A Framework For Exercise Prescription: DOI: 10.1097/TGR.0000000000000011

Topics in Geriatric Rehabilitation • Volume 30, Number 2, 79-101 • Copyright © 2014 Wolters Kluwer Health | Lippincott Williams &
Wilkins
DOI: 10.1097/TGR.0000000000000011
A Framework for Exercise Prescription

Wendy K. Anemaet, PT, PhD, GCS, CWS, GTC, COS-C; Amy Stone Hammerich, PhD, DPT, PT
Exercise prescription is an important part of clinical decision amount of medication was needed and adjusted the
making for rehabilitation professionals. Evidence-based instructions based on what the patient “felt.” Similarly,
practice encourages rehabilitation professionals to have many rehabilitation professionals prescribe therapeutic
strong rationale based on the current literature for all exercise in a like manner, basing exercise selection, fre-
elements of practice including therapeutic exercise. Prescrib- quency, and intensity using nonobjective measures of base-
ing what “has seemed to work in the past” or “what seems line status and often establishing exercise parameters with-
right” may accomplish some positive outcomes for patients; out clear rationale. In contrast, prescription of therapeutic
however, using sound prescription principles from current exercise to assist in the prevention of health issues or the
research more consistently produces optimal outcomes. This restoration to a more healthy state should be grounded in
article presents a framework for exercise prescription based strong baseline data and evidence-based thought pro-
on levels or phases. These include Tissue Healing, Mobility, cesses. Indeed, consumers of health care are more likely to
Performance Initiation, Stability, Motor Control, Performance go to a therapist they know can
Improvement, Advanced Coordination, Agility, and Skill. Avail- 1. significantly improve mobility to perform daily ac-
able research is used to substantiate the framework and tivities, functional activities, and recreational activi-
guide the rehabilitation professional’s decision-making ties;
process when prescribing exercise. 2. provide an alternative to painful and expensive sur-
Key words: decision making, exercise, therapeutic exercise gery, which may or may not improve outcomes; or,
3. manage or eliminate pain without medication and
its side effects.1
Mrs Meowitz visits her physician because she is con-
cerned that she has high blood pressure. She settles Rehabilitation professionals are experts in restoring
into the examination room and describes her symptoms and improving movement in individual’s lives. Ideal move-
as an “occasional dizziness,” feelings of “fatigue,” and a ment is a result on complex interactions of the movement
drug store blood pressure reading in the “high” range. system.2 This system includes support elements such as
The physician asks if she can remember what the read-
the cardiopulmonary, metabolic, and other systems; base
ing was and she states it was around 150/80. From this,
he concurs she has hypertension and hands her a pre-
elements including the muscle and skeletal systems; mod-
scription and starter sample of assorted “blood pressure ulator elements present in the central and peripheral ner-
pills.” Mrs Meowitz is a bit confused about the new medi- vous systems; biomechanical elements; and cognitive or
cations and asks how much she should take. The physi- affective elements including cognitive status, motivation,
cian replies that her blood pressure is only “kind of high” self-efficacy, social supports, and other environmental
so she should take the medium-sized pills once or twice influences.3
a day. If it doesn’t seem to be working, she can progress Therapeutic exercise is the systematic performance or
to the larger pills. If it works a little, but not completely, execution of planned physical movements, postures, or activ-
she should increase to three times a day, and if she feels ities intended to enable the patient or client to remediate
like it is too much she should drop down to the small pills or prevent impairments; enhance function; reduce health-
and only take them once a day. Mrs Meowitz wakes up.
related risk; optimize overall health; and enhance fitness,
Another rough night following dinner at Aunt Chilada’s.
physical activity, and physical and psychosocial well-being.4 It
I f this were a real scenario, most people would be out- includes aerobic and endurance conditioning and recondi-
raged. The physician did not directly assess Mrs Meow- tioning; agility and balance; body mechanics; breathing exer-
itz’s blood pressure to obtain a solid baseline from cises; coordination exercises; developmental activities; gait
which to work. The doctor estimated what type and and locomotion; muscle lengthening/flexibility; neuromotor
development activities; neuromuscular education or reedu-
Author Affiliation: Regis University, School of Physical Therapy, Denver, cation; postural stabilization and training; range-of-motion
Colorado. exercises and soft tissue stretching; relaxation exercises;
The authors of this study have no known conflicts of interest with the and muscle performance exercises for improving strength,
submission of this work.
power, endurance, and hypertrophy.
Correspondence: Wendy K. Anemaet, PT, PhD, GCS, CWS, GTC, COS-C,
School of Physical Therapy, Regis University, 3333 Regis Blvd, G-4, Rehabilitation professionals use all of these types of
Denver, CO 80221 (wanemaet@regis.edu). exercise to accomplish many goals including to enhance
Topics in Geriatric Rehabilitation www.topicsingeriatricrehabilitation.com 79
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
TGR-D-14-00001.indd 79 21/04/14 9:08 PM

bone density; enhance breathing; enhance or maintain Mobility exercises and may begin with exercises focusing on
physical performance; enhance performance in activities Muscle Performance Initiation, Stability, and Motor Control.
of daily living (ADL) and instrumental activities of daily liv- A thorough understanding of each exercise indication assists
ing; improve safety; increase aerobic capacity/endurance; rehabilitation professionals in determining which exercise is
increase muscle strength, power, hypertrophy, and endur- most appropriate for a specific patient.
ance; enhance postural control and relaxation; increase
sensory awareness; increase tolerance to activity; prevent EXERCISE FOR TISSUE HEALING
or remediate impairments, functional limitations, or dis- When considering exercise prescription for Tissue Healing,
abilities; improve physical function; enhance health, well- it is important to review the stages of healing for different
ness, and fitness; reduce complications, pain, restriction, types of tissue and differentiate between acute and suba-
and swelling; reduce risk; and increase safety during activ- cute injury and their differing mechanisms. Tissue Healing
ity performance. is a process that involves 3 stages:
Examining the plethora of exercise interventions and
1. acute or postoperative stage occurs right after
pairing them with the intended outcome(s) is a daunting
injury or surgery;
task. As a result, a sound decision-making strategy is critical
2. repair stage occurs for varying lengths of time de-
to determine what exercise type, intensity, frequency, and
pending on the tissues involved; and
duration may best achieve optimal outcomes. Evidence-
3. remodeling stage begins in the repair stage and
based practice mandates rehabilitation professionals pos-
continues for up to a year in most instances.
sess strong rationale based on the current literature for all
elements of practice including therapeutic exercise. While In wound care terms, these 3 stages are referred to as
prescribing “what feels right” or “what worked in the past” inflammation, proliferation, and remodeling. Whether an
may accomplish some positive outcomes for patients, open wound or a closed wound—a pressure ulcer or a
using sound prescription principles from current research sprained ankle—there are a lot of commonalities in these
more consistently produces optimal outcomes. stages. Basically, all wounds, whether open or closed and
One such framework for exercise prescription catego- regardless of whether it involves skin, ligaments, muscle,
rizes indications for exercise prescription into levels or or bone, go through similar healing processes.
phases. These include the following: Healing begins with inflammation. This stage usually
lasts 2 days but may persist up to 14 days following an ini-
1. Tissue healing;
tial insult or injury. Persisting inflammation beyond 14 days
2. Mobility;
is considered chronic. Overlapping with inflammation is
3. Performance, Initiation, Stability, and Motor
proliferation. This stage begins around day 2 and contin-
Control;
ues until initial healing has occurred. At the end of prolif-
4. Performance Improvement; and
eration, tissue integrity has been restored, but maximum
5. Advanced Coordination, Agility, and Skill.
strength has not been attained. It is during remodeling
These levels may overlap and are not lockstep (Figure 1). that tissues gain strength and reach their maximum poten-
For example, a patient may require exercises addressing tial, which may be restored to normal or less than normal
Tissue Healing and others designed to improve Muscle depending on the type and extent of injury. A fuller, more
Performance. Some patients initiate rehabilitation with detailed understanding of these stages assists rehabilita-
exercises geared to promote Tissue Healing and progress tion professionals in better problem-solving how to facili-
through the other indications in a stepwise progression. tate healing and minimize damage throughout each stage
Other patients may not require Tissue Healing exercises or of recovery.
The inflammatory response begins immediately after
insult, injury, or surgery. Sometimes, inflammation is con-
sidered negatively, but it is very necessary for complete
healing to occur. Cells that are brought to the affected
area during inflammation are imperative for Tissue Heal-
ing and without the inflammatory process, healing would
not occur.5 There are 3 aspects of the inflammatory stage—
vasoconstriction, hypoxia, and vasodilation.6 Vasoconstric-
tion occurs as a result of platelet aggregation at the site of
tissue disruption. These platelets form a fibrin plug that
blocks disrupted vessels and prevents excessive blood
Figure 1. A framework for prescribing exercise based on loss. In addition, the cardiovascular system receives signals
5 overlapping levels. from the individual tissues to vasoconstrict local vessels
80 www.topicsingeriatricrehabilitation.com April–June 2014
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to minimize blood loss.7 Vasoconstriction is mediated by integrity of the tissue but does not allow the muscle to
thromboxane and prostaglandins that cause spasm of the function normally. The muscle fibers now have to contract
vessel walls. Vasoconstriction lasts 5 to 10 minutes and dur- around scar tissue, thereby decreasing its force-generating
ing this time, periods of intermittent hypoxia affecting the capacity.13 However, if the sarcolemma is intact, muscle
tissues supplied by the vessels occurs. This hypoxia is short- cells may regenerate and the muscle should regain normal
lived (less than a few minutes) and is a necessary stimulant or near-normal function.
for the process of angioneogenesis, or the production of Several factors impact Tissue Healing. For example, an
new blood vessels.7 Hypoxia also creates a favorable envi- insufficient response by the phagocytic cells (macrophages
ronment for the cells needed for wound healing. Prolonged and neutrophils) during the inflammatory phase impairs
vasoconstriction would be harmful and as a result, the third efficient removal of damaged tissue and delays healing. In
part of inflammation occurs, which is called vasodilation. addition, too many macrophages, especially those that sig-
This is mediated by histamine, released by the platelets.8 nal inflammatory substances, can perpetuate the inflamma-
Histamine is also responsible for making the blood vessels tory process and delay healing.14 The age of the person is
more porous, allowing cells within the vasculature to enter another factor that impacts Tissue Healing in skeletal mus-
the injured area. It is through this process that the neutro- cle. This occurs in several ways. Older adults have fewer
phils and macrophages, which remove damaged tissue and satellite cells. Satellite cells are cells present at birth that
debris, enter the injured area.9 These phagocytic cells, in can differentiate into any type of cell.15 During childhood
addition to cleaning the area so that healing can occur, also and adolescence, these cells are stimulated to differentiate
signal fibroblasts to the area. Fibroblasts are responsible for into specified cell types (ie, muscle nerve kidney cells, etc).
