Exercise Prescription John M Lavelle, DO. Objectives Objectives: Objectives: 1. Describe the...

Exercise Exercise PrescriptionPrescription

John M Lavelle, DOJohn M Lavelle, DO

ObjectivesObjectives

Objectives:Objectives: 1. Describe the benefits of employing exercise 1. Describe the benefits of employing exercise

prescription as an adjunct to treatment.prescription as an adjunct to treatment. 2. Describe the purpose and elements of a 2. Describe the purpose and elements of a

structural screening exam.structural screening exam. 3. Describe the significance of accurate diagnosis 3. Describe the significance of accurate diagnosis

of somatic dysfunction in exercise prescription.of somatic dysfunction in exercise prescription. 4. Describe normal and common variants of hip 4. Describe normal and common variants of hip

extension and shoulder abduction muscle firing extension and shoulder abduction muscle firing patterns and discuss their significance for exercise patterns and discuss their significance for exercise prescription.prescription.

5. Describe the key elements of exercise 5. Describe the key elements of exercise prescription.prescription.

Somatic DysfunctionSomatic Dysfunction

Impaired function of bodily structures Impaired function of bodily structures (most often of the MSK, nervous or (most often of the MSK, nervous or lymphatic system) treated by OMT.lymphatic system) treated by OMT.

Imparied or altered function of related Imparied or altered function of related components of the somatic (body components of the somatic (body framework) system: skeletal, arthrodial framework) system: skeletal, arthrodial and myofascial structures and their and myofascial structures and their related vascular, lymphatic and nervous related vascular, lymphatic and nervous elements.elements.

Words of WisdomWords of Wisdom

Osteopathy is based on the perfection of Osteopathy is based on the perfection of Nature’s work. When all parts of the human Nature’s work. When all parts of the human body are in line we have health. When they body are in line we have health. When they are not the affect is disease. When the parts are not the affect is disease. When the parts are readjusted disease gives place to health. are readjusted disease gives place to health. . . .. . .

When complete, [the person] is a self-acting, When complete, [the person] is a self-acting, individualized, separate personage, individualized, separate personage, endowed with the power to move, the mind endowed with the power to move, the mind to direct in locomotion . . . .to direct in locomotion . . . .-- A.T. Still-- A.T. Still

Introduction to Exercise PrescriptionIntroduction to Exercise Prescription

Historical: Historical: Qi Gong and Tai Chi from TCMQi Gong and Tai Chi from TCM

Several studies have Several studies have reported positive effects of reported positive effects of Tai ChiTai Chi or or QigongQigong for for enhancing balance and enhancing balance and preventing falls in the preventing falls in the elderlyelderly 1 1

Yoga asana and Yoga asana and pranayama (breathing pranayama (breathing exercises) from Ayurvedaexercises) from Ayurveda

Recent decades in USA have Recent decades in USA have seen significant growth in seen significant growth in popularity of these exercise popularity of these exercise methods that are rooted in methods that are rooted in the healing arts.the healing arts.

Exercise PrescriptionExercise Prescription

Current: Growth in exercise-based Current: Growth in exercise-based modalities such as physical therapy and modalities such as physical therapy and personal training.personal training.

Fitness “craze” in the USAFitness “craze” in the USA Physical exercise has profound benefits Physical exercise has profound benefits

now supported by research. now supported by research. 22

Benefits: Cardiac (HTN, HLD) Mental Health Benefits: Cardiac (HTN, HLD) Mental Health (depression, anxiety) MSK, Pain Medicine, (depression, anxiety) MSK, Pain Medicine, Lymphedema, endocrinology, cancer (PSA), Lymphedema, endocrinology, cancer (PSA), endocrine (DM), etcendocrine (DM), etc


Physicians frequently encourage exercise to Physicians frequently encourage exercise to promote fitness and well-being . . . Often as promote fitness and well-being . . . Often as general recommendation . . .general recommendation . . .

