Exercise prescription; it's not just the tools, it's how you use them!

This week at Advanced Neuro Rehab, our professional development session focused on exercise prescription. It is an enormous topic. As physiotherapists, we prescribe exercises every day, but it is worth asking whether the term exercise prescription sometimes gets reduced to something much simpler than the clinical process it actually represents.

Choose an exercise. Give it some sets and repetitions. Progress it when it becomes easier.  Wouldn't it be great if it was that simple? 

Of course, dose matters. But particularly in neurological and vestibular rehabilitation, exercise prescription is much more than sets and reps. A popular way of thinking about it is the physiotherapist's toolbox. Having a large collection of exercises is useful (and grows with experience), but expertise doesn't come from how many tools we have. It comes from understanding which tool to select, why we are using it, how we use it and when we need to modify it.

Start with function and movement

Before selecting an exercise, we need to be clear about what we are actually trying to change.

What matters to this person? What activity or function are they trying to improve? And what aspect of their movement performance is limiting that function? This distinction is important. We may identify impairments in strength, range of motion, balance, sensation or endurance, but ultimately we need to consider how our intervention relates to the movement and function we want to improve.

Specificity matters. We shouldn't automatically assume that improvement in one exercise will transfer to another task or to the person's everyday life. Our training needs to progressively move towards the movement demands and environments that actually matter to the individual. Of course the 10 movement training principles are fundamental to this process.

Dose matters — but so does challenge

Rehabilitation requires sufficient practice. Some movements require lots of practice. While other movement skills can be acquired very quickly, and need rapid progressions. Are there enough repetitions? Is there enough time engaged in active practice? Are particular components of movement getting enough exposure? Is it safe?

But more is not automatically better. Too many different exercises can wash out any strong effect. Sometimes less exercises but more practice is preferred at certain periods of time. While I may have given my patient three exercises to do, another physiotherapist has given them another 6 exercises, and there are old exercises from a previous injury that they are continuing to do because no one told them to stop! The psychologist has given them meditation exercises, the exercise physiologist has given them exercises also, plus a friend said they should do these great new stretches! Remember advice sometimes is coming from everywhere!

We also need to consider the challenge point. The same task may be trivial for one person and overwhelming for another. Our job is to manipulate the task, the environment and the training conditions so there is enough challenge to stimulate learning while still allowing useful movement performance. This also means distinguishing dose from intensity. They are related, but they are not the same thing. Attention, stimulation and problem-solving can all influence how demanding a rehabilitation task becomes.

Exercise is also motor learning

In neurological rehabilitation, we are frequently trying to change movement behaviour, not simply improve physical capacity.

That raises another series of questions.

What is the person paying attention to? Should our focus be internal or external? How much feedback should we provide? Do we want knowledge of performance or knowledge of results? (being fully aware that they don't always align!) Should practice be blocked or random? How much variability should we introduce? Should we allow errors?

Sometimes errors provide valuable information for learning. At other times, we may deliberately constrain a task or use errorless approaches. There are also times when the therapist needs to say less, provide less guidance, and allow the person to explore, problem-solve and learn through practice on their own.

The exercise may stay the same while the learning experience changes substantially.

Don't forget physical capacity and musculoskeletal load

Motor learning cannot be considered in isolation from the physical system producing the movement. Strength, cardiovascular fitness, range of motion, biomechanics and physical capacity all matter.

Musculoskeletal loading may also require careful consideration. A person with neurological or vestibular problems may simultaneously be managing osteoarthritis, tendinopathy, weakness, reduced conditioning or motor fatigue. Changing performance can have drastic effects on confidence, self-efficacy, and risk of injury and falls.

In these situations, simply increasing repetitions or difficulty may not be appropriate. We need to consider how much load we are applying, how frequently it is applied and how the individual responds and recovers.

This is another reason exercise prescription requires clinical reasoning rather than simply selecting an exercise from a library.

What about symptoms?

This becomes particularly interesting in neurological and vestibular rehabilitation because exercise does not necessarily need to be completely symptom-free.

The more useful questions may be:

What symptoms are we willing to provoke? How much? For how long? How quickly should they settle? And what threshold tells us to continue, modify or stop?

Importantly, those thresholds may be different depending on what we are dealing with. Pain, dizziness, headache, autonomic symptoms, exertional symptoms and motor fatigue are not necessarily things we should respond to in exactly the same way. We want to avoid the simplistic message that symptoms = stop, while equally avoiding an indiscriminate push through it approach. Understanding and prescribing around symptom thresholds is another important tool in our toolbox. Education is important. Cognitive capacity is important. Supervision may also be necessary.

Progression is much more than adding weight

When we think about progressing an exercise, the obvious options are often to add resistance, repetitions or time. But physiotherapists have many more variables available.

We can change base of support, external support, speed, movement amplitude, direction, vision, surface, head and gaze movement, predictability, cognitive load, environment and fatigue/endurance demands.

We can make practice more variable that reflect the challenges in daily life? We can introduce choice. We can make the environment less predictable. We can introduce dual tasking or perturbations. Or we can simplify a task while preserving the movement we ultimately want someone to perform. We have a whole section on task simplification in our Applied Neuroscience for Movement course, because it is so important!

Progression therefore isn't simply about making an exercise harder. It is about deciding what kind of challenge we want to introduce next and why. Does your patient have a clear understanding of the possible pathway towards success?

The most important outcome may happen outside the clinic

There is one final part of exercise prescription that deserves much more attention: behaviour.

We can design the perfect programme physiologically and biomechanically, but it has little value if it never becomes part of someone's life.

Rehabilitation should therefore help develop self-efficacy, confidence, self-management and longer-term behaviour change. Our educational courses deliberately distinguish adherence from simply expecting compliance and place self-management and self-efficacy alongside strength, cardiovascular fitness, skill learning and therapeutic exercise.

The longer-term question is not simply:

Did they do their exercises?

It is also:

Have we helped this person become more confident in their ability to move, exercise and manage their own health?

Ultimately, we want some exercises to move beyond being "homework from the physiotherapist" and become part of sustainable physical activity, participation and lifestyle.

So, what's in your exercise prescription toolbox?

Perhaps this is the broader conversation worth having within physiotherapy. Exercise prescription is not simply:

Exercise + sets + repetitions.

It is the thoughtful combination of:

Function. Movement performance. Task. Dose. Load. Challenge. Practice. Variability. Attention. Feedback. Constraints. Symptoms. Progression. Behaviour. Self-efficacy.

The exercise itself is only the starting point. Does your patient know where this is ultimately heading? The real skill is selecting the right tool for the right job—and knowing how to use it.

This is something we have been exploring with the team at Advanced Neuro Rehab, and it is a major part of the way we approach movement training and clinical education through Advanced Neuro Education.

And it raises a question worth discussing more broadly:

When you prescribe an exercise, what else is in your toolbox?

Anyway, this is what we've been discussing this week! And it's just a taste of what is covered in our Applied Neuroscience for Movement course at Advanced Neuro Education.

Associate Professor James McLoughlin