When prescribing exercises, do you tend to automatically prescribe “three sets of ten” without really knowing why you’re doing it?
There’s a lot to consider when prescribing exercises to a patient:
- Where should the patient begin?
- What’s the right dosage?
- How much do I load them?
- What if they report pain during exercise?
Rest assured that you are not alone in asking these questions. A quick overview of the basic science principles behind exercise prescription will help you answer these questions more easily.
Exercise Is Medicine
There is a ton of evidence in support of exercise to decrease pain and improve function across a number of musculoskeletal disorders. Health benefits include everything from increased muscle strength and tone to improved self-esteem. As rehabilitation professionals, we know that in the end, our best intervention with long-standing benefits is exercise. And yet so often we see the three sets of ten prescribed with no real clinical reasoning to support the dose.
Calling the POLICE
The days of RICE and PRICE are gone. Replacing them are the days of POLICE:1
- Optimal Loading
Immediately after an injury, early protection may be the correct approach in an effort to minimize bleeding, prevent further damage to injured fibers, and reduce the risk of aggravating the injury. That said, while protection may be necessary after an acute soft tissue injury, prolonged immobilization can lead to joint stiffness, degenerative changes, and muscle atrophy. For most muscle injuries, two days of immobilization is sufficient!
Optimal loading strategies refers to an active treatment approach that incorporates the principles of mechanotherapy whereby tissue specific mechanical stress is added as early as tolerated in an effort to facilitate tissue repair, remodeling, and tissue tolerance and capacity. In fact, evidence suggests that when progressing rehabilitation, as tissues adapt to changes in the mechanical properties, the sensory information also changes, prompting the central nervous system to also adapt.2 In other words, optimal loading turns movement into repair. The key is for clinicians to determine correct dosage and progression based on the patient’s clinical presentation.
Ice has been central to acute soft tissue management for decades. Authors suggest that cold-induced analgesia and the potential placebo effect warrants its inclusion3 although more recent principles are further questioning its use as it could potentially disrupt inflammation, angiogenesis, and revascularization; delay neutrophil and macrophage infiltration; and increase immature myofibers.4
Compression continues to play a role in acute soft tissue injury, limiting intra-articular edema and tissue hemorrhage, with studies also reporting reduced swelling and improved quality of life.5
Finally, elevation continues to show some evidence supporting its use through promotion of interstitial fluid flow out of tissues.6
Despite the recommendation guidelines for exercise prescription by the American College of Sports Medicine, the prevalence of physical inactivity continues to rise despite sufficient evidence supporting the benefits of exercise.
Why? Because dosage doesn’t capture the health behavior change component included in performing and adhering to exercise.
You’re probably familiar with the FITT principle of Frequency, Intensity, Time, and Type. But something is still missing here. People still aren’t exercising.
The FITTSBALL principle combines the technical domain of FITT with the cognitive-behavioral domain of SBALL:7
- Stage of change
- Belief of client
- Ability of client
- Life satisfaction
It turns out that when it comes to making lifestyle changes, self-efficacy and emotional responses may play a bigger role than the traditional FITT components. By incorporating the cognitive-behavioral domain, the theory of planned behavior—or a focus on the affective/emotional response to exercise—makes individuals more likely to adhere.
For instance, when addressing the “stage of change” component of FITTSBALL, we have to have an understanding of the four phases of each patient’s readiness for change: precontemplation, contemplation, action, and maintenance.
A patient in the precontemplation stage will benefit from education on the value of exercise for preventing or managing a condition while a patient in the contemplation stage can benefit from an opportunity to exercise to help them become more comfortable with the behavior while you discuss how these actions will help them meet their short- and long-term goals. Support to deal with any limitations should also be provided.
Be the Practitioner of Choice
Always know your “why” when you are prescribing exercise. As rehabilitation professionals, we must be the experts in exercise prescription using best practice guidelines when selecting treatment, overall dosage, and progression.
Therapy and exercise have the ability to improve lives, but only if they are prescribed appropriately. Failed outcomes and outcomes equivalent to placebo may simply be a reflection of underdosing, which shows no real effect.
To learn more about exercise prescription, please check out “A Primer on Exercise and Treatment Prescription.” In this course, I review the basic science principles of therapeutic exercise including tissue healing and mechanotransduction principles,8 as well as exercise prescription training principles and variables in accordance with the updated American College of Sports Medicine guidelines, characteristics of optimal loading treatment principles, tissue-specific mechanical properties, and best loading principles according to tissue-specific mechanical properties.
- Bleakley, C. M., Glasgow, P., & MacAuley, D. C. (2012). PRICE needs updating, should we call the POLICE? British Journal of Sports Medicine, 46, 220–221.
- Glagow, P., Phillips, N., & Bleakley, C. (2015). Optimal loading: key variables and mechanisms. British Journal of Sports Medicine, 49, 278–279.
- Ernst, E. & Fialka, V. (1994). Ice freezes pain? A review of the clinical effectiveness of analgesic cold therapy. Journal of Pain and Symptom Management, 9(1), 56–9.
- Singh, D. P., Lonbani, Z. B., Woodruff, M. A., Parker, T. J., Steck, R., & Peake, J. M. (2017). Effects of topical icing on inflammation, angiogenesis, revascularization, and myofiber regeneration in skeletal muscle following contusion injury. Frontiers in Psychology, 8, 93.
- Block, J. E. (2010). Cold and compression in the management of muculoskeletal injuries and orthopedic operative procedures: a narrative review. Open Access Journal of Sports Medicine, 1, 105–113.
- van der Bekerom, M. P. J., Struijs, P. A. A., Blankevoort, L., Welling, L., Niek van Dijk, C., & Kerkhoffs, G. M. M. J. (2012). What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults? Journal of Athletic Training, 47(4), 435–443.
- Ranasinghe, C., King, N. A., Arena, R., & Hills, A. P. (2019). FITTSBALL—a dynamic tool for supervision of clinical exercise prescription. Disability and Rehabilitation, 41(26), 3216–3226.
- Khan, K. M. & Scott, A. (2009). Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair. British Journal of Sports Medicine, 43, 247–252.