We should consider specific exercise We should consider specific exercise prescription as adjunct to treatment.prescription as adjunct to treatment.

References:References: Dr. Kappler’s section V Introduction, Dr. Kappler’s section V Introduction, Foundations Foundations

for Osteopathic Manipulation,for Osteopathic Manipulation, 2 2ndnd ed. ed. Dr. Philip Greenman, Dr. Philip Greenman, Principles of Manual Principles of Manual

MedicineMedicine, 3, 3rdrd ed. ed. D.O. Professor emeritus of Michigan State UniversityD.O. Professor emeritus of Michigan State University

Why exercise prescription?Why exercise prescription?

Interrelationship of OMT and PT for Interrelationship of OMT and PT for somatic dysfunction and specific somatic dysfunction and specific exercise prescriptionexercise prescription OMM or PT sets the stage for therapeutic OMM or PT sets the stage for therapeutic

exercise and makes the exercise more exercise and makes the exercise more effectiveeffective

Prescribed exercise then reinforces the Prescribed exercise then reinforces the correction or healing facilitated by OMT correction or healing facilitated by OMT or PTor PT

Why exercise prescription? (con’t)Why exercise prescription? (con’t)

Consider key principles of Consider key principles of Osteopathic philosophyOsteopathic philosophy 1. Body is a unit; the person is comprised 1. Body is a unit; the person is comprised

of body, mind, spirit.of body, mind, spirit. 2. Person is capable of self-healing, self-2. Person is capable of self-healing, self-

regulation, self-maintenance.regulation, self-maintenance. 3. Structure and function are 3. Structure and function are

interrelated interrelated 4. Rational treatment is based on the 4. Rational treatment is based on the

understanding of these principlesunderstanding of these principles


. . . Therefore, we as physicians are not . . . Therefore, we as physicians are not healing the patient, per se, but rather healing the patient, per se, but rather facilitating the healing process inherent facilitating the healing process inherent to the patient.to the patient.


Encourages patient to become a Encourages patient to become a consciously active participant in consciously active participant in their own healing processtheir own healing process Brings healing process more to Brings healing process more to

conscious levelconscious level Patient more aware of own agency, own Patient more aware of own agency, own

power to further the healing and health power to further the healing and health maintenance.maintenance.


Additional important reasons for Additional important reasons for prescribing exercise:prescribing exercise: Psychological benefits, i.e. Psychological benefits, i.e.

encouragement and optimismencouragement and optimism Natural biochemical high – diminishing or Natural biochemical high – diminishing or

breaking cycle of chronic painbreaking cycle of chronic pain Cardio-vascular healthCardio-vascular health Weight managementWeight management Facilitates integration of body-mind-spiritFacilitates integration of body-mind-spirit

Diagnostics: Structural Screening Diagnostics: Structural Screening ExamExam

Words of Wisdom: Words of Wisdom: “Is there a significant “Is there a significant musculoskeletal component to the patient’s musculoskeletal component to the patient’s problem?” -- Dr. Kapplerproblem?” -- Dr. Kappler

This ought to be our guiding question as we This ought to be our guiding question as we approach diagnosis. approach diagnosis.

Structural screening exam/standing and Structural screening exam/standing and seated structural exam is a good starting seated structural exam is a good starting place.place.

Efficient overview, broad in scope, yet Efficient overview, broad in scope, yet thorough enough to reveal postural and thorough enough to reveal postural and functional imbalance.functional imbalance.

Diagnostics: Structural Screening Diagnostics: Structural Screening Exam (con’t)Exam (con’t)

May contain all or some of May contain all or some of following components:following components:

1. Gait analysis1. Gait analysis 2. Observation of paired anatomical 2. Observation of paired anatomical

landmarks, antero-posterior and landmarks, antero-posterior and lateral curveslateral curves

3. Active ROM from head to toe.3. Active ROM from head to toe.

Overall “Gestault”Overall “Gestault”

Diagnostics: Structural Screening Diagnostics: Structural Screening Exam (con’t)Exam (con’t)

Allow findings of structural Allow findings of structural screening exam to lead you to a screening exam to lead you to a more detailed, focused exam and more detailed, focused exam and diagnosis. diagnosis.

