By Michael Edgar
Throughout my time coaching and short clinical career, I have had many individuals, especially keen students, hoping to better understand how and when to prescribe exercise in a rehabilitative setting. In a follow-up to Elliott’s article titled, “The Dose Makes The Medicine: Exercise Rehabilitation” I aim to give some of the rationale I use when performing various types of exercise. I will forewarn that this will not be a standard research review (if you were hoping to get bombarded with research citations, please read ‘Breathing and Bracing Part 1 and 2’). This will more so be a commentary piece on my perspective when it comes to assessment and tailoring exercise to the person in front of me.
In a clinical setting, I generally view physical activity and exercise as having five primary objectives. These are immediate pain relief, cardiovascular health and fitness, tissue tolerance, balance, and goal-oriented/activities of daily living (ADLs). This is not an exhaustive list by any means, and they are not done in isolation from one another as each category typically overlaps with one another. Ideally, my goal as a coach or clinician is to try to find as few movements a person can perform that can fall within each category.
Immediate Short Term Pain Relief
The first category of immediate pain relief is a bit of a loaded one as we typically do not have a standardized way to prescribe exercise for this. If you’ve read any of our articles or listened to any of our podcasts, this isn’t exactly a surprise given how multi-factorial pain is (Insert cup of water or smoke alarm analogy). That being said, if we can at least accept that non-specific short term pain relief is a possibility with almost any mode of conservative care, yes even passive care, then we can explore different movements to see what may bring relief. Most individuals may not feel comfortable with the idea of ‘exploring movement’ with this objective, as it appears unorganized, and if there is one thing a musculoskeletal therapist and coach doesn’t like, it’s not having a clear protocol for assessment. So how can we take our traditional means of assessment and adapt them to this context? This may be as simple as reframing your questions and intent during range of motion (ROM) assessments.
For example, you may have a patient come in with non-specific low back pain (Ew…get that diagnosis away from me!) and during your range of motion assessment, you and the patient agree that no gross limitations are present (shared decision making is still important in this context), with moderate pain bending over. What has this really told you from an exercise prescription standpoint? Probably not much, but maybe adding a simple question such as, “Does that position relieve any of your pain?” can allow you to find an entry point to movement and help the patient understand that they hold some control over their symptoms. Using this example, the patient states they feel mild relief with extension of the lower back. So, from here, we could do something as simple as repeating extension 10 times in a row or holding the position for a prolonged period to see if pain levels dissipate more. Perfect, you just took the first step in exploring movement from an immediate pain relief lens.
Cardiovascular Health and Fitness
Cardiovascular exercise is a bit of a misnomer, as it is not simply exercise for the cardiovascular system, but it does involve exercise that causes an elevated heart rate under submaximal loads for a prolonged period. Other names for this can include endurance training or aerobic exercise, and for the sake of this article, we will use ‘aerobic exercise’ moving forward. Aerobic exercises offer a multitude of independent benefits which one does not typically receive during traditional resistance training. These effects are also independent of body composition changes. (1)
Regarding the clinical presentation, assessment, and prescription, this may be done through several means. For example, if an older adult patient comes in with lumbar spinal stenosis with associated vascular claudication, impairing their ability to walk long durations, in addition to comorbid cardiovascular disease and/or diabetes, the imperative to include some form of aerobic exercise becomes even more important. (Carlo Ammendolia at Mount Sinai is a wealth of knowledge in this area – Episode 15 ARME Radio) An assessment may include a basic walking screen to determine duration, distance, or speed before volitional fatigue. Given the ease of access to various smart technologies or even a basic pedometer, these can also offer an objective means for assessment and progression with most patients. (2) Again, the goal is to find an entry point and to progress from there. If we find the patient can walk 15 minutes straight before fatigue, we may introduce a plan that includes two 10-minute walking sessions per day and build up from there. We could also aim to have the patient walk for 15 minutes straight at a lower cadence/intensity and see if symptoms reduce. If we find walking is too symptomatic for the time being or other issues are present, such as balance problems which increase the risk of falls, we could see if they have access to aerobic exercise equipment, such as a stationary bicycle. The goal here is always to introduce the lowest degree of modification to find one’s entry point.