the development of collagen and new tissue to replace the Some satellite cells remain after adolescence, but at this
injured tissue during proliferation.10 With this influx of cells time they enter a quiescent phase during which they no
from the vasculature into the injured area also comes fluid, longer freely differentiate. Under extreme circumstances
or edema. While needed to mobilize cells to the tissue, such as injury, they may be stimulated to differentiate and
the edema is also a source of pain as it puts pressure on develop into muscle cells. Like other cells, satellite cells
nociceptors.9 are susceptible to apoptosis. Older adults more likely have
Thus, inflammation and proliferation begin on the day less satellite cells available for differentiation. In addition to
of injury or insult with inflammation continuing for several fewer satellite cells, older adults have slower phagocytosis
days thereafter. While inflammation is necessary for suc- which prolongs the inflammatory phase.16 With age, there
cessful healing, an early goal is to effectively manage it— is heavy reliance on Wnt signaling, as opposed to notch
allow it to occur, but in a controlled manner, and resolve it signaling, for cell-to-cell interactions.17 In relation to mus-
rapidly so healing may progress as quickly as possible. The cle tissue, this results in greater fibrosis, with Wnt signal-
inflammatory stage brings all the necessary cells into the ing as compared to muscle cell regeneration with notch
injured space. Persons with impairments in inflammation signaling.17 Finally, as one ages, there is lower production
because of pathology or medications may have difficulty of growth factors, which also negatively impacts healing of
healing for this reason.11 This is evident with open wounds muscle tissue.
but applies also to closed wounds. As a general rule, initial muscle healing occurs in about
During the proliferation phase of healing, fibroblasts pre- 6 weeks and continues on through 12 to 14 weeks when
dominate and collagen is formed. Collagen is the substance the tissue possesses near-normal strength. Remodeling
that provides strength for connective tissue. There are many continues 6 months to a year postinjury.
different types of collagen throughout the body. The most For rehabilitation professionals, muscle inflammation
common types include type 2 collagen, found primarily in must be controlled to minimize fibrosis. Exercise assists
cartilage; type 3 collagen, which forms first in the healing in controlling inflammation through light muscle contrac-
process and is gradually replaced by type 1 collagen as pro- tions and range of motion in the pain-free, mid range. This
liferation and remodeling advance. Type 1 collagen gives tis- range of motion could be passive, active, or active-assisted,
sues strength and is the most common form of collagen.12 as long as it is not painful. Pain during exercise at this point
During remodeling, the tissue integrity restored during indicates continued damage to injured tissue, which pro-
proliferation is strengthened. The timeframe for remodel- motes more inflammation and pressure on nociceptors.
ing varies depending on the type of tissue—skeletal muscle, Newly regenerating muscle cells must also be protected.
bone, tendons and ligaments, or cartilage. These cells are quite fragile in their early states and cannot
In skeletal muscle, the amount of Tissue Healing (ie, withstand high stresses and strains.18 Pain and inflamma-
muscle regeneration) that occurs depends on the extent tion are helpful guides for avoiding harmfully high stresses
of damage. If the basement membrane is damaged, and strains and thereby protecting the new cells.
regeneration cannot occur and repair happens primarily In addition, muscle function should be facilitated. While
through scar tissue filling of the gaps. This restores the the newly generating muscle cells need initial protection,
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gradual increase of the stress and strain in a very controlled along with gradually increasing loads may be introduced
manner assists in the development of the tissue.19 after 2 weeks and continue through 10 to 12 weeks postin-
In contrast to muscle tissue, bone heals primarily by jury when primary healing in complete. Intensive exercise
regeneration and remodeling without permanent scar- loads heighten risk for reinjury throughout the remodeling
ring. Indeed, the initial scar formed is resorbed over time. phase (approximately 1 year) and should be avoided.
Bone healing begins with the immediate vascular response Cartilage is a difficult tissue to heal because it is largely
common to all tissue types as described previously. This avascular.23 As a result, in cases of isolated cartilage damage,
vascular response signals chondrocyte precursor cells to there is no vascular response and therefore a very abnor-
the wounded area from the periosteum, bone marrow, and mal inflammatory response. Chondrocytes can still divide
endosteum.20 In addition, chondroblasts from periosteal in the absence of an inflammatory response and they will
cells proximal to the fracture site migrate and form hyaline also increase proteoglycan production.24 However, healing
cartilage. Osteoblasts from the periosteal cells distal to the will be slow and the best healing will occur at the periphery
fracture form woven bone and over time, the hyaline carti- of the cartilage, closer to adjacent blood supplies. While
lage and woven bone meet to form the callus. counter intuitive, prognosis for healing and the potential
This initial callus formation occurs in about 2 weeks. for regeneration is much greater if tissues beneath the car-
Over the next 4 weeks, the hyaline cartilage and woven tilage are also damaged. Deeper injuries actually facilitate
bone is replaced with trabecular bone. When full replace- healing because of carryover healing processes related to
ment of the hyaline cartilage and woven bone occurs, the subcartilaginous tissues.
the bone strength is restored to near full.20 However, the To assist cartilage healing, motion is important because
healing process is not complete. Over the next 5 years, it stimulates synovial fluid, which contains all the cells
osteoclasts will resorb trabecular bone—Howship’s lacuna needed for healing.25 Unloaded motion is considered opti-
form, and the lacuna are filled in with compact bone, thus mal because it causes no pain and does not risk further
removing any evidence of a “bone scar.”20 cartilage damage. However, some advocate gently loaded
In terms of exercise prescription for bone-related inju- motion for its mechanotherapeutical effects.19 Unfortu-
ries, fracture sites must be protected during initial healing nately, adequate imaging techniques to observe and ascer-
until callus formation, or about 2 weeks. After that time, tain the safety of loaded exercise do not currently exist.
controlled stress on the bone, according to Wolf ’s Law, is Regardless, gradually increasing loads and strengthening
necessary for at least the next 4 weeks.21 After hard callus of supporting structures aid in protecting the healing car-
is formed, full activity may be resumed. The timeframes tilage surfaces.
given are for “usual” healing. Patients who heal atypically
because of pathology, age, or medication may not follow Exercises for tissue healing
the same timeframes. In these cases, it is best to ascertain Two main types of exercise that address Tissue Healing are
the presence of soft and hard callus with radiographs. range of motion and isometric exercises. As with most
In contrast to muscle and bone, tendons and ligaments types of exercise, these may be used in other phases of the
heal by tenoblast proliferation at the cut ends of the struc- Tissue Healing framework.
tures, assuming no vasculature is disrupted.22 In the pres- Several types of range of motion exercise are appropri-
ence of vasculature disruption, fibroblast proliferation ate for Tissue Healing. In passive range of motion, there is
from neighboring tissues occurs. These fibroblasts secrete no voluntary muscle contraction. All movement occurs as
collagen, which later forms into fibrils. Within about a result of an outside force. This force may be manual or
2 weeks, these fibrils have some strength, although at this mechanical (ie, continuous passive motion device). With
point, they are comprised primarily of water and only pos- active range of motion, the muscles generate all of the
sess about 20% collagen.22 While this results in impaired movement. In between passive and active, active-assisted
strength, the fibril’s high water content gives them vis- range of motion occurs when the muscles move the body
coelastic properties that help them withstand shear and part with the aid of an outside manual or mechanical
torsion. Final maturation of tendon and ligament tissues force. All 3 range of motion types may be helpful in Tis-
occurs at about 10 weeks postinjury with complete healing sue Healing. The key is knowing when to apply which
at about 1 year. and how.
From an exercise prescription perspective, tendons Passive is the least desirable form of range of motion
and ligaments are often immobilized for the initial 2 exercise for Tissue Healing because while some mecha-
weeks to decrease stress to the healing tissue. During this notherapeutic effects exist, this benefit is not as strong
time, it is important to perform light, quick isometrics to as when muscle contraction occurs.19 However, passive
increase blood flow for ligament injuries. These may also motion does promote joint and fluid movement and offer
be performed with tendon injuries as long as no move- some minimal stress on tissues that aid in the laying down
ment occurs to disrupt the healing segments. Movement of collagen in a functional fashion. The main indications
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for passive range of motion include patient inability to as well. Rushing through or omitting Tissue Healing exer-
perform active motion or a medical restriction. This might cises may result in incomplete or delayed attainment of
occur in patients with deep muscle, ligament, or tendon the Tissue Healing goal.
injury. Passive range is also used as an examination tech- When prescribing range of motion exercise for Tissue
nique to detect restrictions, as a means to teach an exer- Healing, rehabilitation professionals consider the param-
cise or correct a movement pattern (as in the Performance eters. High frequency exercise promotes increased circula-
Initiation and Motor Control level of the framework), and tion and the laying down of collagen in a functional man-
in preparation for stretching to take up the slack in the tis- ner. Therefore, patients should perform range of motion
sues (as in the mobility level of the framework). exercise as often as able, even as much as several times an
Active-assisted range of motion is indicated for the hour. Incorporating exercise into their daily routines (ie,
same reasons as passive as well as for someone who is performing them during every commercial break when
permitted to contract muscles but lacks the strength to watching television, before and after every meal or snack,
go through full range without assistance. This is encoun- or bathroom break, etc) facilitates compliance. Exercise
tered in patients following immobilization, in which mus- intensity should be very low as the purpose of the exer-
cle atrophy limits motion, especially at end range. These cise is to increase Tissue Healing. As a result, resistance is
patients may independently move the body part through not indicated. Exercise duration should be short. Frequent,
some of the range but need assistance for other portions. brief exercise, rather than fewer, sustained exercise is pre-
Other patents may be limited by pain. These patients may ferred as it achieves better increases in circulation and ulti-
actively move through their pain-free range but require mately, better Tissue Healing. In addition to high frequency
assistance to move through the painful part of the range. and low intensity, Tissue Healing range of motion exercise
Active-assisted range of motion offers sensory feedback parameters should consider the posture or movement.
and because of the active movement, there is more stimu- Range of motion exercise should be performed in the pain-
lation to bone and joint and other tissues and enhanced free mid-range and so in this case, the saying of “no pain,
local circulation owing to the muscle pump.26 no gain” does not apply.
When possible, active range of motion is the exercise Besides range of motion, muscle contraction also facili-
type of choice over passive and active assisted for patients tates Tissue Healing. This exercise type will be revisited in
who are permitted to contract the muscle and are able to all the other levels of exercise—Mobility, Performance Ini-
go through the range without assistance. In addition to the tiation and Motor Control, Performance Improvement, and
benefits listed for active-assisted exercise, active range of Advanced Coordination, Agility, and Skill. However, as with
motion enhances coordination and motor control because range of motion, it the way in which muscle contraction
of the totally volitional movement involved. is prescribed that qualifies it as a Tissue Healing exercise.