Consider how your findings may play Consider how your findings may play into presenting complaint or into presenting complaint or problem under scrutiny.problem under scrutiny.

Diagnostics: Somatic DysfunctionDiagnostics: Somatic Dysfunction

Words of wisdom: Words of wisdom: We must be able to move We must be able to move beyond the mindset of “fixing isolated beyond the mindset of “fixing isolated booboos” to an awareness of treating a booboos” to an awareness of treating a human system, even when our immediate human system, even when our immediate focus is on a particular dysfunction. If we focus is on a particular dysfunction. If we allow our structural screening exam to lead allow our structural screening exam to lead us into our regional or segmental diagnosis, us into our regional or segmental diagnosis, we will be more apt to see a particular we will be more apt to see a particular somatic dysfunction in relation to the somatic dysfunction in relation to the whole, integrated body system.whole, integrated body system.

paraphrased from Dr. Hugh paraphrased from Dr. Hugh EttlingerEttlinger

Diagnostics: Somatic Dysfunction Diagnostics: Somatic Dysfunction (con’t)(con’t)

Identify problem.Identify problem. Try to identify source of problem.Try to identify source of problem. Devise therapeutic plan to address Devise therapeutic plan to address

source of somatic dysfunction as best source of somatic dysfunction as best as possible or to prevent as possible or to prevent reoccurrence of the injury or reoccurrence of the injury or dysfunction.dysfunction.

i.e. “Shoulder bone connected to the i.e. “Shoulder bone connected to the foot bone”foot bone”

Diagnostics: Muscle Firing PatternsDiagnostics: Muscle Firing Patterns

Vladimir Janda, physiatrist Vladimir Janda, physiatrist from Czech from Czech RepublicRepublic Studied muscle function and found Studied muscle function and found

characteristic “normal” patterns of characteristic “normal” patterns of neuromuscular activation and common neuromuscular activation and common patterns of dysfunction/abnormal patterns of dysfunction/abnormal activation.activation.

Evaluated muscle function based on tone, Evaluated muscle function based on tone, sequence or patterns of muscle activation, sequence or patterns of muscle activation, and bilateral symmetry/asymmetry of and bilateral symmetry/asymmetry of muscle activation.muscle activation.

Diagnostics: Muscle Firing Patterns Diagnostics: Muscle Firing Patterns (con’t)(con’t)

Postural/tonic Postural/tonic musclesmuscles iliopsoasiliopsoas rectus femorisrectus femoris piriformispiriformis adductorsadductors tensor fascia latatensor fascia lata levator scapulalevator scapula upper trapeziusupper trapezius pectoralspectorals

>In dysfunction >In dysfunction these tend to these tend to become become hypertonic, hypertonic, facilitated or facilitated or contractedcontracted


Dynamic/phasic Dynamic/phasic musclesmuscles gluteus medius and gluteus medius and

maximusmaximus supraspinatussupraspinatus deltoidsdeltoids infraspinatusinfraspinatus rhomboidsrhomboids lower trapeziuslower trapezius serratus anteriorserratus anterior

>In dysfunction >In dysfunction these tend to these tend to become hypotonic, become hypotonic, inhibited, inhibited, weakened.weakened.

Janda called this Janda called this “pseudoparesis”.“pseudoparesis”.


Muscle function and dysfunction charactized Muscle function and dysfunction charactized by sequential neuromuscular firing patternsby sequential neuromuscular firing patterns

Observing firing patterns offers additional Observing firing patterns offers additional perspective with which to evaluate somatic perspective with which to evaluate somatic dysfunction and postural balance/imbalance.dysfunction and postural balance/imbalance.

