Exercise prescription and basic principles of therapeutic exercise

Author(s): Kim Barker, MD and Austin Johnston. DO

Originally published:10/22/2013

Last updated:3/23/2017

1. OVERVIEW AND DESCRIPTION

Exercise is the most underutilized treatment option in modern healthcare where the emphasis is often placed on medications or procedures. The benefits of exercise have been researched and documented by many groups and agencies over at least the past 25-30 years. The American College of Sports Medicine (ACSM), U.S. Centers for Disease Control and Prevention (CDC), the U.S. Surgeon General, and the National Institutes of Health (NIH) have issued landmark publications on physical activity and health.1,2,3 An exercise program including aerobic, resistance, flexibility, and neuromotor training is indispensable to improve and maintain physical fitness and health.4

Exercise has been shown to:

  • Benefit cardiovascular and respiratory function
  • Reduce cardiovascular disease risk factors
  • Decrease morbidity and mortality
  • Decrease anxiety and depression5
  • Reduce pain.6
  • Improve cognitive function
  • Enhance physical function and independent living in older individuals
  • Enhance feelings of well-being
  • Reduce risk of falls in older individuals
  • Prevent or mitigate functional limitations in older adults
  • Enhance performance of work, recreational and sport activities.5

Exercise and physical activity are often overlooked as a prescription or remedy for physical or mental afflictions but may be among the oldest forms of treatment. Prescribing exercise can be challenging, as many patients look for an ‘easy fix’.  When appropriately provided, exercise can be a very effective long-term treatment for many conditions.7 While the benefits of exercise are well-researched and well-defined, exercise prescription requires careful consideration tailored to individual needs. The U.S. Department of Health and Human Services (HHS) published Physical Activity Guidelines in 2008, with recommendations for specific populations. For adults, key guidelines are to avoid inactivity and to aim for at least 150 minutes a week of moderate-intensity aerobic activity, or 75 minutes a week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic activity. Children and adolescents are encouraged to perform 60 minutes or more of physical activity daily, including aerobic, muscle-strengthening and bone-strengthening activities.8 While these recommendations provide a general target for most of our patients, others need specific directions. Exercise prescription should be designed to meet the specific needs of individual patient, geared to their comorbidities and age.  Physical therapists and athletic trainers can be valuable resources in developing a patient’s program. Exercise prescription involves careful screening including history and physical examination to determine a patient’s capacity for physical activity, as well as a survey of goals and interests. Evidence shows that the benefits of regular physical activity are clear and far outweigh the inherent risk of adverse events.9 Evaluating for issues such as cardiovascular, pulmonary and metabolic health is an important part of an initial assessment.10

There are several methodologies to exercise prescription.

One method utilizes the FITT 10 protocol: Frequency, Intensity, Time and Type. The ACSM also recommends the FITT-VP (Frequency, Intensity, Time, Type, Volume and Progression)4,5 principle of exercise prescription. Each component of the prescription provides a patient with specific information to incorporate aerobic, resistance, flexibility and neuromotor exercise training into a fitness program,5 and parallels the format of a typical medication prescription. An effective home exercise program should be individualized and be directed to help the individual develop fitness, maintain health, and/or treat specific conditions.7 Special consideration needs to be placed on pain, which can serve both as a barrier or compensation leading to failure11. Patients should be counseled on appropriate timing to advance or reduce his or her exercise program. The person performing the exercise should be focused on maintaining proper form and how his or her body feels while doing it. Insistence on perfect technique will allow the patient to reach much higher levels of challenge, while increasing their strength and endurance gains with less risk of pain or injury. Finding the optimal dosage of load is also critical.12 As the volume or quantity of the exercises builds, the patient may feel overwhelmed and at risk to abandoning the prescription. If a patient cannot perform the exercise due to pain, muscle tension or fatigue, various tools should be made available to the patient, such as  medications – topical, oral, or injected – or other modalities such as manual therapy, massage, TENS, etc., to facilitate the exercises.13 Lastly, a home exercise program should prepare the patient for his or her activities, fitness needs/goals, occupation, sport, or recreational activities. Many well-intended practitioners prescribe exercises that are appropriate and fit the suggestions above, but do not assist the patient in returning to the desired job, or activity because the home exercise program can only be performed in positions that are not supported by their environment; for example, supine exercises for low back tension given to a production line worker. Other exercises can potentially put the area to be treated under too much strain, such as using resistance bands or weights to “strengthen” a still painful rotator cuff injury.