To summarize range of motion exercise recommen- Several types of muscle contraction exist. During a
dations, passive range is limited because it does not concentric contraction, the muscle generates force as it
assist in circulation, prevent muscle atrophy, increase shortens. In an eccentric contraction, the muscle gener-
strength, or enhance endurance because no active con- ates force as it lengthens. In an isometric contraction, the
traction of muscle, and therefore no exercise intensity, muscle generates force as it is held at a constant length. In
occurs. For these reasons, passive range of motion is the Tissue Healing phase, isometric exercises and concen-
best used in the Tissue Healing and mobility phases and tric exercises without resistance are indicated.
is rarely used in the Muscle Performance Initiation, Sta- When prescribing muscle contraction exercise for
bility, and Motor Control, and the Muscle Performance Tissue Healing, the frequency should be high and the
Improvement levels. intensity should be low. Patients should be instructed to
When prescribing range of motion exercise for Tissue perform 20 to 30 repetitions at least hourly, or more fre-
Healing, it is important to monitor patients continually quently, if possible. When performing concentric contrac-
for tolerance and signs of trauma through observation of tions, resistance is avoided as the intent of the exercise is
verbal and nonverbal expression during exercise. Tissue to facilitate Tissue Healing, not to increase strength. With
integrity should be assessed before and after each session isometric exercise, patients should contract the muscle at
to ensure damage was prevented. Range of motion exer- about 25% of their maximal ability or less and with a very
cise may be a valuable intervention during Tissue Heal- short “hold.” Longer holds, especially at higher intensities,
ing, but the potential for injury does exist. Rehabilitation result in decreased blood flow to the area for short periods
professionals and patients may underestimate the efficacy of time.27 The goal for Tissue Healing exercise is to activate
of range of motion exercise, perceiving that “not enough a muscle pump to improve local circulation. Therefore,
is being done” or “the exercise is too easy.” It is impor- an isometric “flicker” exercise, in which patients gently
tant to recall the purpose for the range of motion exercise tighten the muscle very briefly (ie, less than a second) and
(ie, to aid Tissue Healing) and communicate it to patients repeats it 20, 30, or more times, is indicated.
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EXERCISE FOR MOBILITY Tissue Healing, including the provision of positive circu-
Mobility exercises are the second phase or level of the exer- lation and vascular dynamics, diffusion of materials in the
cise prescription framework. While some patients may joint, freer synovial movement, and inhibition of pain. In
begin at this level of the framework, often, especially for addition, when used for mobility, range of motion exercises
patients with an acute injury or recent surgery, Mobility also help maintain or improve joint and soft tissue integ-
exercises begin after Tissue Healing exercises. Therefore, it rity and the elasticity of muscle, thus preventing injuries.
is helpful to know when to progress from Tissue Healing Range of motion exercise may also minimize contracture
interventions to Mobility exercises. Certainly, if all signs of development and prevent bone demineralization.29
inflammation—pain, edema, redness, and heat—are For purposes of addressing mobility, range of motion is
absent and the tissue involved has undergone the initial employed to examine patients as a means to assess both
proliferation phase, Mobility exercises may be indicated. contractile and inert tissue as well as joint hyper- and hypo-
However, sometimes signs of inflammation linger, espe- mobility, and to determine if limitations in movement are
cially pain and edema. In these cases, Mobility exercises the result of tightness in the joint capsule, muscle, or fascia.
may be introduced if the inflammation is decreasing and if Regarding a treatment adjunct, range of motion exercise
inflammation continues to decrease with the implementa- may also be performed in preparation for stretching such
tion of Mobility exercises. In practical terms, pain and/or as when passive range of motion is used to take up the
edema should be minimized and stabilized (ie, decreasing) joint and tissue slack prior to a passive stretch.
and should not increase with Mobility exercises. While pain In a discussion of joint mobility exercise, it is impor-
and edema may not be completely absent prior mobility tant to distinguish between range of motion and flexibil-
exercise initiation, they should not increase with exercise. ity. Flexibility is the combination of joint range of motion
If they do, it is an indication that tissue trauma is occurring and the length of the muscles surrounding a joint.30 Mus-
and reinitiating the inflammatory process. While one might cle flexibility and joint range of motion are not synony-
argue that edema may be easily reduced again, this repeti- mous. A patient may have normal joint range of motion
tive pattern of overexercise, micro- or macrotrauma, and but because of shortened muscle length crossing the joint
inflammation results in the presence of an abundance of have decreased flexibility. Flexibility depends on the ability
proinflammatory cytokines that can lead to chronic inflam- of the muscle and its surrounding fascia to deform and is
mation and may result in the development of fibrosis and important for both static and dynamic movement. Patients
osteoarthritis.28 If signs of increased inflammation develop, lacking flexibility often have decreased functional range
exercises for Tissue Healing are more appropriate than of motion and strength loss.29 Along similar lines, contrac-
those for mobility. ture is the presence of a fixed, high resistance to passive
Sometimes patients do not receive rehabilitation ser- stretch of the tissue.31 This could be the result of fibrosis or
vices during the Tissue Healing phase, seeking treatment adaptive shortening of muscle or tissues around the joint
when ready for more advanced exercise such as those for as is the case with soft or mobile contractures. Contrac-
mobility. In all cases, assessment guides the determination ture may result from bony abnormality or calcification of
of what type of exercise is needed. For example, if assess- the joint, as is the case with fixed contractures. The pres-
ment reveals a limitation in joint or tissue mobility, exercise ence of impaired range of motion, flexibility, and contrac-
prescription should target this area. ture are each indications for mobility exercise.
Range of motion limitations may result from a variety of Stretching is another procedure used when prescrib-
causes. Soft tissue restrictions such as capsular tightness, ing mobility exercise. Stretching lengthens muscles that
scarring, ligamentous tightness, and single-joint muscle have become shortened because of disease, disorders,
shortening may be addressed with mobility exercise. Lim- or pathologies. Stretching may be passive, in which the
ited joint mobility may also affect range of motion. Use of patient is relaxed and some external force is applied to
manual techniques in conjunction with mobility exercise provide the stretch, or active, in which the patient par-
is indicated in these cases. Certain pathologies and immo- ticipates in the stretch to inhibit tone.32 Selective stretch-
bility may also result in limited range of motion. Pain and ing occurs when muscles are stretched or purposely left
edema are known causes of impaired range; however, if tight to improve function. For example, the finger flexor
these are causative factors it should be ascertained that Tis- muscles may be intentionally left tight to maximize the
sue Healing is complete and pain and edema have stabi- use of tenodesis with wrist extension in patients with
lized prior to initiating mobility exercise. amyotrophic lateral sclerosis resulting in a weak grasp.33
One of the mainstays of mobility exercise is range of This is sometimes done with athletes, such as pitchers,
motion exercise. As mentioned in the previous discussion who increase their elbow and shoulder range of motion
of Tissue Healing, there are 3 types of range of motion— beyond normal to enhance efficacy on the mound. Over-
passive, active, and active-assisted. Each may be helpful stretch may be detrimental if it results in hypermobility to
for mobility, offering benefits as described for purposes of the point of weakness, also termed as stretch weakness.
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In the presence of stretch weakness, the muscle requires 24 hours daily. These are effective ways to achieve plastic
strengthening in the overstretched range to function effec- changes in collagen. Following up with active movement
tively and minimize risk for injury. after the force is removed is important to gain muscle acti-
Several factors may impact stretching efficacy. Stretch- vation in the newly acquired range.
ing should occur in muscles that are warm, or possess Active stretch techniques involve volitional muscle acti-
good circulation. Muscles with impaired blood supply are vation by patients. These techniques include autogenic
“cold” and an overstretch on muscles that are “cold” may inhibition and reciprocal inhibition. Both autogenic and
result in injury.32 Immobilization may also weaken tissue reciprocal inhibition occur when muscles are inhibited
because of reduced collagen turnover and weak bonding from contracting as a result of Golgi tendon organs and
between new, nonstressed fibers, which are not laid down muscle spindles, which respond to changes in muscle
in a functional fashion but rather randomly.34 Immobilized tension and length. Muscle spindles are receptors found
tissues may also include areas of adhesions within the mus- within muscle, which is made up of unique muscle fibers,
cle where scar tissue has developed. In this situation, rapid sensory endings, and motor endings.41 The purpose of the
stretching may break adhesions and damage underlying muscle spindle is to prevent overstretching of the muscle
muscle. Inactive patients tend to have decreased amount in which it is contained. When a muscle is stretched, the
and size of collagen, weakened tissue, and a predominance sensory endings in the spindle are activated and send a
of elastin, which may alter the ability for the muscles to message to the muscle telling it to contract. This contrac-
resist stressors.35 Age also affects stretching in that there is tion prevents the muscle from stretching into a plastic
a decrease in maximum tensile strength and elastic modu- stage and attempts to prevent tearing of the muscle.
lus with age.36 In addition, the rate of adaptation to stress Attached to the fibers of the tendons of a muscle, the
is slower in older adults, necessitating longer stretch holds Golgi tendon organ works to relax a muscle so that the
to effect change.37 There is also an increased tendency for stretch being applied does not cause tearing or overactiv-
overuse, fatigue failures, and tears with stretching in the ity of the nerve fibers. The Golgi tendon organ structure is
older population because of tissue fragility. Finally, some made up of sensory nerve afferent fibers, which are very
medications, such as corticosteroid agents, have long- sensitive to the changes in tension of the tendon. When a
lasting deleterious effects on the mechanical properties of muscle is stretched for a prolonged amount of time or con-
muscle and decrease its tensile strength.38 tracts isometrically, the Golgi tendon organ is activated and
When performing passive stretching, the tissue slack inhibits the tension, allowing the muscle to relax and elon-
should be taken up by passively moving past the available gate. This elongation during a stretch or extreme tension
range of motion. It is at this point that force is applied for at helps prevent tearing of a tendon or muscle. This process
least 6 seconds to effect change, holding up to 2 minutes.39 is known as autogenic inhibition.
A longer stretch yields greater change, and older adults Hold-relax is a technique in which autogenic inhibition
require a longer stretch—at least 60 seconds for beneficial is used purposefully. The patient isometrically contracts the
outcome.37 Even younger adults should hold stretches for muscle and holds. As a result, the muscle spindles and Golgi
at least 30 seconds to effect a greater elastic change in the tendon organs inhibit the muscle, thus allowing further
collagen. Stretching should then be followed immediately stretching of the muscle upon relaxation. Contract-relax
by active use of the stretched muscle in the new range to is a similar strict technique, except instead of an isometric
make the elastic changes more permanent. muscle contraction, the patient performs a concentric con-
Passive stretching could occur either statically or with traction, usually against manual resistance. For example,
prolonged mechanical passive stretch. Static stretching to increase the length of the pectoralis muscle in patients
manually moves the muscle and other soft tissues beyond with rounded shoulders, the hold-relax technique requires
the available range, holding it at a determined end range. the patient to push into the clinician’s hand, using shoul-
This may be performed by rehabilitation professionals der protraction. The clinician meets the force, preventing
or patients themselves. Prolonged mechanical passive any movement. Upon relaxation, the clinician moves or
stretching involves the use of an outside device, such as stretches the shoulder into a more retracted position and
a splint, that holds the muscle or soft tissue in a length- repeat the procedure. In contrast, with contract-relax, the
ened position beyond the available range of motion for patient pushes into the clinician’s hand with their shoulder
an extended period of time—often several hours. Both and the clinician provides resistance but allows movement
are effective ways to gain range of motion or flexibility. through their available protraction range. Upon relaxation,
Other example of prolonged mechanical passive stretch is the shoulder is stretched into retraction and the procedure
the application of low, external force using traction, pul- repeated.
leys, dynamic splinting, or serial casts. This force should be Reciprocal inhibition is the physiological process that
about 5% to 10% of the person’s body weight.40 The force occurs when the agonist muscle concentrically contracts,
is maintained for at least 20 minutes to several hours to causing the antagonist muscle to in turn relax.42 This
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relaxation of the antagonist muscle allows the agonist function. For example, tight hamstrings may assist trunk
muscle to move the limb through the total allowed range stability in sitting for patients with spinal cord injury and
of motion without interfering tension. To employ agonist increasing hamstring mobility may impair sitting balance
contraction, the patient contracts the agonist muscle and for this population.
the antagonist muscle relaxes. Upon relaxation, the clini-
cian stretches the antagonist muscle. This may be per- EXERCISE FOR PERFORMANCE INITIATION,
formed either concentrically for agonist contraction or STABILITY, AND MOTOR CONTROL
isometrically for hold-relax agonist contraction. Using the The third level on the exercise prescription framework, Per-
prior example of increasing pectoralis muscle length in pat- formance Initiation, Stability, and Motor Control, includes
ents with rounded shoulders, the hold-relax agonist con- muscle initiation, motor control, and stabilization. Although
traction requires the patient to push into the therapist’s this level follows the mobility level, the framework is not
hand by retracting his/her shoulder. The clinician meets the lock step. Patients requiring exercises for initiation, stability,
force and prevents joint movement. Upon relaxation, the and/or motor control need not have full mobility before
clinician stretches the shoulder into a more retraction posi- beginning this phase. At the same time, patients without
tion and repeats the procedure. In contrast, with agonist inflammation who possess full mobility may bypass Tissue
contraction, the patient pushes into the clinician’s hand Healing and mobility exercise, proceeding with initiation,
with his/her shoulder as the clinician provides resistance stabilization, and motor control exercise directly.
and yet allows shoulder movement through the available At this point, most if not all signs of inflammation—pain,
retraction range. Upon relaxation, the shoulder is passively edema, redness, and heat—should be absent and tissues
stretched into retraction and the procedure repeated. should be into the proliferative and remodeling phases.