Assessed by physician palpating focus Assessed by physician palpating focus muscle groups while patient actively moves muscle groups while patient actively moves a joint through specific range of motion, i.e. a joint through specific range of motion, i.e. hip extension or shoulder abduction.hip extension or shoulder abduction.

Physician then compares by evaluating Physician then compares by evaluating contralateral firing pattern, evaluating then contralateral firing pattern, evaluating then for symmetry of neuromuscular activation.for symmetry of neuromuscular activation.


Important in exercise prescription Important in exercise prescription for accurate and effective prescriptionfor accurate and effective prescription to prevent injury . . .to prevent injury . . . If a patient has significant imbalance in If a patient has significant imbalance in

firing patterns, continued activity, or firing patterns, continued activity, or increased focal activity may serve to increased focal activity may serve to exacerbate the problem and exacerbate the problem and dysfunction. dysfunction.


Prone Hip Extension Muscle Firing Pattern

Normal Most Common Variation

1. hamstrings2. gluteus maximus3. contralat. lower lumbar erector spinae4. ipsilat. lower lumbar erector spinae

1. hamstrings2. upper lumbar and low thoracic erectors3. inhibited gluteus maximus

Prone Hip Extension Firing Prone Hip Extension Firing PatternsPatterns


Seated Shoulder Abduction

Normal Most Common Variation

1. supraspinatus2. deltoid3. infraspinatus4. mid and lower trapezius5. contralat. quadratus lumborum

1. levator scapulae2. upper trapezius3. early firing of quadratus lumborum

Shoulder Abduction Firing Shoulder Abduction Firing PatternsPatterns

OMT OMT Greenman writes in his chapter on Exercise Greenman writes in his chapter on Exercise

Principles, “Principles, “the goal for an exercise program the goal for an exercise program is to maintain the enhanced functional is to maintain the enhanced functional capacity of the musculoskeletal system that capacity of the musculoskeletal system that has been achieved by appropriate manual has been achieved by appropriate manual medicine interventionmedicine intervention” (Greenman, 498). ” (Greenman, 498).

Once the structural screening, somatic Once the structural screening, somatic dysfunction diagnosis, and asymmetries of dysfunction diagnosis, and asymmetries of muscle firing have been assessed, manipulative muscle firing have been assessed, manipulative treatment begins restoring balance to the treatment begins restoring balance to the system. system.

the the patient is then be ready to begin a patient is then be ready to begin a progression into an exercise program.progression into an exercise program.

Elements of Exercise PrescriptionElements of Exercise Prescription

Words of wisdom: Words of wisdom: “The body is no “The body is no stronger than its weakest link. Many stronger than its weakest link. Many well-conditioned patients have a back or well-conditioned patients have a back or musculoskeletal problem that severely musculoskeletal problem that severely limits their function. The physician limits their function. The physician should direct treatment to strengthen the should direct treatment to strengthen the weak link.”weak link.”

-- Dr. -- Dr. Robert KapplerRobert Kappler

Elements of Exercise Prescription Elements of Exercise Prescription (con’t)(con’t)

Order of progression for exercise Order of progression for exercise prescriptionprescription Stage one: proprioceptive balance Stage one: proprioceptive balance

trainingtraining Stage two: stretch hypertonic musclesStage two: stretch hypertonic muscles Stage three: strengthen hypotonic Stage three: strengthen hypotonic

musclesmuscles Stage four: aerobic trainingStage four: aerobic training

The Patient . . .The Patient . . .“Doc, my back hurts and I can’t “Doc, my back hurts and I can’t

straighten up . . . .”straighten up . . . .”


Diagnostics, OMT or PT, then . . .Diagnostics, OMT or PT, then . . . Stage one: proprioceptive balance trainingStage one: proprioceptive balance training

Proprioceptive balance training is the first stage of Proprioceptive balance training is the first stage of addressing that “weak link” and restoring addressing that “weak link” and restoring symmetry to muscle firing patterns and motor symmetry to muscle firing patterns and motor function control.function control.

