The balancing act: How many exercises should we be prescribing?
I saw a social media post recently by Darryl Yardley asking how many home exercises we should give our patients. It’s not a question often thought about, but it’s more important than many clinicians realise. Too little exercise and you may not make progress, while too much exercise can flare a patient up, lead to poor adherence, or cause the patient to lose trust in you.
The number of home exercises you give a patient is a nuanced topic. So grab a coffee or tea, and read on while we discuss how to determine how many home exercises to prescribe your patients.
Principles to follow
Before we get into this article there are a couple points to be made. Firstly, it’s also important when prescribing exercises to:
- Make sure they’re tolerable: exercise may not always be pain-free, but it shouldn’t be making them super sore.
- Explain the reasoning behind the exercise(s) and how the exercise(s) contribute towards the patient’s goals.
- Make sure that they can be done with equipment the patient has. In some cases this may require getting a gym membership or buying additional home equipment if high level strengthening is needed.
- Follow up regularly to monitor adherence.
These are similar to a lot of the tips that Mike Studer makes in what is one of my favourite Masterclasses on behavioural economics and psychologically informed techniques. In his class, Mike really emphasises the importance of making exercises convenient and easier to do, as well as communicating the ‘why’ behind what you’re prescribing. Another tip from Mike is to give patients options and choices – sometimes I show patients two exercises that do the same thing and let them pick which one they like most.
Questions to guide exercise prescription
Now, back to the question of how many exercises you should give your patients! There are a few questions I ask myself to assist in my decision-making process, they are:
1) How much time do they have?
Quite simply I ask my patients – how much time are you 100% sure you can put into home exercises everyday? This almost always sets things off on the right foot. There will be the odd time I have to negotiate on time spent with exercises (i.e. post-surgical, patients with busy schedules or multiple areas involved) but for the most part, patients give me workable times and I fit their home program around that.
The only issue I find with this is that sometimes patients are not completely honest in their answers. It’s not a case of lying so much as simply overestimating how much time they can commit, or potentially wanting to please the therapist. If in doubt – aim low and go from there.
2) Which area(s) are involved?
If it’s a back/hip/knee or neck/shoulder issue you can certainly overlap a lot of the exercises and treatments in general. By contrast, if you’re trying to treat a neck, thumb and ankle you may very well need a higher number of exercises.
Side note: leapfrogging off my Failing Physiotherapy blog, there’s a lot to be said for not trying to do many things, or treat too many areas at once – but this is easier said than done.
3) What is the patient’s level of sensitivity?
A patient with a low level of sensitivity can do a higher volume, whereas a patient who is more hypersensitive may need a lower volume of exercise to start off with. Understanding different pain presentations AND the level of sensitivity is key in appropriate exercise prescription. This is why I struggle with a lot of popular “template” programs out there. The exercises themselves may not be bad – but a patient may not tolerate all of them at once.
4) What is your perception of the patient’s level of commitment?
We all know those hyper-motivated type A patients who would jump off a cliff if you asked them to. Giving them only a couple of exercises may seem less appropriate compared to a patient who gets overwhelmed easily, or has a lot of life priorities.
It is also important to consider lifestyle factors. We’ve all had patients who think that they’re able to do 30-60+ minutes of rehab exercise, then they come to their follow-up appointment and say they haven’t done anything. Things will come up in life, it’s important to understand realistic commitments, and be able to adjust your exercise prescription to the patient’s changing needs throughout the course of treatment.
5) Are they post-surgery, fracture or dislocation?
With these patients (especially the first two categories) you don’t have anywhere near as much flexibility in terms of both type and volume of exercises. I never like to say to a patient that they HAVE to do something, but in these cases they have to move the affected area through a range of motion (as per appropriate protocols) to prevent long term complications. Doing two exercises a day doesn’t make much sense for someone early post Total Knee Replacement (TKR). One area I see surgical and post-surgical care go wrong with is not properly setting expectations with the patient – if you are fortunate enough to see a patient pre-op, it is critical to set realistic expectations with them in terms of post-op symptom response, recovery timelines, and required time commitment to rehab.
6) What other physical activities is the patient involved in?
Quite often with my weight training patients, I don’t add a tonne of extra exercise on top of their training – I just modify what needs to be improved in their program and give them some more specific exercises to fill in gaps. I often like to incorporate rehab exercises as part of warm-up, cool-down, or as something that can be done between sets of their main workout movements. This follows suit with Mike’s Masterclass, where he recommends pairing rehab exercises with existing activities (e.g. doing bodyweight squats or calf raises at the counter while waiting for the kettle to boil).
Similarly, with in-season athletes, I’m very cognisant of avoiding post-exercise soreness, so I try to prioritise exercises and limit the extra work they’re doing. On the flipside, a patient who is not doing any physical activity and has a sedentary job can likely do a higher exercise volume (or at least work up to over time).
7) What is the patient’s confidence with exercise?
Some patients, particularly those who have not exercised a lot in the past, may wish to have a smaller number of exercises to get comfortable with. There may also be some intentional underloading required to get them on board. In Mike’s Masterclass he mentions how patients may have a negative representation of exercise, and as such need a different “spin” put on things to make it workable. By contrast, others who are comfortable with a variety of exercises (e.g. people who do Crossfit) may want a larger number of exercises to work with.
8) What are the patient’s expectations of exercise?
Some patients look at me like I have three heads if I only give them a couple of exercises, while some are relieved when I only give them an exercise or two. Expectations feed a lot into exercise compliance – it’s important to discuss realistic expectations and goals with patients. If they can only put in five minutes of exercise every other day or so (e.g. a nurse who does 12 hour shifts) then it is important for them to know that progress may be slower. Sometimes the perception that a patient is failing physiotherapy is really an issue of inappropriate goals and timelines being set.
9) What is the intent of the exercises you’re prescribing?
The intent of the exercises also matters. Simple posture exercises such as chin tucks can be done in large numbers, whereas harder strengthening exercises aren’t conducive to being done in large numbers. Similarly, doing static quads early post Anterior Cruciate Ligament Reconstruction (ACLR) isn’t overly systemically fatiguing. By contrast, doing bulgarian split squats months down the road is far more fatiguing. As exercises get harder you can’t do as many.
NOTE: I don’t prescribe a lot of repeated movement exercises in lying. As Mike Studer notes in his Masterclass, convenience is best, so I’m a big fan of doing repeated movements in practical positions such as sitting or standing.
10) What are the patient’s goals?
Goals that may require physical capacity improvement (e.g. strength, bone density, ability to do X activity) may require more strenuous and potentially less convenient exercises than solely pain goals (although rehab usually involves working on both).
11) How time sensitive are the goals?
Time-sensitive goals such as trying to regain range of motion after surgery, or trying to get back for a sporting tournament in a few weeks, will often require a higher volume of exercises and a larger time commitment. Conversely, a goal that is less time sensitive, or which needs to be addressed in a slower fashion (e.g. getting back to an activity when dealing with a chronic issue) may very well be handled with a slower and more gentle approach.
Looking at these factors you can see that the number of exercises to give people isn’t a simple “one size fits all” answer and encompasses both clinical and personality factors which need to be considered. If there are any other factors you look at please add them in the comments below. Thanks for reading!
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