Physical therapists as experts in exercise prescription: bridging the gap between clinical practices


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by Mireille Landry

Evidence-based exercise prescription is a fundamental Physical Therapy skill. Despite this, exercise prescription may be under-employed. So, how do physical therapists raise the standard for exercise prescription in practice? Are we doing all we can to maximize function beyond therapeutic benefit for all of our patients?

The Big Idea

A well designed exercise program will complement the hands-on treatment provided by a physical therapist. But these aren’t just any old run of the mill exercises — they’re hand-picked to help patients move better by strengthening targeted muscles and addressing any muscular imbalances that may exist. We might also suggest they walk more often, further or longer to help with recovery. They are chosen for their ability to significantly reduce the risk of re-injury, improve the speed of recovery and a return to function. In managing chronic disease, we are essential interdisciplinary team members in prescribing exercise for health and recovery. But all too often, in both cases, we stop prescribing exercise prematurely.

In June 2011, the World Confederation for Physical Therapy hosted a panel discussion between five physiotherapists and an exercise physiologist entitled Evidence-based Exercise Prescription: Raising the Standard of Delivery that asked, “Are we, as physiotherapists, fulfilling our potential as experts in exercise prescription?” The transcript of this session is definitely worth a read. We should also be asking ourselves that same question.

My take on things…

How many of us have heard some version of this statement: “I went to physio and it helped for a while, but the pain just came back again”? Meaningful and sustained gains in functional performance after an injury or illness require exercise prescription to address whole body exercise training beyond therapeutic exercises. By doing this, we move beyond ‘rescuing’ patients from their conditions/ailments, and we help them become the heroes of their story!

My clinical practice is one of extremes of levels of function – an athletic population involved in high performance sport on one side, and those living with multiple chronic conditions and comorbidities on the other. I’ve seen and heard patients living with chronic conditions revel at how regular physical activity and exercise has changed their lives, without exercise being the “big change” they thought it would be. They report less arthritic pain, less use of pain medication, and big gains in aerobic capacity. I will see this in patients with a primary complaint of shoulder pain, or who live in diabetes, just as much as those I see in cardiac rehabilitation. Seeing the power of exercise firsthand, I can’t image a treatment plan without it for a comprehensive approach to patient care.

Clinicians shouldn’t be asking themselves “Should I prescribe exercise?” but rather “What type of exercise should I prescribe?”

I had an early interest in sport and exercise physiology and I credit this professional training, knowledge, and experience with why I now work so effectively with the chronic disease population. Many lessons can be learned from the training methods of sport and exercise medicine, and can be applied to our patient’s every day. I use modified concepts of periodization, interval and circuit training, optimal training loads and work to rest ratios (including sleep!) to optimize a patient’s functional performance when pain, strength, and ROM goals have been reached. Proper movement patterns quickly progress quality muscular strength, power, endurance, and cardiovascular training. Addressing psychosocial factors in recovery is as important as physical recovery too. The majority of patients I see leave in a better condition than they were prior to their illness or injury.

Everyone has heard the catchphrase “Exercise is Medicine” by now – and there’s no debating the power of physical activity and exercise. Exercise is the first line of intervention for many clinical presentations and has been shown to outperform pharmacotherapy and surgery to manage a wide range of medical, musculoskeletal and psychological conditions. Physical activity has comprehensive benefits across the lifespan: it promotes healthy growth and development in the young, helps to prevent leading risk factors for non-communicable diseases (hypertension, diabetes, dyslipidemia), and is important for healthy aging, including improving and maintaining quality of life and independence in older adults.

CSEP’s Physical Activity Guidelines for Adults suggest that each of us should accumulate 150 minutes of moderate to vigorous activity per week – that’s equivalent to just 22 minutes a day of purposeful walking. On an individual level, it makes good sense to aim for 30-60 minutes to make the most of the dose-response curve of the benefits that come from physical activity. Add some whole body strengthening twice a week, and flexibility activities, and you’re good to go!

So what’s the problem?

I hear too often that colleagues don’t feel comfortable going beyond the ‘therapeutic’ exercise prescription and are happy to defer to others.