Improved neuromuscular firing through balance Improved neuromuscular firing through balance training prepares the way for stretching facilitated training prepares the way for stretching facilitated muscles and strengthening inhibited muscles. muscles and strengthening inhibited muscles.

If during your initial screening the patient has If during your initial screening the patient has trouble balancing on one leg (i.e. during stork trouble balancing on one leg (i.e. during stork test), this should prompt you to make further test), this should prompt you to make further assessments. assessments.

Elements of Exercise Prescription: Elements of Exercise Prescription: Proprioceptive Balance Training (con’t)Proprioceptive Balance Training (con’t)

Greenman suggests the following Greenman suggests the following progression:progression: Level 1: Patient stands, with bare feet, first on one Level 1: Patient stands, with bare feet, first on one

leg then the other. Compare steadiness of balance leg then the other. Compare steadiness of balance on right and left legs.on right and left legs.

Level 2: Patient stands on one leg with arms Level 2: Patient stands on one leg with arms crossed. Compare right and left.crossed. Compare right and left.

Level 3: Patient stands on one leg with arms Level 3: Patient stands on one leg with arms crossed and eyes closed.crossed and eyes closed.

The goal is be able to stand in level three for The goal is be able to stand in level three for 30 seconds. A more important and 30 seconds. A more important and immediate goal is to restore symmetry of immediate goal is to restore symmetry of balance. balance.

Proprioceptive Balance, level 1Proprioceptive Balance, level 1







Stage two: Stretching hypertonic musclesStage two: Stretching hypertonic muscles stretch the tight muscles identified during initial stretch the tight muscles identified during initial

assessment or during the course of treatment. assessment or during the course of treatment. If the physician employs muscle energy If the physician employs muscle energy

techniques, the initial steps of patient education techniques, the initial steps of patient education can readily be addressed in the course of can readily be addressed in the course of manipulation. manipulation.

identify the key muscles to be stretched -- this identify the key muscles to be stretched -- this may change as the patient progresses with may change as the patient progresses with exercises and treatment.exercises and treatment.

Teach the patient how to isolate the specific Teach the patient how to isolate the specific muscles or muscle group to be stretched.muscles or muscle group to be stretched.

Stage 2: Stretch Hypertonic Stage 2: Stretch Hypertonic MusclesMuscles



CAREFUL!!!!!CAREFUL!!!!!


CRAAAAAZYYYYCRAAAAAZYYYY!!!!! Easy does !!!!! Easy does it!!!it!!!


Stage three: Strength TrainingStage three: Strength Training When symmetry has been restored or When symmetry has been restored or

improved, inhibition of the antagonist improved, inhibition of the antagonist muscles will decrease. This will allow the muscles will decrease. This will allow the focused strength training to be more focused strength training to be more effective.effective.

Danger: patients often try to do more than Danger: patients often try to do more than they are truly prepared to do. The patient they are truly prepared to do. The patient may not feel tired or winded from the may not feel tired or winded from the exercises at the early stages of training, exercises at the early stages of training, and therefore lose sight of and therefore lose sight of the goal: to the goal: to restore balance to the system.restore balance to the system.


Stage three: Strength training (con’t)Stage three: Strength training (con’t) As the patient pushes beyond their As the patient pushes beyond their

preparation, the first aspect to be lost preparation, the first aspect to be lost will often be precision and will often be precision and structural/postural integrity while structural/postural integrity while performing a given exercise.performing a given exercise.

Alignment and correct performance of Alignment and correct performance of any exercise prescribed must be taught any exercise prescribed must be taught and emphasized in order to maximize and emphasized in order to maximize the benefits and to prevent further the benefits and to prevent further injury. injury.