Some precautions exist for Mobility exercises. First, Occasionally, some signs of inflammation may linger, espe-
these exercises should be performed with low force cially pain and edema, but they should be decreasing and
whenever possible and the patient should feel a stretch continue to decrease with initiation exercises that are per-
rather than a sharp pain. While performing mobility exer- formed. As mentioned previously, pain and edema should
cise over a fracture, the fracture site must be stabilized so not increase with exercise. An increase in either indicates
as not to inhibit bone healing by potentially moving the trauma to the tissue and reinitiation of the inflammatory
approximated ends. Clinicians should not prescribe mobil- process. Also patients should have mobility, although it
ity exercise over a fracture site as a home program. These does not have to be full mobility. Patients should have a
exercises require the skill of rehabilitation professionals to pain-free range through which they can move. If they do
ensure safer administration. Patients who have, or are sus- not, exercises for mobility would be more appropriate.
pected to have, osteoporosis should be monitored closely Muscle initiation is more complex than simple muscle
for signs of insidious fracture. Low grade forces should not activation. Successful muscle initiation requires neural
result in fracture even in someone with moderate osteopo- input, vascular regulation, metabolic responses, and muscle
rosis, but care should be taken to ensure no heavy forces contractility. Muscle contraction is accomplished by muscle
are used.43 As mentioned previously, recently immobilized fiber shortening or lengthening because thick myosin and
tissue is more susceptible to injury with vigorous stretch- thin actin myofilaments slide past each other. The actin
ing, so care should be taken with these patients. Pain from and myosin form cross bridges and the cyclical attaching,
mobility exercise should not persist beyond 24 hours. If it rotating, and detaching of the myosin head, and the actin
does, the exercises may have been too vigorous. Likewise, filament drives the shortening process. The sequence of
edema requires special consideration because edematous events by which transmission of an action potential along
tissue is more prone to injury because of the presence of the sarcolemma leads to sliding of myofilaments is known
catabolic substances in the edema. Clinicians must moni- as excitation-contraction coupling.
tor edema, and mobility exercise should not increase fluid With excitation-contraction coupling, an action poten-
retention. Finally, overstretching weak muscles requires tial is sent from the neuron in the brain or spinal cord
caution. Gaining new mobility without gaining muscle acti- and travels along the sarcolemma of the axon and down
vation and strength sets patients up for injury. the t-tubules. When it passes the triad region, it causes the
Some contraindications for mobility exercise include sarcoplasmic reticulum to release calcium ions into the
forced mobility of a bony block, mobility over a recent muscle cell. Within the muscle cell are proteins, specifically
fracture with inadequate stabilization of the fracture site, troponin and tropomyosin, which bind to each other and
mobility during acute inflammation that is not stabilized also bind to actin. In the presence of calcium, troponin and
or during infection, sharp pain that may indicate an acute tropomyosin release their bond on actin. This frees actin
injury, and mobility over a hematoma as this may exacer- up to bind with myosin and cross bridging occurs. When
bate the hematoma. Finally, avoid mobility exercise tar- supplied with energy from the breakdown of adenosine
geting tissues surrounding joints that need stability for triphosphate by ATPase, the myosin head rotates bringing
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actin along. When calcium levels are too low, troponin and restoration of body systems involved. However, Perfor-
tropomyosin bind to actin again blocking the crossbridg- mance Initiation, Stability, and Motor Control exercises gen-
ing with myosin, and relaxation occurs. Successful muscle erally avoid higher intensities, which foster performance
contraction is a complex interplay of neural inputs (send- improvement. In terms of frequency, these exercises may
ing the signal along the axon), vascular inputs (bringing cal- be performed on a daily basis as long as the intensity is
cium, adenosine triphosphate, and other substances to the less than 50% of the 1 repetition maximum (1RM). Keep-
area), and muscular (presence of muscle proteins—actin, ing the intensity below 50% 1RM is expected in this level of
myosin, troponin, tropomyosin). exercise, especially in the early days of Performance Initia-
Exercises that cause muscle contraction are integral tion, Stability, and Motor Control and in patients just past
because progressive loading of tissues is imperative to Tissue Healing. Too high of an intensity may risk for injury to
achieve full healing. Collagen, the main constituent of tissue—staying under 50% 1RM minimizes this.
most soft tissue, reacts to forces acting on it to determine To maintain an intensity of less than 50% 1RM, the 1RM
how it is laid down. Muscle contraction provides functional must be evaluated. Guessing the 1RM may be wrong and
direction for this collagen lay down. Bone also responds to actually place too much of a load. Using prediction equa-
stresses placed on it. Muscle contraction offers and means tions is the preferred method for 1RM determination (see
to introduce low loads on structures and apply increasing Appendix for explanation of prediction equations).
loads. In addition, muscle contraction and muscle initia- When prescribing Performance Initiation, Stability, and
tion exercises lay the foundation for proper recruitment of Motor Control exercise, a low weight and higher repeti-
muscles, including synergists and stabilizers, which are tions should be employed. Two of the prediction equa-
integral for stabilization. Repetitive muscle contraction tions (Lander’s and O’Connor), while quite good for
improves endurance, not only of the contracting muscle Performance Improvement prescription, are not as suit-
but also of the cardiovascular system. In this way, muscle able for predicting a 1RM for Performance Initiation, Sta-
initiation exercise may be used for not only muscle initia- bility, and Motor Control as they tend to give false results
tion but also initiation of the cardiovascular system. Muscle when more than 20 repetitions are performed. For Perfor-
contraction is imperative for motor control, and of course, mance Initiation, Stability, and Motor Control exercise, the
both muscle contraction and motor control are key to Oddvar Holten method may be better suited to ensure
functional activities. low loads and still get a fairly accurate prediction of 1RM.
Exercise that elicits muscle contraction include isometric When prescribing an intensity for isometric exercise,
and isotonic. In isometric exercise, muscle length does not the general recommendation is to tighten or contract with
change as tension or force is generated. In isotonic exer- 25% to 50% or less of maximal strength. This, of course, is
cise, the muscle generates force or tension as the length difficult to quantify. Contracting against a blood pressure
changes. Isotonic exercises can be further subcategorized cuff as described in the modified sphygmomanometer test
as eccentric or concentric. An eccentric contraction involves may assist in quantifying the isometric contraction.44-46
the generation of force as the muscle lengthens and a con- With lower intensity exercise, higher repetitions may be
centric contraction involves the generation of force as the performed. With intensities of less than 50% 1RM, the mus-
muscle shortens. The quadriceps muscle provides a readily cular system is working primarily aerobically and as long as
accessible illustration of the muscle contraction types. In a the vascular supply is patent, there is a continuous supply
quad set exercise, the muscle contracts isometrically. When of energy. Eventually that supply will run out, the timing
actually moving the lower leg, the quadriceps contract iso- of which depends on the patient’s cardiovascular fitness.
tonically. This could be concentrically, as in a sit to stand In general, patients should be able to perform high repeti-
activity, or eccentrically, as in a stand to sit activity. tions of Muscle Performance Initiation, Stability, and Motor
Isometric exercise was discussed as an option for Control exercises.
Tissue Healing and also for mobility in the form of auto- In determining what type of exercise is most
genic and reciprocal inhibition. Likewise, isotonic exercise appropriate—isometric, isotonic, eccentric, concentric,
was discussed for both Tissue Healing and Mobility. Both of open chain, and close chain—the principle of specific-
these exercise types are also appropriate for Performance ity should be considered. This principle states exercise
Initiation, Stability, and Motor Control. What distinguishes should be relevant and appropriate to the activity for
them when used for muscle initiation is the way in which which the individual is training to produce optimal effects.
they are dosed. That is, how does that muscle need to act to perform the
When dosing for Performance Initiation, Stability, and functional activity with which the patient has difficulty or
Motor Control, an inverse relationship between exer- the client wishes to improve? If it is a stabilizing muscle,
cise frequency and intensity exists. As exercise intensity isometrics are preferable. If the muscle works primarily
increases (especially more than 50% of maximal effort), eccentrically, eccentrics are indicated. The same applies
frequency needs to decrease to allow adequate rest and to open chain versus closed chain exercise. Consider how
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the muscle or tissue needs to function and train in that desired movement and inhibition of undesired movement.
manner, when possible. If it is not possible to train spe- Today, they now focus more on functional movement
cifically, exercise in another manner is not wasted. Gains instead of “normal” movement and incorporate more
are still accomplished. However, gains in terms of function motor learning principles like practice schedules, feedback,
will be more rapid and optimized through application of and stages of motor learning. While a complete discussion
the principle of specificity. of motor learning theories and the physiology behind the
In addition to low load resistance, exercise stability and techniques is beyond the scope of this article, but several
motor control are important for Muscle Performance Initia- techniques and how they can be used to enhance Muscle
tion, Stability, and Motor Control. Stability, or static control, Performance Initiation, Stability, and Motor Control and
involves the coordination of both motor and sensory com- later performance improvement and skill acquisition will
ponents. It is the balance of soft tissue function around a be discussed.
joint or body part. This soft tissue is primarily muscle, but Graded resistance is manual resistance tailored to the
ligaments, tendons, and joint capsules also contribute to patient’s capabilities at various points through the arc of
stability. When these other soft tissues become injured, sta- movement. Resistance assists in the recruitment of motor
bilization exercise becomes even more important to pro- units and overflow into adjacent muscles. Reflex inhibiting
tect the joint. The attainment of static control provides a postures are positions that facilitate certain movements.
stable foundation from which to move and thus enhances For example, external hip rotation facilitates knee extension
performance. As a result, there is an overlap on the frame- and internal hip rotation encourages knee flexion. Rein-
work of stability in Performance Initiation and Advanced forcement is accomplished through manual contacts that
Coordination, Agility, and Skill. encourage motor and sensory inputs. By inhibiting abnor-
When stability is lacking, several things may occur. mal movement and facilitating normal movement, accurate
First, there may be altered joint mechanics. For exam- motor plans are reinforced. Both verbal and visual stimula-
ple, patients with a torn adenosine triphosphatase may tion are also used as means of reinforcing movement. These
have increased forward translation of the tibia on the address more of the central systems of motor control. Trac-
femur. Over time, this can result in joint damage, lim- tion of a joint is an inhibitory technique, whereas approxi-
ited range of motion, and a compensatory hypermobil- mation is a facilitatory technique. Both work as a result of
ity. Patients with limited range of motion at L2-L3 often their effect on joint receptors, which signal central systems
have increased mobility above and below the segment. and ultimately lead to modulation of the motor response.