Greenman discusses restoring length, strength and control of muscle function as the process of treating muscle imbalances. A successful exercise program restores nervous system control of muscle function as much as possible. To achieve this, he recommends the following sequence:

  • Sensory motor balance training
  • Stretching of short, tight, hypertonic muscle to symmetry
  • Strengthening of inhibited weak muscles to balance
  • Restoration of symmetrical movement patterns
  • Aerobic conditioning.14

McGill describes five stages of patient training. The first stage involves detection and correction of perturbed motor patterns by “grooving” motion patterns, motor patterns and corrective exercise. The second stage establishes whole-body and joint stability through exercises and education, with a focus on spine stability. The third stage entails developing endurance and applying these skills to daily activities. For training athletes, the fourth and fifth stages add training strength and then speed, power, and agility.12

2. RELEVANCE TO CLINICAL PRACTICE

Rehabilitative therapies can be divided into two broad categories: passive and active.

Passive treatments are those done to or for a patient, while the active treatment is done by the patient. Examples of passive therapies include massage, medications, injections, manual therapy, ultrasound, and even surgery. Active treatment is generally encompassed by exercise and physical activity. While passive treatments can be very helpful, they are generally not long-lasting, and any derived benefits eventually wear off.14  Greenman states, “Active care adheres to psychosocial principles by providing unambiguous cognitive and behavioral advice to enhance coping ability and motivate patients to gradually resume normal activities. Patients who worry about their functional status or fear their pain are more likely to have chronic problems.”14

Patients often present with a variety of reasons why they do not exercise, citing lack of time, low energy or motivation, and poor ability to maintain adherence as the most common reasons.15 Thus it is crucial to consider these reasons and to formulate a prescription that addresses time, costs, pain, etc. 10 One example may be the utilization of high-intensity interval training (HIIT) for patients with which time is the major barrier.  A recent meta-analysis on HIIT training for cardiometabolic health cited that compared to moderate intensity continuous aerobic training, HIIT may be more effective at increasing aerobic capacity and reducing risk factors associated with metabolic syndrome.15 The authors encourage clinicians to incorporate HIIT, performed three times a week for at least 12 weeks, into exercise programs for obese patients.15 Another recent review looking at HIIT in patients with coronary heart disease found that the optimal protocol involved short interval duration (15 seconds) and maintaining close work/recovery ratios.16 Additional considerations towards stages or progressions of the exercise can be made from the foundation laid by the initial prescribed regimen. Providing a progression of an exercise also allows the body to adapt to the stresses of it, from a muscular level, including tendons, fascia/connective tissues and joints. When the exercise is progressed too quickly, there can be a risk of injury. Patients must also understand how to recognize the difference between signs of exercise stress, such as increased heart rate and muscle soreness, and symptoms of overexertion or injury.7 Informing the patient that these symptoms generally improve after the first few days of starting or increasing a program can be helpful.

Current recommendations advise accumulation of moderate-intensity aerobic physical activity to attain a daily goal of around 30 minutes. Additional data is available to show that bouts of approximately 10 min each can be effective in attaining this goal and suggest that the volume of energy expended is more important than the duration of the exercise.4 Large prospective studies of diverse populations show that an energy expenditure of approximately 1000 kcal.wk-1 of moderate intensity physical activity is associated with lower rates of cardiovascular disease and premature mortality.4 Significant risk reductions for these has been shown to begin at volumes below the recommended targets, and as low as one-half the recommended volume. While measuring kcal’s is useful, perhaps a more practical measurement for aerobic activity is the metabolic equivalent (MET). MET’s measure the absolute intensity of aerobic activity, with 1 MET equivalent to the resting metabolic oxygen consumption rate of approximately 3.5mL/kg/minute.17 It is known that significant health benefits emerge with a volume of 500 to 1000 MET minutes/week and this volume can be met by walking at 3.0 mile per hour on 3 days a week for 50 minutes.17

A meta-analysis in 2016 quantified the dose-response association between physical activity and five chronic diseases (Diabetes, Ischemic Heart Disease, Ischemic stroke, Breast and Colon Cancer) and found that higher levels of total physical activity, compared to current minimums recommended by the WHO and ACSM, were associated with lower risk for all outcomes.23 However, it should be noted that the dose-response relationship between volume and health benefits is curvilinear, with the greatest return on investment at lower levels of activity and decreasing return of health benefits at higher levels of activity.18

Accordingly, although the recommendation to our patients that “some is good, more is better”4 certainly is well-supported we should keep in mind that small and well-spaced increments will reduce the incidence of adverse events and improve adherence.18

3. CUTTING EDGE/UNIQUE CONCEPTS/EMERGING ISSUES

While the majority of the recommendations for exercise are targeted at a general, healthy adult or youth population, evidence suggests that exercise therapy are especially beneficial for patient populations with certain co-morbidities. Guidelines and recommendations are available for chronic diseases such as diabetes, obesity, arthritis, peripheral arterial disease, poliomyelitis, spinal cord injury, cardiac disease, COPD, multiple sclerosis, and cancer.

