the common errors found and reviewing 1-2 cues that led to success will help with compliance and effectiveness (especially if it's included in the HEP). For convenience to both PT and patient, I like to provide the cues while I’m recording the exercise on his/her phone.
Facilitate before strengthening
The mindset of facilitation is different than wanting actual gains in strength capacity. Many times I will promote a muscle group through facilitation techniques (PNF, place and holds, reciprocal inhibition of the antagonist, quick stretches) prior to strengthening. In general, PNF principles follow the rule of applying a sufficient amount of force but not causing a cessation of movement. Separate to PNF, I also have found benefits in applying a spinal manipulation not only to restore mobility but also for facilitation. A 2004 study by Cleland et al, showed the immediate changes in EMG activation to the lower trap after a directed thrust to the lower thoracic spine. Pragmatically, I can apply a very quick technique to make a short-term gain to promote long-term change. To elaborate, I will strategically apply a spinal thrust prior to the application of isolated exercises in hopes to improve the effectiveness of muscular firing and carryover to function.
Teach them to Fish
PTs need to remember the value of teaching patients how to fish and not provide them a meal. The best treatment option for the patient is the one that he/she can complete to make a therapeutic change. In general, we as PTs have a tendency of stepping up to be the hero when truly we need to step back and be the educator. Follow up visits should always consist of reviewing the established HEP to check on form and effectiveness. There are three key reasons why you should integrate this clinical habit: (1) to simply check if he/she is doing it correctly, (2) the reiteration of clinical importance and (3) to confirm that it is genuinely therapeutic and assisting the patient to attain his/her goals. Not to mention, if you choose not to re-address the HEP, it truly exposes where this intervention falls on the priority list. By valuing the HEP at such a high level, the chances of non-compliance will steadily drop. Value in = Value out.
Another strategy that I find useful with HEP compliance is to simply change the terminology. Instead of the label, “exercise”, I have found improved focus when I’ve address the exercise as self-treatment or a self-management technique. By simply changing the designation, it creates a heightened sense of independence while cultivating an increase in compliance longevity.
In addition, the investment of believing in a positive expectation may actually be more important than selecting the correct exercise. With the extensive literature behind the value of placebo effect and positive expectations, it would be a wasted opportunity to not use this to your advantage. Humans are very intuitive…unless they’re on their phones, then they are useless. Intuitive recognition of the clinician’s confidence towards a self-management technique can effectively promote a positive expectation from the patient. If the PT believes the intervention will be helpful and emulate that belief with confidence, there’s a good chance the patient’s status will essentially change in a positive manner. Believe in what you sell!
Creativity is not a lack of ideas... It's a lack of effort
Not only is it a lack of effort, it’s a loss of emphasis of principles. The importance of clinical understanding should be directed toward the functional goal, not measured by the sheer volume of exercise nor the level of complexity but the actual application. The question should be “what are you trying to achieve” and that vague investigative question provides an open canvas for creativity. Applying the correct exercise should be based on a few variables: functionality, practicality, attainability, and buy-in factor.
With the current clinical attention on manipulation, dry needling, and pain sciences, we need to always remember exercise is intentional movement and that movement is the driver to activity and function. The ability to move in a pain-free manner can cause neurophysiological changes that passive treatments can provide and pragmatically breaks down fear-avoidance behavior, which is addressed with pain science education. It’s the “glue” that bonds the other treatments and should always be central to care. As a profession we laid claim to being movement specialists, shouldn’t we then focus on movement with the intent of enabling patient independence in their desired movements? Let’s make sure we avoid clinical laziness and take a conscious effort in developing appropriate exercise programs and HEP.
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Todd JS, Shurley JP, Todd TC. Thomas L. DeLorme and the science of progressive resistance exercise. J Strength Cond Res. 2012 Nov;26(11):2913-23.
Cleland J., Selleck B., Stowell T., Browne, L., Alberini, S., Cry H., Caron T., Short-Term Effects of Thoracic Manipulation on Lower Trapezius Muscle Strength. Journal of Manual and Manipulative Therapy. July 18, 2013: 82-90.