The majority of physiotherapists in Canada are primary care providers. We have a strong exercise background and strong patient relationships, which makes us ideal exercise prescription providers and experts. Clinicians shouldn’t be asking themselves “Should I prescribe exercise?” but rather “What type of exercise should I prescribe to return my patient to a function that’s better than what they had previously?”

Enhancing performance has different meanings for different people depending on age, occupation, severity and type of injury or illness and healing capacity. Adequate strength and power strongly correlate to functional independence in older adults. Take for example a 63 year old sedentary female with a long history of diabetes and heart disease, with a BMI of 40, who has difficulty with sit to stand. When you really think about it, this sit-to-stand task stresses the same energy system that power athletes use. A specific, focused resistance training plan should:

Start with muscular endurance training, progressing to strength, then power (think speed of contraction) with periods of rest and recovery built in. This approach will improve her capacity to perform many functional and household tasks. Consider periodization principles and how they can apply to your rehabilitation plan. The American College of Sports Medicine has a Position Stand on Progressive Models of Resistance Training that is a great review.
Address the whole person by also addressing cognitive, sleep and nutritional aspects for healing and health. Consider the goals of exercise for your patients based on the type of tissue involved, the stage of healing, and the co-morbid conditions that your patients may have that influence their ability to train successfully. Undiagnosed obstructive sleep apnea, hypoglycaemic events, and poor eating patterns contribute to their rehabilitation success, as well as to their health.
Assess physical activity levels, and if your patients are not meeting guidelines, ask them if they’d be willing to move a little more, more often, and encourage them to meet guidelines.
There are a number of other professions qualified in their own ways to prescribe certain types of activity to certain types of people, but as physiotherapists, I feel it is important that we recognize and take ownership our specific expertise in this area.

Dig Deeper

Here’s what else WCPT has to say about the subject: Physical Therapists are regarded as exercise experts

Those who know me know that I’m really passionate about this topic! If you’re on Twitter, I suggest you follow @exerciseworks and Karim Khan at @BJSM_BMJ for inspiring and up-to-date exercise information.

Discuss

Let’s get a friendly debate going here! A hot topic debate outside of CPA’s regular Congress session. Which side of the ‘PTs as exercise prescribers’ argument are you on?

Post your best argument in the comments box below, or on the CPA Facebook page or on Twitter (hashtag: #30Reps) and let the games begin!

About Mireille Landry

Mireille Landry received a BScPT from Queen’s University and a MSc from the Graduate Department of Rehabilitation Sciences, University of Toronto. Mireille’s clinical background includes cardiorespiratory, musculoskeletal and exercise physical therapy in acute care, private practice, and ambulatory care settings. She is currently the Exercise Coordinator for the Women’s Cardiovascular Health Initiative at Women’s College Hospital, as well as an Adjunct Lecturer with the Department of Physical Therapy at the University of Toronto. Mireille is also an active member of the Sport Physiotherapy Canada (SPC) division of the Canadian Physiotherapy Association and is currently a director on the board of SPC. She also has post-graduate certification through SPC. In 2011, she became a Certified Diabetes Educator, one of few physiotherapists to hold that designation.

@exercisephysio

  • Samuel Down

    Great article. I agree – we cannot over emphasize the importance of exercise and we need to be willing and able to prescribe and progress exercise at all stages of care; as well as to any type of patient…whether it is the elite athlete with a niggle, or the morbidly obese elderly person who does not really move anymore. The society we now live in where the majority of people spend far too long sitting, and eating poorly has left us with a society of people who do not know how to move properly, are weak, and funnily enough are in pain. 95% of the clients I see cannot squat properly…an absolutely fundamental movement to function…yet my 1 year old son, who has never been taught how to squat properly, performs perfect squats all day long as he toddles around and goes about his world of play and exploration….somewhere along the way too many of us our losing the strength, the range, the neuromuscluar control and the movement patterns to move and function properly. I am completely convinced that exercise is the key, and as physiotherapists we need to be better at prescribing it.

  • Ling Kwok

    Helpful analysis . I was fascinated by the analysis . Does anyone know where I would be able to locate a template a form document to complete ?