Changes in proprioceptive input, as well as impaired Timing is the use of velocity and changes in velocity to
reciprocal inhibition, often accompany instability and impact motor control. It also acts on motor control modu-
may lead to altered programming of movement patterns. lators through joint receptor response. Rhythmic initiation
For these reasons, stability exercises are an important should start passively and progress to active movement
part of restoration of muscle initiation as soon as patients through the available range and uses progressively active
acquire some mobility. exercise to establish and reinforce motor plans. Rhythmic
Motor control is the study of movement and the systems stabilization promotes stability through alternating isomet-
that control it under both normal and pathological condi- ric contractions. These techniques can be used during any
tions. Motor control concepts are used with patients of all type of exercise to enhance motor control. Other methods
capacities, from the high-level athlete seeking to improve of enhancing motor control are to incorporate functional
performance to the patient with a functional deficit seek- activities and modify the environment.
ing to regain a functional ability or activity. Dosing stability and motor control exercise employ
There are several theories of motor control including similar concepts as previously discussed for other initia-
the reflex theory that states movement is controlled by tion exercise. For purposes of stability, prolonged holds
a series of chained reflexes; the hierarchical theory that are desirable. The length of this hold is dependent first on
views movement as controlled by a system of 3 levels with how the muscle needs to act. For a muscle that provides
a rigid top down organization with higher centers control- short bursts of stabilization, such as hip abductors during
ling lower ones; and complex systems theory that holds stair climbing, 3- to 5-second holds are appropriate. For a
movement emerges spontaneously from the interaction muscle that needs to provide prolonged, low-grade con-
of the individual, the task, and the environment. It is on traction, such as shoulder retractors for posture, holds of
these theories that many neurofacilitory techniques, such several minutes would be indicated. Isotonic exercises are
as Bobath, proprioceptive neuromuscular facilitation, and best used for motor control going through the functional
sensory integration, are based. Though these neurofacili- range using a slow velocity and incorporating some of the
tory techniques have changed over the years as the the- motor control techniques mentioned previously, such as
ories have evolved, they each attempt to address move- graded resistance, verbal stimulation, approximation, and
ment through the central nervous system via facilitation of others.
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EXERCISE FOR PERFORMANCE is frequently overlooked. Many functional and recreational
IMPROVEMENT activities require power, such as climbing stairs, standing
Accurate prescription of Performance Improvement exer- up from a chair, walking quickly, opening doors, and lifting
cises hinges on a thorough baseline assessment. Because the objects. While these activities also require strength, power
focus of this article is exercise prescription, assessment meth- is paramount. Consider patients who require prolonged
ods will not be detailed here. Please see Appendix for more amounts of time to stand from a chair. They may possess
information on Muscle Performance Improvement assess- adequate strength but lack the ability to use that strength
ment. Second, a thorough assessment of which muscle per- quickly to accomplish the functional chair rise task. While
formance component requires treatment—hypertrophy, most older adults experience a decline in strength as they
strength, power, or endurance—is essential. age, the loss of power is even more pronounced.50 Remedi-
Muscle hypertrophy is the increase of muscle mass by ating power loss by training the muscle for power results in
increasing the size or girth of a muscle. This is primarily greater functional gains in shorter periods of time.
accomplished by enlarging the existing muscle fibers, not The final component of Muscle Performance Improve-
adding new muscle fibers. The number of muscle fibers ment addressed with therapeutic exercise is muscle endur-
an individual has is determined in utero.47 When a muscle ance. Muscle endurance is the ability of a muscle to con-
fiber dies as a result of injury, illness, disease, disuse, or tract repetitively with low load (dynamic endurance) or to
apoptosis, a new muscle fiber does not develop to replace maintain a low load contraction for an extended period of
it. While some small increases in the number of muscle time (static endurance).51 Endurance, just as power, also
fibers could be achieved through the differentiation of has a component of strength involved, but in this case, it
satellite cells into muscle cells, this does not readily occur is a low level of strength used over longer periods of time.
except in extreme situations and the number of available While any exercise resulting in muscle contraction has
satellite muscle cells is limited. Rather, to accommodate the capacity to positively affect all 4 of these components
the loss of muscle fibers, surrounding muscle fibers must (crossover effects), the best outcomes will result when
enlarge, or hypertrophy. exercise is designed to specifically impact the component
Rehabilitation professionals working with older adults most involved in the functional limitation of interest. For
do not often target muscle hypertrophy specifically with example, performing lower extremity strengthening exer-
therapeutic exercise. Muscle hypertrophy training is often cises will eventually result in the patient performing chair
the purview of younger adults seeking larger muscles for rise tasks more efficiently and being able to stand longer
cosmetic or competitive purposes, however, there are without knee collapse. But according to the principle of
times when muscle hypertrophy exercises are indicated specificity, exercise targeting power improvement will
for the older population. One example concerns patients result in quicker improvements in sit to stand, and muscle
with cancer who are preparing to undergo or are currently endurance exercises will more efficiently delay the onset of
undergoing chemotherapy or radiation. These cancer knee collapse.
interventions result in loss of muscle mass. By perform- When establishing a program of Muscle Performance
ing hypertrophy exercises, this muscle mass loss may be Improvement, the first step involves determining which
mitigated or reversed. Another example is patients who component to target—hypertrophy, strength, power, or
have had an extremity immobilized for a period of time endurance. This is best ascertained by identifying with
and experience muscle atrophy. Hypertrophy exercises what functional tasks the patient is having difficulty and
may normalize the appearance of the atrophied limb while what muscle component is most involved in those tasks—
improving the strength, as strength is directly related to hypertrophy, strength, power, or endurance. In reality,
hypertrophy.48 patients have multiple functional tasks with which they
A second target for Muscle Performance Improvement have difficulty, resulting in more than 1 component that
exercise is strength. Strength is the ability of a muscle to requires targeting. For example, a patient may have diffi-
withstand stress or strain, or the force-generating capac- culty with sit-to-stand transfers indicating a power impair-
ity of a muscle. Strength is an underlying component of ment of the quadriceps and gluteals. This same patient
all functional activities and therefore important for virtually often has an increased fall risk because after 30 steps, he
all rehabilitation patients. Furthermore, most older adults tends to “catch his toe” during the swing phase of gait,
lack normal strength and, as a result, have difficulty with indicating a muscle endurance deficit of the dorsiflexors.
functional and recreational activities.49 Strength is directly Muscle Performance Improvement exercise for this patient
related to hypertrophy—as one increases the size of the should include exercises to increase power in the quadri-
muscle, strength is also increased—and is a component of ceps and gluteals and exercises to increase muscle endur-
both power and endurance. ance in the dorsiflexors.
Power, the ability to use strength quickly, is an important Once the targeted component is identified, the next
target for Muscle Performance Improvement exercise and step is to establish the exercise in such a way to directly
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affect the targeted component. When establishing the more time. However, muscle soreness may be avoided with
exercise prescription for Muscle Performance Improve- concentrics especially if the intensity is kept at or below
ment, many parameters must be addressed including mus- 70% of the 1RM.52 Patients may then make an informed
cle action, load, number of repetitions and sets, exercise decision with the clinician. Some patients are willing to
position, equipment, exercise order, rest periods, velocity, “risk” soreness for the “benefit” of a more rapid recovery of
and frequency. How each of these parameters is set will function. Others choose to not “risk” soreness, preferring
determine what outcomes are achieved (Tables 1–3). a lengthier, but more tolerable return to function. Patient
Muscle action with isotonic exercise is divided into con- involvement is important to avoid compliance issues.
centric and eccentric. Concentric activity, force generation The other type of muscle contraction to consider is iso-
while the muscle shortens, is usually the load-limiting por- metric. During an isometric contraction, the muscle does
tion of an exercise as it is the weaker muscle action. An not change in length as it generates force. Isometrics are
example of a concentric muscle contraction would be the helpful when addressing selective recruitment and with
biceps as a book is lifted from the table. Eccentric muscle postural or stabilization exercises (the muscle initiation,
actions, or the force generation as the muscle lengthens, stabilization, and motor control level of the framework).
is the stronger component of isotonic contractions and When establishing an isometric exercise, take into consid-
produces greater force per unit of muscle size. Eccentric eration what angle is preferable for the exercise.53 Accord-
contractions are more conducive to hypertrophy. Unfor- ing to the principle of specificity, with isometric training,
tunately their performance results in more delayed onset optimal results occur at the angle at which the muscle is
muscle soreness. For this reason, it is important for reha- trained. Gains may result in other angles of the muscle, but
bilitation professionals to ensure patients are making an these gains will not be as dramatic.
informed decision when doing eccentric exercises. Explain As with all the parameters, consider what action is
to patients that better gains in hypertrophy and possibly needed for the functional task or tasks then establish the
strength result with eccentric exercise, especially if they are exercise to address that task. For example, many patients
high intensity, but muscle soreness will result. Similar gains have quadriceps weakness, but the muscle action pre-
may be accomplished with concentrics, but it will require scribed depends on with which functional task patients
TABLE 1 Parameters for Resistance Training in Individuals Who Are Novice: A Side-by-Side
Comparison of Parameters for Strength, Hypertrophy, Power, and Endurance
Parameters for Novice Resistance Training
Strength Hypertrophy Power Endurance
Muscle action Concentric and Concentric and Concentric and Concentric and
eccentric eccentric eccentric eccentric
Load 60%-80% of 1RM 70%-85% of 1RM 30%-80% of 1RM 30%-60% of 1RM
Volume (repetitions and 7-12R X 1-4S 6-10R X 1-3S 7-30R X 1-3S 12-30R X 4-7S
sets)
Exercise selection Multijoint and single joint Multijoint and single joint Multijoint Multijoint and single
joint
Exercise order Large before small Large before small Large before small Various sequencing
combinations
Multijoint before single Multijoint before single Multijoint before single
joint joint joint
Higher intensity before Higher intensity before Higher intensity before
lower intensity lower intensity lower intensity
Rest periods 2-3 min for multijoint 1-2 min 2-3 min for multijoint <1 min
exercises using heavy exercises using heavy
loads loads
1-2 min for assistance 1-2 min for assistance
exercises exercises
Velocity Slow and moderate Slow to moderate Fast Intentionally slow
Frequency 2-3 times per week 2-3 times per week 2-3 times per week 2-3 times per week
Abbreviations: R, repetition; RM, repetition maximum; S, sets.