Tissue Tolerance
Now, let’s talk about tissue tolerance, or in other words, the golden goose, the apex bias, or the strength and conditioning coach’s ultimate trump card when it comes to exercise prescription. Exercise aimed at tissue tolerance is traditionally done through a standard training plan. This is because musculoskeletal tissues adapt through load and as such, are easily prescribed through our basic training variables such as sets, repetitions, weight, exercise type, range of motion, intensity, rest time and tempo, to name a few (see again The Dose Makes the Medicine). Progressive overload is king. In this setting, we are generally interested in exercises which will improve the strength, muscle or bone mass of our patients and clients.
You have a 19-year-old male soccer player who comes in with a history of repetitive groin strains once his competitive season started with hopes that you can help him reduce his risk of future injury. He brings in diagnostic imaging which does not show any complete tears of the adductor compartment musculature, and no other emergent conditions. He states that ever since he had his last growth spurt, he feels skinny and not as confident in the gym. You ask him what his training plan consists of, and he states that he does aerobic training on the treadmill for 60 minutes, 3 times per week with no form of resistance training.
Upon discussion, you find out that he really enjoys the idea of resistance training but is too afraid to try it, as he is unsure how to start. After doing a basic assessment, screening for red flags, range of motion, vitals, and a basic neurological assessment, you find nothing of relevance. Perfect, you just found the ideal patient to put your strength and conditioning (S&C) hat on for. In this context, bringing the patient to the gym and teaching him some fundamental movements which can be progressed through loading may be an appropriate first step. Exercises could include the standard compound movements, such as squats, deadlifts, lunges, presses, and rows. If we wanted to get more specific, given his sport and the work done through FIFA 11+, the Copenhagen adductor drill may be an appropriate evidence-based exercise.(3) We could also regress or progress the exercise dependent on his strength and endurance through the various S&C parameters listed above. Another thing to consider is his desire to add body weight, ideally muscle mass, in which volume will be the primary driver of results (Refer to hip thrusters – king of the booty builders).
Balance
The area of balance in exercise prescription is usually not discussed in most clinical practices, I assume because it’s not as glamorous, but it probably is one of the best tools we have when building confidence and reducing the risk of falls in older adults.(4) When it comes to fall prevention, I would argue that balance training reigns supreme, but when do we decide to focus on this key element and how do we prescribe and progress it?
When in a clinical setting, balance training typically holds significant relevance to older adults, especially those living independently, and whose BMD is low. It also is extremely important to be aware that true ‘ foot drop’ is a large risk factor for falls given impaired gait. When it comes to prescription of balance exercises, this simply requires reframing our assessment tools. Most clinicians perform gait assessments with patients, including heel and toe walking. We also have patients perform a Rhomberg’s test or tandem gait. If we reframe our approach to these tests, we can easily find an entry point towards its use as an exercise for self-management purposes. For example, a Rhomberg’s test can be modified to have the patient hold it for longer durations, use of a narrower or wider stance, or perform it with their eyes open instead of closed. Each of these parameters can be recorded and progressed as the patient improves. We can also do the same with tandem gait, or heel and toe walking, using a wider or narrower gait, or using the parameters for aerobic exercise, such as cadence, speed, duration, and distance.
We’ve now taken a basic assessment tool and individualized it to the person as a means of intervention. We could also look to the standard balance exercises, such as a star excursion, in which we modify how far out one reaches with their feet (how big they make the star). Finally, we could incorporate something as simple as Tai-Chi, which may also offer the added benefit of social support and cultural relevance. At the end of the day, it’s all about…balancing what is meaningful and what is needed by the patient in front of you.
Goal-Oriented and Activities of Daily Living (ADLs)
Goal-oriented and ADL-based exercise prescription is a little bit fickle. There are standard movements that are considered requirements for most individuals’ ADLs, such as a sit-to-stand and step-up, but this also becomes much more individualized dependent on the requirements of that person’s daily life and what they enjoy.(5-6) With this in mind, the best approach is simply to ask, “What are some things you typically enjoy doing but are unable to?” The big thing when taking this approach is to find concrete examples and tasks.
