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Avoiding common misconceptions in therapeutic exercise programming

This is an excerpt from Therapeutic Interventions for Musculoskeletal Conditions With HKPropel Online Video by Craig R. Denegar,Grant Norte,Neal Glaviano.

Many understand exercise through a personal commitment to an active lifestyle. From that perspective it is easy to assume that everyone knows how to put together and follow an exercise program. Never make assumptions: Even those who are physically active may have misconceptions regarding program structure, exercise technique, or the parameters that facilitate success in the presence of a musculoskeletal condition.

This section is not exhaustive but highlights common issues that persist in the care of patients with musculoskeletal conditions. One of the more common misconceptions is that more is always better, and therefore there may be a tendency to do too much too soon in terms of intensity or volume of activity. This is a common mistake when beginning an exercise program, whether on the part of the provider or the result of a patient’s zealous commitment. Exercise imposes new demands on the body to stimulate adaptation, but when the load is excessive, pain and injury can result. We recommend two simple guidelines when initiating a program of therapeutic exercise: (1) you should be able to do tomorrow what was done today, and (2) exercise should not be painful.

These recommendations require some explanation. Although it is hoped that an exercise program will progress to the point that a day or two of recovery is needed to allow for tissue adaptation, exercise at an intensity requiring such recovery early in the rehabilitation process is an invitation for reinjury, new injury, or poor adherence to the program. It is far easier to progress a program if a greater volume or intensity of work is tolerated than to restructure a plan resulting from excessive loading early in a program.

The provider must also acknowledge that exercise induces discomfort. A level of discomfort that affects the quality of movement can be defined as pain. However, if an activity can be performed without substitution of aberrant movement and can be completed tomorrow as it was done today, the training load is appropriate despite discomfort. Patients fearful of exercise and pain (i.e., kinesiophobic) often require a more graded exposure as well as attention to maladaptive beliefs related to exercise.

Local Isolation to Regional Exercise Progression

Pain, swelling, and instability result in inhibition of neuromuscular control pathways. Inhibition of the quadriceps is readily apparent following knee injury or surgery and in those with persisting pain related to the patellofemoral joint and osteoarthritis. Less observable but commonly affected muscles include the multifidi and transverse abdominus in patients with spine-related pain and the muscles of the rotator cuff in patients with shoulder pain. When treating these patients, the provider should include exercises that isolate the affected muscles to ensure proper function in stabilization before initiating more dynamic exercises involving larger muscle groups. The trunk serves as the foundation for all forceful movements, and it is likely that most patients will benefit from assessment, and targeted exercises when indicated, to foster neuromuscular control along the kinetic chain.

Open kinetic chain (OKC) exercises have been a subject of debate in postsurgical rehabilitation, with much attention directed toward patients recovering from anterior cruciate ligament (ACL) reconstruction. Historically, there were concerns that OKC exercises would place excessive strain on the healing ACL graft, potentially leading to graft laxity. However, a growing evidence base¹ and new perspectives on the historical interpretation of empirical data challenge this notion. ACL strain is shown to be 2 to 3 times higher during activities of daily living, such as walking, than during OKC knee extension exercises with 30 N∙m of torque (~22 lb) at 15 degrees of knee flexion.² Furthermore, a review³ of nine randomized clinical trials found no difference in anterior tibial laxity between patients who performed OKC versus closed kinetic chain (CKC) exercises after ACL reconstruction. Despite this evidence, some providers still hesitate to incorporate OKC exercises early in rehabilitation. Unfortunately, compensatory movement patterns and offloading of the impaired musculature are likely when only relying on CKC exercises. In this way, OKC exercises are crucial for isolating and strengthening weak muscles, provided they are appropriately dosed and progressed based on the patient’s stage of healing and individual needs.⁴

Program Quality

In the clinical setting, patients receive instruction in the performance of prescribed exercises. As with many learning experiences, an initial exposure may not be fully understood and attempts to replicate may be imprecise. This point may be evident in the case of the patient who can initially demonstrate correct exercise performance as instructed but cannot retain the correct movement pattern in subsequent rehabilitation sessions. This can be addressed through a nonjudgmental review of instructions: On follow-up with a patient, and after appraising changes in health status, inquiring about performance of an exercise program is warranted. Statements such as “show me what you are doing at home” allow the provider to correct any errors in technique while reinforcing the link between the prescribed exercises and treatment goals.