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TABLE 2 Parameters for Resistance Training in Individuals who are Intermediate. A Side-by-Side
Parameters for Intermediate Resistance Training
Muscle action Concentric and Concentric and Concentric and Concentric and
eccentric eccentric eccentric eccentric
Volume (repetitions and 7-12R X 1-4 6-10R X 1-3 7-30R X 1-3 12-30R X 4-7
sets)
Exercise selection Multijoint and single joint Multijoint and single Multijoint Multijoint and single
joint joint
combinations
joint joint joint
Rest periods 2-3 min for multijoint 1-2 min 2-3 min for multijoint <1 min
loads loads
1-2 min for assistance 1-2 min for assistance
exercises exercises
Velocity Moderate Slow to moderate Fast to very fast Intentionally slow
experience difficulty. For example, for an inability to rise Peterson et al performed a meta-analysis of strength
from a chair, concentric exercise to target the concentric training studies to determine the optimal settings for each
contraction needed for sit to stand is indicated. On the parameter to improve strength for untrained individuals
contrary, patients struggling to control the descent to sit- (ie, had not done resistance training in the recent past).
ting who “plop” into chairs derive greater benefit from Participants obtained strength gains even in ranges of
eccentric exercise to address the lack of eccentric strength 1RM that were less than where strength gains usually occur
to control his descent into the chair. Those patents unable (60%-80% 1RM).55 However, the optimal intensity for indi-
to do the dishes because the knee collapses after 3 minutes viduals who are untrained is 60% to 65% 1RM. Intensities
of standing require isometric exercise, specifically executed greater than that result in diminishing returns and inten-
at full extension. With all the parameters, it is essential to sities greater than 80% 1RM are not very beneficial for
determine the primary problem(s) and tailor the param- these individuals. For individuals who are trained (have
eters to address these directly. performed resistance training recently), no strength ben-
The load, intensity, or amount of resistance performed efit at lower intensities occurs. Trained persons require
each repetition is paramount to accurate exercise prescrip- intensity of at least 65% 1RM to achieve gains and gains are
tion for Muscle Performance Improvement. Appropriate maximized at about 80% 1RM. For senior athletes with con-
load differs depending on what component of Muscle sistent resistant training, the intensity needs to be even a
Performance Improvement is targeted–strength, power, little higher, somewhere around 85% 1RM. This is because
endurance, or hypertrophy. The other consideration for it takes more to activate neural and muscular adaptations
appropriate load is the patient’s training level. Novices because the body has had time to accommodate to resis-
who have not performed resistance training in the recent tance training.
past do not require as high of a load to get results because So, in summary, to improve strength, 50% 1RM is rec-
muscle adaptations occur more rapidly because everything ommended initially to allow learning of proper form and
about the program is novel to the body systems.54 Those technique.55 As soon as patients demonstrate good form,
who have trained in the recent past can still achieve gains; which could be after the first set or may take several sets,
however, a higher load is needed. the intensity should be increased to 60% to 80% 1RM.55
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TABLE 3 Parameters for Resistance Training in Individuals Who Are Advanced: A Side-by-Side
Parameters for Advanced Resistance Training
Muscle action Concentric and eccentric Concentric and eccentric Concentric and eccentric Concentric and eccentric
Volume (repetitions 6-10R X 4-6 1-10R X 3-6 6-308R X 3-6 12-30R X 4-7
and sets)
Exercise selection Multijoint and single joint Multijoint and single joint Multijoint Multijoint and single joint
combinations
joint joint joint
Rest periods 2-3 min for multijoint 2-3 min for high intensity 2-3 min for multijoint 1-2 min for >15R
loads 1-2 min for moderate loads <1 min for 10-15R
to moderate high
1-2 min for assistance intensity 1-2 min for assistance
exercises exercises
Velocity Unintentionally slow to Slow to fast Fast very fast Intentionally slow with
fast 10-1ß5R
Moderate to fast for
>15R
Hypertrophy training occurs at high intensities—80% to be noted, but the greatest gains will be in strength. The
85% 1RM. Exercising at intensities greater than 85% 1RM exception to these crossover effects is endurance. With
is not recommended in older adults because these inten- endurance training, the optimal gains are obtained endur-
sities promote Valsalva, which predisposes individuals to ance, but because the intensity is so low and the velocity is
cardiac events.56 Endurance gains are made with low loads so slow, gains in strength, power, or hypertrophy are not
(30%-60% 1RM) and high numbers of repetitions (12-30 realized.
or more).57 The lower the intensity, the greater the num- Besides intensity and repetitions, another exercise
ber of repetitions that may be performed. Power gains parameter to consider is the number of exercise sets. The
have been shown in the literature with both high and low Peterson et al’s55 meta-analysis found that single-set pro-
intensities.57-59 The important component for improving grams benefitted individuals who were untrained, but best
power is the velocity. The individual must train at high results in strength were achieved with increasing number
velocity, which will be discussed later. When determining of sets, up to 4 sets. More than 5 sets resulted in dimin-
the approbate intensity for power training, consider the ishing gains. This was also observed in trained individuals.
secondary gain desired. Power gains are accomplished as In this population, 8 to 9 sets were optimal for individuals
long as training occurs at a fast velocity.60 If strength gains with a high level of training. While 9 sets of an exercise may
as well as power gains are desired, patents should train at seem excessive, those 9 sets need not be all of the same
higher intensities (60%-80% 1RM). If endurance gains as exercise, just of the same muscle or muscle groups. For
well as power gains are sought, patients should train at example, patients may perform 3 sets of long arc quads,
lower intensities (30%-60% 1RM). 3 sets of leg press, and 3 sets of sit-to-stand, thus accom-
Some crossover effects with resistance training occurs.61 plishing 9 sets of quadriceps exercise. Studies have not
If training occurs for power, some strength, hypertrophy, addressed the optimal number of sets for power, endur-
and endurance gains are also achieved. However, the power ance, or hypertrophy. However, it is thought that endur-
gains are optimized. Similarly, if training targets strength, ance gains are made with high-volume programs with
improvements in hypertrophy, power, and endurance will low loads (30%-60% 1RM), high repetitions (12-30), and
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moderate to high number of sets (3-7).62 The optimal num- patient has biceps weakness and has difficulty picking up
ber of sets to increase power again depends on what is the her toddler, exercise in an open-chain position such as a
secondary gain you are seeking—strength or endurance. biceps curl would be most appropriate.
When prescribing more than 1 exercise type, not all When prescribing more than 1 set of exercises, rest peri-
exercises must be performed with the same number of ods must be considered because they affect performance
sets. Some endurance exercise, some strength exercise, on subsequent sets.64 Insufficient rest periods may inter-
and some power exercise may be prescribed to 1 patient. fere with restoration of the muscular, vascular, and meta-
Especially if exercises are supervised, it should not be dif- bolic systems, and performance will be compromised. This
ficult to monitor how many sets are needed for each exer- generally occurs when intensities are greater than 60%
cise. However, for patients with cognitive difficulties, it may 1RM and the rest period is less than a minute.64 As a general
be prudent to prescribe all exercises with the same num- rule, rest periods should not be less than a minute unless
ber of repetitions and sets as a home program to minimize performing endurance training, which occurs at lower
confusion and enhance program compliance. Finally, the intensities. The literature shows greater strength increases
literature also shows single-set programs are beneficial, with longer rest periods of 2 to 3 minutes.55 Generally, rest
especially initially, but programs should progress to mul- periods are just rest of that particular muscle, not total
tiple sets as quickly as possible to optimize results.63 body rest. It is not necessary to have patients sit idly for
There are a lot of different ways to exercise any muscle. 3 minutes between each set. Instead, patients may move
For example, hip abductor strengthening could occur in to 1 or 2 different muscles groups before returning to that
sidelying, supine, prone, quadruped, sitting, and stand- first exercise. This offers an adequate 2- to 3-minute rest
ing. In addition to exercise position, clinicians must make period for each muscle.
decisions about other features such as single-joint versus As with previous parameters, an underlying guideline
multiple-joint exercises and open-chain versus closed- for rest periods is to identify the targeted component—
chain exercises. Single-joint exercises work a muscle over strength, power, endurance, or hypertrophy—based on
just 1 joint and multiple-joint exercises work a muscle over the observed or reported functional limitations and pre-
2 joints. Open chain exercises work the muscle in space scribe the rest period accordingly. With higher intensity
with a free end, such as a triceps kick back or a long arc exercise, longer rest periods are indicated. When focusing
quad. Closed chain exercises work the muscle in a fixed on muscle endurance, short rest periods are appropriate.
position, such as a chair push up or squat. The literature Short rest periods may also be indicated for hypertrophy
shows no difference in the gains made between open- training but will likely increase muscle soreness.
chain and closed-chain exercise and no difference in gains Establishing what is the most appropriate type of equip-
between single-joint and multiple-joint exercises.55 Rather, ment to use for Muscle Performance Improvement exercise
the more important consideration is that the exercises are is not difficult. If all the other parameters are established
prescribed accurately with the correct intensity. However, correctly—muscle action, repetitions, sets, load, rests, etc—
there is some evidence that multiple-joint exercises are training goals may be achieved with any type of equipment.55
more neurally complex and, as such, may be more difficult It does not matter if using expensive weight machines or
for a patient to use correct form without supervision.55 On milk jugs filled with sand, as long as the resistance may be
the positive side, because they are more neurally complex, quantified, an effective program may be established.
multiple-joint exercises may create neural overload and When multiple types of equipment are available, it is
produce more adaptations. Conversely, single-joint exer- important to note that weight machines are considered
cises require less skill and technique and may be a better safer to use and easier to learn because patients must move
choice for patients who have cognitive deficits or for any the way the machine was intended and therefore, patients
patient with poor body awareness and are unable to get are less likely to employ faulty form. Free weights may be a
proper form on more complex exercises.55 good choice when mimicking functional tasks. Sometimes
Whenever possible, patients and clients should exercise weight machines do not allow this freedom. For example,
in a functional position because of the principle of specific- if the patient has anterior deltoid weakness and difficulty
ity. However, “functional position” should not be equated putting groceries away in the cupboard, a military press
with “closed chain” because sometimes muscles must machine could be used to mimic the overhead activity.
function in an open-chain position (ie, the tibialis anterior However, free weights might be a better option to allow
during the swing phase of gait). For example, if a patient training using the actual movement required for the task.
with quad weakness is having difficulty standing from a Resistance bands provide another option. They are inex-
chair, it is appropriate to prescribe a sit-to-stand exercise pensive, readily available in any setting, and resistance can
from an increased surface height. A patient unable to per- be quantified just as accurately as with free weights.65 How-
form this with good form or safely may still achieve gains ever, they do require training for accurate use in exercise
in quadriceps strength with a long arc quad exercise. If a prescription.