A second perspective to take when prescribing exercises in this context would be in relation to patients suffering from chronic widespread pain impairing their daily lives (this approach would be taken after appropriate diagnostic testing to rule out any serious pathology which could be manifesting as widespread pain). The use of exercise in this context is highlighted by Toronto Rehabilitation Institute’s (TRI) comprehensive integrated pain program. Some patients would present with a multitude of pain sites of unknown etiology, in which a standard conservative approach to pain management through localized exercise rehabilitation simply did not work. In this setting, we typically re-approached our primary objective to helping them regain some function in their daily lives, which would hopefully offer secondary improvement towards their pain (some may argue that this is never an appropriate response but that is a debate for another day). This was done through referral to the RECOUP program, a coaching-based inter-professional program at the hospital. On our part, this involved some basic pain and autoregulation education, such as through the ‘traffic light’ analogy, anchoring their ability to perform an exercise to an activity they have to do daily for themselves.
For example, an older adult patient came into the clinic with mild low back pain and a limited ability to garden with his wife, causing some resentment in their relationship. After looking at his imaging and diagnostic tests, it showed that he had an old insufficiency fracture and DXA imaging indicated that he was slightly more than one standard deviation below the average T-score for bone mineral density (BMD). He was osteopenic. During clinical testing, it was found that he had sarcopenia. So, knowing what we know now, this may be a great time to take a ‘goal-oriented/ADL’ perspective in the context of exercise prescription. Luckily, Ben wrote an article on this topic specifically.
Moving back to our example case, we simply included a ‘sit-to-stand’ and ‘step-up’ assessment counting repetitions until volitional failure. This gave us an entry point and starting point to progress him through the various S&C parameters. We also went through some of the typical tasks the patient would have to do in the context of gardening. What was discovered was that prolonged periods of bending over were inciting his pain and instilling fear towards gardening. Instead of simply avoiding bending over, we modified his approach to the movement, using a predominant hip hinge and shifting his weight back towards his heels to offload the sensitive tissues. We also found that a staggered stance reduced his pain. Him and his wife both had a sense of relief and understanding, realizing that pain isn’t black and white, and by doing something as simple as modifying the movement slightly, he could get back to something he truly enjoyed doing. As Bronnie Thompson would say, “It is meaningful movement.”
To Wrap Up
This is not an ‘end all, be all’ article on every approach and perspective to exercise prescription, nor is it a way to neatly package every exercise you give a patient, as none of these categories are mutually exclusive. It is simply a way to view assessment and prescription of exercise, and potentially a means to see the multitude of benefits exercise has. There are countless other approaches to exercise, such as through ‘play-based’ assessment and rehabilitation, which offers a unique benefit in the area of fear-avoidance. Remember, conservative care for musculoskeletal pain is a messy topic and we typically are figuring things out as we go. When you start to embrace the chaos, you can start to be more flexible in your approaches and cater to what matters to the person in front of you.
References
Wewege MA, Thom JM, Rye KA, Parmenter BJ. Aerobic, resistance or combined training: A systematic review and meta-analysis of exercise to reduce cardiovascular risk in adults with metabolic syndrome. Atherosclerosis. 2018 Jul 1;274:162-71.
Tomkins-Lane CC, Lafave LM, Parnell JA, Rempel J, Moriartey S, Andreas Y, Wilson PM, Hepler C, Ray HA, Hu R. The spinal stenosis pedometer and nutrition lifestyle intervention (SSPANLI): development and pilot. The Spine Journal. 2015 Apr 1;15(4):577-86.
Harøy J, Thorborg K, Serner A, Bjørkheim A, Rolstad LE, Hölmich P, Bahr R, Andersen TE. Including the Copenhagen adduction exercise in the FIFA 11+ provides missing eccentric hip adduction strength effect in male soccer players: a randomized controlled trial. The American journal of sports medicine. 2017 Nov;45(13):3052-9.
Thomas E, Battaglia G, Patti A, Brusa J, Leonardi V, Palma A, Bellafiore M. Physical activity programs for balance and fall prevention in elderly: A systematic review. Medicine. 2019 Jul;98(27).
Zhang F, Ferrucci L, Culham E, Metter EJ, Guralnik J, Deshpande N. Performance on five times sit-to-stand task as a predictor of subsequent falls and disability in older persons. Journal of aging and health. 2013 Apr;25(3):478-92.
Kato Y, Islam MM, Koizumi D, Rogers ME, Takeshima N. Effects of a 12-week marching in place and chair rise daily exercise intervention on ADL and functional mobility in frail older adults. Journal of physical therapy science. 2018;30(4):549-54.