Sports Injury Fix Director Mike James (aka The Endurance Physio) has been prescribing exercises in various guises for over 20 years. Here he offers some thoughts to stimulate thinking regarding exercise prescription for therapists.
More than 20 years ago when I worked as a personal trainer, I remember a less than healthy trend developing where trainers would try to produce the most complicated, complex and overly detailed programmes in some sort of quest to demonstrate knowledge.
Unfortunately, many missed the point that this was the exact opposite of what most clients wanted - simple, easy to understand and easy to perform exercises.
All the former did was create dependence, stress and fear of exercise. A population of people who slowly drifted away from the trainer through a lack of understanding, poor alliance and in search of simplicity.In fact, you could argue that this was what created the opportunity for the celebrity fitness DVD boom that ensued. Whether intentionally or not, these DVD’s provided exactly what people both wanted and needed - easy to follow exercises that could be performed with relatively little interruption to a person’s day, and all in a quick and easy manner.
What was the magic ingredient? What was the X factor – adherence. These DVD’s (and many other fitness fad success stories before and after) have created an environment that people are happy to work in. They created a situation that the person felt they could achieve and maintain a regime for the long haul.
I remember trying really hard to get the message across to trainers that we were missing something that could make a big difference in a really short time. If we stripped back what we were giving to people, then they would stick to them more and make more gains!.
Fast forward to today, and history has repeated itself. Two decades later and here I am again, writing about the systematic over complexity, and poor prescription of exercise. This time however it’s with reference to the MSK therapy world.
It’s got so bad, that my Physiotherapy colleagues are collectively gaining a reputation for prescribing pages of generic, one size fits all exercise algorithms on a mass scale. More and more people are coming back into clinics with poor adherence to the programme due to poor understanding and confusion with the prescribed exercises.
Of course there are exceptions to this, and I would never want to tar everyone with the same brush, many prescribe consistently first class, bespoke exercise regimes.
Generally, I see two errors on a wide scale basis:
1. Poorly prescribed, generically written exercise plans for a general injury or population.
In fact, I can recall too many occasions than I care to remember, of finding colleagues printing off exercise sheets from a software package BEFORE even meeting the patient, simply based on a referral letter or diagnosis. Although pattern recognition can often lead to us identifying exercises that are more successful than others, we surely cannot decide what someone needs without speaking to, and assessing them?.
2. Therapists prescribing exercises with overly complicated coaching cues, equipment and environmental requirements to perform.
Those who often have a background in exercise science or strength training can use this knowledge effectively, but sometimes seem to over sell it, much in the theme of "paralysis by analysis" and possibly prescribing by preference or flavour of exercise rather than the necessity of a particular exercise?
These scenarios always have a common theme - little to no consideration of the individual about to perform them.
Many times, therapists report time and equipment constraints, or lack of formal training in exercise prescription. Yet all of these factors are easily overcome and negated with nothing more than a little common sense and planning.
Why do we feel the need to change an exercise or overhaul a complete programme every time we see a patient – particularly when the exercise is helping?!.
I have learned over many years that in fact, less is more with exercise prescription. Much in the way we are starting to retract from performing batteries of objective tests that may not be required through a simple process of reasoning, we can buy back time within a session or appointment by simply considering the patients needs.
By listening to their story, needs and requirements, then exercise prescription can become a simple process of 1-2 exercises that are best suited to that individual, but may well be different from the same injury, or type of person who attends next.
Ultimately, we know from multiple studies that adherence is the key to success in exercise and giving less exercise can have significantly greater effects on adherence. If we don’t do all in our power to promote adherence, then surely the battle is lost before the first shot is fired?
I was taught a long time ago that any test can be an exercise and any exercise a test, so why not use that as a starting point for prescribing exercise? Feel safe and liberated in the knowledge that the only limits to your exercise library is your imagination.
Done correctly, you can progress and regress an exercise to almost limitless boundaries standing on the same spot. A wise old mentor once told me that I should be able to rehab anyone inside a phone box, certainly a lesson that I have never forgotten.
Once an appropriate exercise has been selected, then why not play around with key variables such as these to gain the progress you require.
If we then want to promote further adherence, make sure it can be done wherever the patient finds it most convenient and accessible.
Home based, gym based, work based, and with whatever equipment or not that they find effective. Simply use the patients phone and film that exercise and provide 1-2 verbal cues and no more for them to take away.
I have deliberately left this blog short and without heavy references to studies, as I want it merely to serve as food for thought, a discussion promoter in clinics and departments across the profession. I will follow it up soon with a heavier, weightier bigger brother so to speak blog of sorts that will delve much deeper into the weeds of this subject.
But to finish, I have a challenge for you - try with your next 10 patients to only give them 1 exercise and progress that exercise to the limits of your imagination before changing it.
Remember that the number one priority with exercise prescription is the promotion and successful application of adherence.
Explain your thinking - If you give an exercise, then ensure the receiver understands the relevance to them and their outcomes of each and every exercise – this will reinforce the adherence that we seek and reduce the chances of creating barriers that are often difficult to overcome once built.
Thanks for taking the time to read.