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When prescribing more than 1 exercise, the order of strength (crossover effects), but the best power gains are
exercises should be considered. Generally speaking, the made with power training.
exercise performed first will obtain the greatest benefit.55 Slow velocities may also be beneficial for strength and
Therefore, maximize gains by performing those exer- endurance gains because they increase the time of muscle
cises that target the primary functional goal first. Most overload. When discussing slow velocity, it is important to
often, patients have multiple muscles that may be cab distinguish between unintentionally slow and intentionally
dates for priority. In that case, there are other helpful slow velocities. Unintentional slow velocities occur when
guidelines. Exercise large muscle groups before small patients perform high-intensity training, and either the
muscle groups, perform multiple joint exercises before load or fatigue is responsible for limiting the velocity and
the single-joint exercises, and do high-intensity exercises slowing the exercise. For example, a patient who is given a
before lower-intensity exercises.56 The last recommenda- very heavy load experiences rapid fatigue and an ability to
tion, high intensity before low intensity, is more for psy- lift the weight any faster. As a result, there is an extended
chological reasons. If an exercise prescription includes period of overload as the exercise is completed. The high
3 endurance exercises at 30% 1RM and 1 strength exer- weight prevents a faster velocity. This is very different than
cise at 80% 1RM, the strength exercise should be per- an intentional slow-velocity exercise during which the
formed first. If the endurance exercises are done first, patient purposely decides to perform slower repetitions
the patient is exercising at a lower intensity and the mus- with a lightened load. Although there is a longer period of
cles are primarily working aerobically and therefore not overload, the training volume is less because of the lighter
really approaching fatigue very rapidly. Then the final, intensity.
higher-intensity exercise may be perceived as “very diffi- Westcott et al68 illustrate this in their study of strength
cult” compared with the other exercises. Performing the training and velocity. They compared regular speed con-
higher-intensity exercise first in this case may result in tractions, defined as a 2-second lift, 1-second pause, and
better compliance. 4-second lowering, to super-slow contractions defined as
Velocity, or speed of contraction, is another exercise 10-second lifts, with 4-second lowering. They found the
parameter for consideration. Studies have found that train- super-slow training resulted in a 50% greater increase in
ing at moderate velocity, defined as 180 to 240 degrees strength for both men and women compared with regular
per second, produces the best strength gains across all speed training. Both groups were trained at 70% 1RM so
velocities.66 This is applicable when training on isokinetic the super-slow group trained with the same intensity but
machines. For isotonic training, velocity is most important experienced a longer overload. They concluded that super-
when trying to increase power. Because power has both slow training is an effective method for middle-aged and
a strength component and a time component, improve- older adults to increase strength.
ments in strength as well as speed of contraction are neces- Recommendations for velocity are to start with slow and
sary. With power training, patients should perform the con- moderate velocities to ensure proper form, advancing to a
centric portion “as fast as possible,” hold for 1 second, and continuum of velocities to achieve gains across all veloci-
then slowly lower eccentrically. The 1-second hold is impor- ties. If the goal is to increase power, train as quickly as pos-
tant to ensure correct form. Using this technique results in sible. Always use proper technique regardless of velocity. If
twofold power gains compared with a comparison group patients are unable to maintain good form at high veloci-
as illustrated in a study by Fielding et al.67 They randomized ties, revert to slower speeds. Some power gains still occur
30 subjects into 2 groups. Both trained at 70% 1RM, 10 rep- at slier velocity, just not as quickly. The most important
etitions, 3 sets, and 3 times a week for 16 weeks. The differ- thing is patient safety and improper form compromises
ence between groups was the velocity. One group trained that.
at high velocity—concentric as fast as possible, a 1-second The last parameter to discuss is frequency or the num-
hold, and 2-second eccentric contraction. The other group ber of workouts per week. Frequency is dependent on
trained at low velocity—2-second concentric contrac- training volume, intensity, the patient’s training level, and
tion, 1-second hold, and 2-second eccentric. Both groups the patient’s recovery ability, which most often relates to
showed similar gains in strength. The high-velocity group comorbidities. It is rarely advised to perform resistance
increased leg press strength by 35% and knee extension training of the same muscle groups on consecutive days to
strength by 45%, and the low-velocity group increased leg allow adequate recovery of all body systems (neural, mus-
press strength by 33% and knee extension strength by 41%. cular, vascular, and metabolic).56 Peterson detected a linear
The difference was in the power gains. The high-velocity relationship in untrained individuals between frequency
group increased power by 97%, and the low-velocity only and strength gains.55 Some gains are made with once a week
increased power by 45%. This illustrates the importance training, better gains with twice a week, and best gains with
of velocity in improving power and also shows that some thrice a week. For trained individuals, twice weekly is opti-
power gains are achieved even when you are training for mal because gains are not made with once weekly training
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and because gains diminish with thrice-weekly regimens. Agility, or the ability to move quickly and easily through
For highly trained individuals, both twice and thrice weekly space with both speed and coordination is an important
programs were equally effective. focus of exercise in this level. Another is coordination, the
Identifying the appropriate muscle component to target ability to perform activities that require reciprocal motions
and accurately prescribing each parameter to achieve gains and the ability to switch back and forth from agonist to
in that component results not only in hypertrophy, and antagonist. Promoting correctly sequenced synergies con-
strength, power, or endurance gains, but also improved sistently and precisely, improving accuracy of activities, and
function, such as increased gait velocity, improved trans- enhancing proprioception or the awareness of the body in
fers, and improved activities of daily living.52 In addition, space are other elements of focus for exercise in this level.
gains have been noted in other areas including metabolic To perform Advanced Coordination, Agility, and Skill
(improved nitrogen balance, improved glycemic control)69 exercises, patients and clients should have progressed
and psychologic (improved cognition,70 decreased depres- through the previous levels and no longer have any tis-
sive symptoms)71 and quality of life.72 sue injury, mobility restrictions, or instability. They should
demonstrate some basic motor control as well as adequate
EXERCISE FOR ADVANCED COORDINATION, muscle performance—functioning at near-normal ranges
AGILITY, AND SKILL of muscle strength.
The final level of the exercise prescription framework is While exercises in this level are appropriate for ath-
Advanced Coordination, Agility, and Skill. As patients letes preparing to return to competition or improve sport
approach near-normal strength, power, and endurance, performance, exercise prescription in this level should
they are ready to begin exercises in which components of also address broader populations. For example, patients
the previous phases are combined, resulting in higher-level working on balance who have progressed through Muscle
coordination and skill activities. Some rehabilitation pro- Performance Improvement would be ideal for Advanced
fessionals may not always treat patients through this phase Coordination, Agility, and Skill exercises to hone quick
because they are quite functional at this point and many reactions to large grade perturbations and other advanced
insurers may not reimburse for treatment. However, there balance training.
are times when such patients receive rehabilitation and Many different types of exercises are included in this
require exercises appropriate for this level, so it is helpful advanced level. Drills that require speed, agility, and coor-
to understand the components of exercise prescription for dination, such as dribbling a figure-eight with a ball, line
this phase. jumping patterns, and pitter-patters (rapid alternating
Exercises to advocate Advanced Coordination, Agil- stepping in place) with twists on command, may be used
ity, and Skill combine components from the other levels to improve Advanced Coordination, Agility, and Skill. Com-
and expand on them. When prescribing exercises for this plex tasks, such as passing and catching a ball while walk-
level, numerous variables should be considered to make ing backwards on a treadmill, are Advanced Coordination,
an exercise more difficult or more advanced. First is body Agility, and Skill exercises. Dynamic stability exercises that
position. An exercise such as the squat may be a Muscle may have been appropriate in the muscle initiation, stabil-
Performance Improvement–level exercise but becomes ity, and motor control level could be used at this level if the
an Advanced Coordination, Agility, and Skill–level exer- parameters are advanced. For example, performing single-
cise when it is changed to a single-limb squat. Likewise, limb stance might be an exercise for muscle initiation, sta-
a push-up may be progressed at this level by bringing the bility, and motor control but performing it on a balance
hands close together or removing 1 hand for support. board or bosu ball progresses it to an Advanced Coordina-
Alternately, the complexity of a task could place an exer- tion, Agility, and Skill exercise.
cise in this level as well. For example, more difficult tasks Another type of exercise commonly used in this level
like co-contracting the hip abductors while sidestepping is plyometrics or jump training. The purpose of plyomet-
in a squat position (monster walks) would fit into this cat- rics is to produce power through combining strength and
egory. Varying the surface on which a task is performed speed with physiological properties of muscle, especially
could advance that exercise into an Advanced Coordina- stretch reflexes.73 To perform plyometrics correctly, good
tion, Agility, and Skill activity. Performing hip abduction on neuromotor control is needed. In addition to improving
foam—a compliant surface—and doing that on a dynamic speed and power, endurance is also enhanced. Plyomet-
balance board are examples of this. Increasing resistance rics work off of the elastic components of the musculo-
greater than 80% 1RM and varying resistance during the tendinous junction. By stretching the muscle quickly in an
movement would also occur in this phase as would speed eccentric manner before initiating a quick concentric con-
changes and high-speed activities. Finally, adding an ele- traction, more motor units are recruited and greater force
ment of accuracy during the exercise would be appropri- produced. The energy stored during the eccentric contrac-
ate for this level. tion is quickly converted to power during the concentric
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TABLE 4 Types of Exercise Performed by Rehabilitation Professionals and How They Fit Into
the Framework for Exercise Prescription
Exercise for Muscle Exercise for
Performance Advanced
Exercise Initiation, Exercise for Coordination,
for Tissue Exercise for Stabilization, and Performance Agility, and
Healing Mobility Motor Control Improvement Skill
Range of motion X X X
Stretching X X X
Aerobic conditioning X X X
Body mechanics X X X
Stability/control X X X
Cardiovascular X X X X X
Breathing exercise X X X X X
Developmental activities X X X
Neuromuscular X X X
reeducation
Relaxation exercise X X X
Muscle strength X X
Muscle power X X
Muscle hypertrophy X X
Muscle endurance X X X
Agility and balance X X
Coordination X X
Gait and locomotion X X X
exercise
contraction as long as there is no lapse in the muscle con- especially important for injury prevention in activities that
traction as the muscle moves from an eccentric to a concen- require a quick transition from eccentrics to concentrics,
tric contraction. This may be conceptualized by viewing the such as catching yourself when falling.
muscle as a spring. If the spring is stretched first and then Principles and parameters discussed in the previous
released, more energy will be released than if the spring exercise prescription levels apply to plyometrics and other
were released without stretching. The stretching of the Advanced Coordination, Agility, and Skill exercise. The
spring is the eccentric contraction and the release of the principle of specificity should be used to select the type
spring is the concentric. The important part of this process and position of exercise, if possible. In terms of intensity,
is the amortization phase, which occurs with the transfer there are several ways to modulate the intensity. Progress-
of energy during the transition between the eccentric and ing from simple to complex, as in progressing from straight
concentric phases of the exercise.73 If this transition does jumps to reciprocal jumps, progressing from double-leg
not take place quickly, the stored energy is lost and there is jumps to single-leg jumps, moving from straight patterns
no difference between the exercise and a regular concen- to diagonals and rotations, increasing the speed, adding
tric exercise. When the exercise occurs quickly, the energy external loads, and jumping from higher heights are all
or force from the eccentric phase is transferred over to the ways to modulate intensity.