Progression and Intensity

Too little volume and intensity lies at the opposite end of the spectrum from too much. As the body adapts to increased load and activity, an exercise program should progress in intensity, complexity, and total volume. Intensity represents the resistance in strength training programs, or the load, speed, and duration of cardiovascular activities. As the patient recovers, a program can progress to more complex multijoint and functional exercises. Such progression is intuitive for an athlete seeking to return to participation in a sport but less intuitive for those without more specific performance goals.

A common shortcoming in the health care system is the failure to work beyond addressing impairment and daily function. Once the goals of treatment related to a health condition are met, care ends. Although patients often choose to not pursue a more active lifestyle, the overall benefits to health and the prevention of recurrent and new musculoskeletal conditions often receive little attention. Preparing the patient to maintain and progress an exercise program is essential to secondary and tertiary injury prevention and warrants attention by the provider as well as the health care system. Providers and patients should be rewarded for promoting and engaging in an active lifestyle regardless of the setting in which care is provided.

Adequate dosage of therapeutic exercise is foundational to promoting beneficial tissue adaptation after musculoskeletal injury. In this context, the mode of exercise prescribed plays a meaningful role in the dose–response relationship. Eccentric loading warrants some attention in conjunction with a discussion of exercise progression and intensity. Eccentric loading is associated with the phenomenon of delayed onset muscle soreness and should be introduced judiciously, especially with patients who do not exercise regularly. However, eccentric loading will enhance range-of-motion gains while promoting neuromuscular control and muscle hypertrophy, which are essential to address in the plan of care. As loads are increased, proper technique and adequate recovery becomes increasingly important to prevent a recurrent or new injury.

Whole Body Exercise

A therapeutic exercise program should extend beyond local and regional musculoskeletal strength and neuromuscular control. Global or whole body exercise can upregulate pain modulating pathways and offer other benefits to overall health. Whole body exercise in sufficient frequency, duration, and intensity is often missing from programs developed to address impairments and functional loss associated with a musculoskeletal condition.

Whole body programs consisting of circuit training or aerobic exercise interspersed with strength, balance, and flexibility exercises are generally too resource- and time-consuming to be completed in a typical outpatient setting. Such training may also be missing from a comprehensive program for athletic patients. A patient must have sufficient endurance to allow them to complete work and athletic tasks without fatigue-induced biomechanical overload that places them at risk of a recurrent or new injury. Providers should seek to incorporate global exercises as early as possible in an exercise program such that the patient can follow through at home or using community resources. Ultimately, a well-designed regimen goes beyond the direct management of a musculoskeletal condition (i.e., biological model of health care) to address the comprehensive needs and health of the whole person. This is evident when considering the ICF framework, which now guides modern health care practices.

Age and Comorbidity

The tendency to underprescribe and progress exercises for less fit and older patients and those with multiple health conditions warrants discussion. Although some extra caution may be warranted for individual patients, it is important to recognize that all patients will benefit from a well-planned exercise regimen. It is hoped that patients will maintain an exercise regimen after discontinuing a course of clinical care, yet continuing exercises that do not introduce a load sufficient to stimulate adaptation will often result in suboptimal outcomes and declining adherence. Providers should discuss exercise progression and serve as resources for those seeking to lead a more active lifestyle. Providers should also be prepared to help patients find community resources that will support their activity goals. In many ways, the provider may be viewed as a case manager or gatekeeper for chronic disease management.⁵

Education and Training

Recent evidence has highlighted a disconnect between young providers’ perceptions of exercise prescription and their actual preparedness to implement it effectively for patients with musculoskeletal pain. New graduates recognize the pivotal role of exercise in managing musculoskeletal conditions but often feel underprepared to progress exercises beyond initial stages and struggle with patient engagement, particularly with patients with chronic pain.⁶ These findings align with data, highlighting the need for comprehensive education and training.⁷ Despite acknowledging exercise as a core component of their practice, only 38% to 50% of providers report having the confidence, training, or skills to prescribe aerobic exercise; 49% to 70% report the same for resistance training.⁷ This gap between perceived importance and actual preparedness underscores the need for enhanced preprofessional education and continued professional development in exercise prescription. Addressing this disconnect is necessary to avoid common misconceptions in therapeutic exercise programming and to ensure that new providers can effectively implement contemporary and emerging therapeutic considerations, including motor learning principles and psychologically informed interventions, in their practice.

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