Results from the HF-ACTION trial (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) suggest that exercise therapy reduces cardiac mortality and hospitalizations in patients with coronary heart disease and that exercise therapy may be safely conducted in certain HF populations.26 A recent meta-analysis supports this evidence found reduction in the risk of re-hospitalization due to heart failure and improvements in health-related quality of life following exercise interventions.27  The American Heart Association and American Stroke Association have also provided a detailed report on guidelines for prescribing exercise for stroke survivors across all stages of recovery.28

In regards to pulmonary rehabilitation and exercise prescription in chronic obstructive pulmonary disease (COPD), a recent review found that of the current three major guidelines, there was no optimal exercise prescription strategy established for COPD.29 The guidelines discussed were created by the American Association of Cardiovascular and Pulmonary Rehabilitation, the American College of Sports Medicine, and the American Thoracic Society / European Respiratory Society. The authors advise that health care professionals should be familiar with all major, evidence based pulmonary rehabilitation guidelines.29 The authors also cite the core components of exercise training programs for COPD as endurance and resistance training.29

A review on exercise therapy for patients with MS found that combining aerobic training, strength training and yoga yielded improvements in balance, dynamic gait, and symptoms of fatigue.30 Another review of exercise in neuromuscular disease (NMD)19 summarizes studies and information about a variety of neuromuscular conditions. Some basic recommendations for patients in this population include exercising carefully and under the supervision of their physician, and also targeting certain muscles and breathing exercises rather than whole body aerobic conditioning. These recommendations include non-ambulatory individuals with NMD.14

The American College of Sports Medicine published guidelines for physical activity in cancer survivors in 2010 with general recommendations to avoid inactivity and continue exercise as soon, and as often as possible.31 For both aerobic and resistance exercises, certain recommendations were provided for specific conditions. In summary, for aerobic exercise ACSM recommends increased awareness for potential fractures in individuals with metastatic bone disease. Caution must also be taken with overtraining in individuals with hematologic malignancies who received hematopoietic stem cell transplantation, due to concern for adverse immune effects.30 With breast cancer and resistance training, the ACSM recommends a “low and slow” approach, and no upper limit on the amount of resistance an individual is capable of progressing towards.31

Within the able-bodied population, special considerations and modifications are recommended for exercise during pregnancy, as well as in the elderly population.7  The PARmed-X for Pregnancy (2013) is a tool that may be utilized by the health care provider to medically screen pregnant women for exercise therapy, track their progress with exercise, and monitor for indications to stop exercise.32 The American College of Sports Medicine has published position statements regarding promotion of exercise in some of these conditions, and they are available free of charge on their website:

http://journals.lww.com/acsm-msse/pages/collectiondetails.aspx?TopicalCollectionId=1.

Much attention has been directed recently at the importance of building core stability as a central focus of an exercise program. As the core forms the link between upper and lower body, the greater the stability of this part of the body,19 the more successful one’s movements and exercise program can be with lower risk for certain injuries.20,21 Additional evidence is available to support inclusion of proprioceptive-rich exercises as a part of the exercise program as well.22,23

Use of performance enhancing substances has become quite controversial. This is sometimes referred to as “doping.” Doping refers to the use of prohibited performance-enhancing drugs (PEDs), hormones and growth factors, or methods (e.g., gene doping, blood doping, etc) specifically to enhance athletic performance beyond normal physiologic levels and not for the purposes of treating a legitimate medical condition.24 Our role as physicians should be to direct our patients away from these substances and provide education on the harmful effects that can arise from their use.

4. GAPS IN KNOWLEDGE/EVIDENCE BASE

While most exercise research is focused on the healthy, able-bodied population, additional studies are needed to further refine recommendations and guidelines for this population. Even though it is known that exercise is beneficial in many patient populations, the exact dose and intensity of exercise, as well as the exact types of exercise that are most beneficial still need to be clarified. Even more research is needed in special populations, including those with neuromuscular disorders, conditions affecting the central or peripheral nervous system, as well as other impairments or disabilities. Additionally as the population ages, further research is needed in elderly population to enhance their function while keeping into consideration their comorbidities. The current guidelines available for these populations may lack clear and specific recommendations, or recommendations may be inconsistent across guidelines leaving concern for errors such as under-dosing or overdosing.33

REFERENCES

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Original Version of the Topic

Adam P. Cugalj, DO. Exercise prescription and basic principles of therapeutic exercise. 10/22/2013.

Author Disclosure

Kim Barker, MD
Nothing to Disclose

Austin Johnston, DO
Nothing to Disclose

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