concentric phase and the result is greater concentric force Another parameter to consider is the volume. Vol-
production.74 ume for plyometrics is usually measured by counting the
In addition to serving as a form of advanced strength total contacts. This varies inversely with the intensity of
and power training, plyometric training is also thought to the exercise, just as repetitions in Muscle Performance
improve joint range of motion and muscle flexibility and Improvement exercises. Initial plyometrics begin with low
promoting adaptations in the neurologic system.74 It is intensity—perhaps 60 to 100 contacts of simple straight
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jumps with both legs in anterior-posterior direction and contraction of the cardiac muscle. This allows adequate cir-
no load. As the patient or client progresses, intensity culation without overstressing the heart. As signs of inflam-
increases to reciprocal jumps with single leg in diago- mation decrease—in this case in the form of more normal
nals with 10-pound weights and the number of contacts serum cardiac markers—cardiac muscle Performance Ini-
decreases to 30. Plyometrics and other high-intensity exer- tiation can progress much in the same way as described
cises in this level should not be performed on consecutive earlier for aerobic exercise. As patients continue into car-
days. At least, 48 to 72 hours of rest is recommended for diac Muscle Performance Improvement, progressive over-
adequate recovery. load of the cardiac muscle is important to strengthen the
muscle without damaging it. Again, good baseline assess-
AEROBIC EXERCISE, CARDIAC ment of VO2max and HRmax are imperative as well as accurate
REHABILITATION, AND BALANCE TRAINING prescription according to a rate pressure product (HR mul-
While it is easy to see where and how most types of exer- tiplied by systolic blood pressure) so that the heart muscle
cise fit into this framework, some are not so clear-cut. For sufficiently works to obtain strengthening benefits but
example, where does aerobic exercise, cardiac rehabilita- does not cause harm. Generally accepted ranges for rate
tion, and balance training fit? A closer look at what is pressure product are 13 000 to 32 000.75 In this way, patients
involved in each helps to determine where each fits in the not only regain functional activities but also rehabilitate the
framework. heart muscle. Once near-normal cardiac muscle function
When performing aerobic exercise, the goal is usually is achieved, patients progress to Advanced Coordination,
to improve cardiovascular fitness. This ultimately involves Agility, and Skill exercises during which increasingly chal-
improving cardiac and respiratory function. It would be lenging activities under diverse situations are employed to
understood that patients deemed ready for aerobic train- bring the cardiac system to optimal performance.
ing are beyond Tissue Healing (ie, any active, acute illness Balance training fits into both the third level (Perfor-
associated with the cardiopulmonary system is under mance Initiation, Stability, and Motor Control) and the fifth
control) and they would have functional mobility of the level (Advanced Coordination, Agility, and Skill) of exercise
pulmonary system (ie, adequate chest expansion for prescription. The difference between them concerns the
breathing). Given this, aerobic training would first fit into degree of difficulty and complexity. Basic balance training
the exercise prescription framework within the Perfor- begins with Performance Initiation in the form of static and
mance Initiation, Stability, and Motor Control level. Aero- dynamic balance activities using similar parameters and
bic exercises at this level are prescribed to get progressive concepts as discussed for that level. Advanced Coordina-
loading, beginning with light loads to promote accurate tion, Agility, and Skill–level exercises would be used as the
initiation of the cardiac and pulmonary systems. Parame- patient or client progresses and is able to attempt more
ters are adjusted depending on the desired outcome. For challenging tasks (ie, compliant surfaces, duel or multiple
example, if working toward improved stability, the load is tasks employed simultaneously).
kept consistent and increasing durations and frequencies The 5 levels of exercise prescription in this framework
are used. If targeting motor control within the cardiopul- for decision making are the foundations for establishing
monary system, variable loads are used. Heart rate, blood safe and effective exercise programs. By determining what
pressure response, and oxygen saturation indicate stabil- level(s) of exercise is indicated for patients and then turn-
ity and motor control of the systems, or lack thereof. As ing to the available evidence for dosing exercise in each
patients exhibit good initiation, stability, and motor con- level, effective interventions may be designed to assist in
trol, they progress into the Performance Improvement achieving the greatest outcomes in the shortest amount of
level. Herein, aerobic exercise is increased to the point of time (Table 4).
progressive overload, where the intensity of such adapta-
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APPENDIX patient’s full strength—it is only measuring how much
force is needed to overcome the tester. When patients are
Objectively Measuring Hypertrophy, Strength, stronger than testers, the tester can position him or her to
Power, and Muscle Endurance have a mechanical advantage over the patient.
Another way to assess strength is to determine the rep-
Hypertrophy etition maximum (RM). This method is reliable and valid
The best way to assess increases in muscle mass is with and measures strength isotonically, so it lays the founda-
dual x-ray absorptiometry or DEXA. While this is very accu- tion for the intensity of the exercise program. A 1RM is
rate, it is not very applicable in the clinic. When muscles simply the amount of weight an individual can lift one time
hypertrophy there is an increase in the size of the muscle. and one time only with good form through the intended
So girth measures are the most clinically relevant way to range. If one more pound is added the patient cannot
assess hypertrophy. However, keep in mind that girth go through the intended range, or compensates to go
measures are only accurate for hypertrophy in younger through the intended range. If one pound is removed, the
adults and children. In middle aged and older adults the patient is able to perform more than 1 repetition.
replacement of muscle mass by adipose and connective tis- In performing a 1RM assessment, determine which
sue makes girth measurements unreliable. Strength meas- muscle to test. This is often done by using a manual mus-
ures are used as a proxy measure of hypertrophy because cle test to screen and the patient’s subjective information
as a muscle hypertrophies, strength increases. to help determine which muscle or muscles most need
resistance training. Next, determine the test position.
Strength This should be the same position in which the patient
There are 2 objective methods for assessing strength pre- will exercise. Assessing a patient’s hip abduction strength
sented here—handheld dynamometry and repetition max- in standing and then exercising in sidelying because you
imum testing. Manual muscle testing is another method for are concerned he could fall in standing results in an inac-
assessing strength, but it lacks the reliability and sensitivity curate intensity prescription. The 1RM determined in
to make it a good outcome measure for the effects of ther- standing will be much lighter than the 1RM in sidelying
apeutic exercise. It can however be used as an effective because of the effect of gravity and the weight of the leg.
screen to determine muscles or muscle groups that require So prescribing an exercise off a different position will not
a more in-depth assessment. provide an accurate intensity. Once the test position is
Handheld dynamometry uses a strain gauge to detect established, instruct the patient in how to do the exercise.
how much force an individual is exerting. It measures iso- Then observe the patient performing the exercise without
metric strength and provides a sensitive, objective measure any weight. This observation accomplishes 2 purposes:
of strength. In addition, it has good to excellent reliability— ensuring the patient is performing the exercise correctly
intratester, intertester, intrasession, and among units. and determining how far the patient can move in the
When doing handheld dynamometry, the first step is exercise because the 1RM is through the intended range
choosing a test position. There is no “one” way to do hand- and it is necessary to know what is the intended range.
held dynamometry. Manual muscle test positions, posi- Next, resistance is added. How much resistance is really
tions used in other research studies, or positions devel- just a guessing game. With practice and experience, it gets
oped by the tester are all options. The important thing is easier. After adding the weight, have the patient do the
to document the test position so that it can be duplicated exercise. If he cannot go through the intended range or if
on subsequent tests. Included in the test position is not he compensates, the weight is too heavy. If he does more
only the body position but also the angle at which the test than 1 repetition with good form, the weight is too light.
occurs. Remember handheld dynamometry is an isometric The weight is adjusted accordingly and this trial and error
test and because the muscle is stronger at different points method continues until the patient can do 1 repetition
in the arc of movement, the angle at which it is tested is and 1 repetition only with good form. This is their 1RM. It
important. Handheld dynamometry values should be the generally takes 3 to 5 attempts.
average of at least 2 tests, and the 2 tests should be within There are other versions of repetition maximum test-
10% of each other. If they are not, there was some error in ing like 5 RM and 10 RM. These are very similar to what
the method. The most important thing to keep in mind for was just described except the goal is to determine at what
accurate measures is the patient’s force needs to be met, weight the patient can do 5 or 10 repetitions through the
but not overcome. As a result, the tester should not move intended range with good form. These alternate methods
the patient and the patient should not move the tester. If can be quite fatiguing, but were developed because there
the tester moves the patient, all what the dynamometer is are times when a maximal contraction is not indicated. The
measuring is how strong is the tester Similarly, if the patient 5 RM and 10 RM are solutions for that. Prediction equa-
moves the tester, the dynamometer is not assessing the tions are also solutions for this issue.
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or a fitrodyne on weight stack machines. For the majority
TABLE A1 Oddvar Holten Number of of rehabilitation professionals who do not have these, the
Repetitions and Corresponding use of functional measures can be useful when those
Percentages measures are correlated with power. For example, chair
No. of Repetitions Percentage rise, gait velocity, and stair climb are all correlated with
1 100 lower extremity power, and therefore as lower extremity
2 95
power improves, scores on these tests will also improve.
Similarly, the seated medicine ball toss is correlated to
4 90 upper extremity power and scores will improve on this test
7 85 as upper extremity power improves.
11 80
16 75
Muscle Endurance Testing
Muscle endurance is assessed primarily using 1 of 2
22 70 methods—repetitions to failure and duration to failure.
29 65 Both assess endurance but repetition to failure assesses
37 60 dynamic endurance whereas duration to failure assesses
static endurance. Dynamic endurance is the ability of the
46 55
muscle to repetitively contract over time. This occurs with
56 50 the tibialis anterior during gait to repetitively achieve dor-
siflexion for each step. There is a low load—just the weight
of the foot and shoe—and the tibialis anterior contracts
These equations allow the tester to choose an arbitrary hundreds of time consecutively. Static endurance is the
amount of weight, preferably a weight the patient can lift ability of the muscle to maintain a contraction over time.
less than 20 times and ideally less than 10 times, have the This occurs with the quadriceps in standing (unless you
patient lift it as many times as possible with good form, lock out your knees and hang on your ligaments). The
record the number of repetitions performed, and enter quadriceps must maintain a low level contraction for
the weight used along with the number of repetitions the duration of standing. If it does not remain contracted,
the patient lifted the weight into the equation. The value the knee buckles.
obtained is the predicted 1RM. Two such equations are Assessing repetitions to failure is similar to predicting
the Lander’s: 1RM = 100 × repetition wt/[101.3-2.67123 a 1RM except the patient is intentionally given a low load
(repetitions)] and the O’Connor: 1RM = repetition weight and asked to perform as many contractions as possible,
[1 + 0.025 (repetitions)]. Both of these equations, how- stopping only when fatigue is reached and form breaks
ever, become inaccurate above 20 repetitions, so a weight down or when unable to complete movement through
that is fairly difficult and can be lifted by the patient less the full arc. The weight used and the number of repeti-
than 20 times should be chosen. tions performed is recorded and used as a benchmark
A final method for predicting a 1RM is the Oddvar against which to compare progress. Upon reassessment,
Holten method. For this method, the number of rep- the same weight is used and the number of repetitions
etitions corresponds to a specific percentage (Table A1). counted. Progress is shown by the ability to perform more
This is not the percentage of 1RM. It is simply the Oddvar repetitions.
Holten percentage. This percentage is divided into the Assessing duration to failure is the same concept but
weight used to get the 1RM. This is an acceptable method instead of having the patient do as many repetitions pos-
for predicting 1RM but is much more conservative than sible, the patient holds the contraction as long as possi-
the other prediction equations. ble. A weight is placed on the limb of the patient who con-
tracts the muscle holds until fatigue occurs as evidenced
Power Testing by no longer being able to maintain the same angle. The
When assessing power, strength can be used as a proxy length of time the muscle contracted is recorded and
measure because power has a component of strength and used as a benchmark against which to compare progress.
as strength improves, so too should power. In addition, it is Upon reassessment, the same weight is used and length
helpful to try to assess power more directly. Clinically, this of time counted. Progress is shown by the ability to hold
presents a challenge unless there is isokinetic equipment for a longer period of time.
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