Exercise Prescription: Are You Really a Movement Expert?

Prescribing Exercise in Physical Therapy

 

I wanted to write this blog post to call out all of my fellow physical therapists. This topic has been on my mind for a while, and I have seen several related posts by the likes of Scot Morrison, Jason Silvernail, and Roderick Henderson just to name a few. As physical therapists, we often claim to be THE movement and exercise specialists. I love that this mantra is so entrenched into our mindset and culture. However, and I absolutely hate to admit this, but much of the time I don’t necessarily agree with this statement. As I get further into my career, I continue to meet more and more physical therapists that fail to have a specific plan when prescribing therapeutic exercise. There doesn't seem to be a plan to improve a patient’s strength or tax their system with the intent of causing adaptation to overload.

At so many of the clinics I have seen, as well as talking with many of my colleagues, it is evident that there are droves and droves of patients in PT clinics across America performing every exercise on their flow sheet for 20 reps with a yellow or red theraband. There is no set scheme, no rep scheme, no focus on strength, no focus on endurance, no focus on power, and no focus on progressive overload. A lot of clinicians are going to read this and know that they fall into that group, and I personally (as well as the APTA) feel that this is unacceptable. Hence why the APTA joined the choosing wisely campaign and placed this issue as number 2 on the list.

We cannot be a “doctoring profession” focused on exercise and not fully grasp and implement the basic concepts of strength training and the body’s response to the stimuli we load it with. The body is a system (an incredibly complex system) that you apply an input or stimulus to and will ultimately get a result or adaptation out of. Not enough stimulus and the system weakens, too much stimulus and is breaks down, and with just the right stimulus you elicit desired effects of increasing tissue tolerance/strength. The desired outcome of exercise should be some form of adaptation to the patients neuro-musculo-skeletal system. However, without a strong enough stimulus there is not enough stress to the body to stimulate an adaptation.

At the root of training/rehab, specificity and overload are the two main principles that everything boils down to. Overload can be described as some form of stimulus that is ample in strength, duration, and/or frequency that it forces an organism to change or adapt by improving the capacity of the structures that those demands were placed upon. Variation requires the manipulation of training variables, which ultimately will result in changes in the overload stimulus. To address this you can think of training at a variety of different rep ranges with varying loads to achieve a variety of different stimuli. Additional examples of modifiable variables could be total volume or speed of movement.

I’m not suggesting that we need to implement undulating or blocked periodization programs for each patient. I am however, implying that we should at least be using critical thinking skills daily when choosing what weight to hand them, how many sets, and how many reps we ask them to do. Are you trying to improve motor control? Are you trying to improve endurance? Are you trying to improve strength? We need to take a page from the strength and conditioning coaches' books and attempt to make people stronger. To do that, it is essential to at least understand the basics of what causes hypertrophy, strength gains, and improved neuromuscular endurance.

When appropriate, try pushing a patient close to muscular failure in specific rep ranges instead of grabbing the smallest dumbbell and arbitrarily prescribing 30 repetitions. See where THEY ACTUALLY FATIGUE and what their capacity is. Then use strategies to progressively overload this and cause positive adaptation. I often have 2xfailure or 3xfailure written on my flow sheet.  Give patients the value that their copays and insurance payments are meant for. Don’t check your brain at the door and give every patient the same exercises and repetitions all day long. They deserve better and so does the profession of physical therapy. Make an attempt to become the movement experts we claim ourselves to be.

-Jarod Hall, PT, DPT, CSCS

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