Stage four: Aerobic TrainingStage four: Aerobic Training Added to the regimen only after the goals of Added to the regimen only after the goals of

the previous stages have been met. the previous stages have been met. It is often the case that patients will come with It is often the case that patients will come with

exercise programs already in place. In these exercise programs already in place. In these cases, unless the injury or dysfunction is cases, unless the injury or dysfunction is preventing participation in the exercise of preventing participation in the exercise of choice, the previous stages of proprioceptive choice, the previous stages of proprioceptive balance training, stretching, strengthening, balance training, stretching, strengthening, and integration/combination exercise will be and integration/combination exercise will be progressively incorporated into the patient’s progressively incorporated into the patient’s established routine.established routine.


Essential principle: BREATHEEssential principle: BREATHE Controlled, conscious breathingControlled, conscious breathing Often when learning new exercise Often when learning new exercise

patients will focus on details of posture patients will focus on details of posture or movement and develop or movement and develop counterproductive tension.counterproductive tension.

To prevent problem, after presenting To prevent problem, after presenting exercise, and while patient is exercise, and while patient is demonstrating proper technique, demonstrating proper technique, instruct patient in breath control.instruct patient in breath control.


Breathe!!!! (con’t)Breathe!!!! (con’t) Performance of exercise will improvePerformance of exercise will improve Perceived benefit will improvePerceived benefit will improve Patient awareness of immediate effects of Patient awareness of immediate effects of

exercise will be heightenedexercise will be heightened With controlled breathing the patient becomes With controlled breathing the patient becomes

more focused and more actively and more focused and more actively and intentionally participates in own healingintentionally participates in own healing


Effective prescriptionEffective prescription Give clear and precise explanations of Give clear and precise explanations of

exercisesexercises Have patient demonstrate to ensure Have patient demonstrate to ensure

proper technique or formproper technique or form Incorporate breath-workIncorporate breath-work Communicate goal of the program and Communicate goal of the program and

each specific exerciseeach specific exercise DosageDosage

Elements of Exercise Elements of Exercise Prescription (con’t)Prescription (con’t)

Dosage:Dosage: IntensityIntensity – how far to go or how hard to – how far to go or how hard to

push oneself with any given exercisepush oneself with any given exercise DurationDuration – how long to hold a position or – how long to hold a position or

sustain a prescribed exercisesustain a prescribed exercise Frequency Frequency – how many repetitions per set – how many repetitions per set

and how many sets per session or dayand how many sets per session or day Discuss warning signs of Discuss warning signs of “overdose”“overdose” Oral Oral explanationexplanation and and written written

prescriptionprescription


Through careful diagnosis, focused Through careful diagnosis, focused manipulative treatment, and exercise manipulative treatment, and exercise prescription we can reinforce and augment the prescription we can reinforce and augment the effects of rehab treatment. In doing so, we effects of rehab treatment. In doing so, we demonstrate the profound importance of demonstrate the profound importance of patients’ active participation in their own patients’ active participation in their own healing and maintenance of health.healing and maintenance of health.

Words of Wisdom: Words of Wisdom: “Despite the altered “Despite the altered anatomy and pathology present, it is surprising anatomy and pathology present, it is surprising and satisfying to both the practitioner and the and satisfying to both the practitioner and the patient to see the amount of functional patient to see the amount of functional capacity that can be restored and maintained capacity that can be restored and maintained by an appropriate exercise program.”by an appropriate exercise program.”

-- Dr. Philip Greenman-- Dr. Philip Greenman

ReferencesReferences1) Qigong and Tai Chi Detailed Scientific Review, MD Andersen

Center- The University of Texas. http://www.mdanderson.org/education-and-research/resources-for-professionals/clinical-tools-and-resources/cimer/therapies/alternative-medical-systems/qigong-tai-chi-scientific.html

Kessenich Cathy R. Tai Chi as a method of fall prevention in the elderly. Kessenich Cathy R. Tai Chi as a method of fall prevention in the elderly. Orthopaedic Nursing 1998 Jul-1998 Aug;27-9Orthopaedic Nursing 1998 Jul-1998 Aug;27-9

Wolf SL, Barnhart HX, Ellison GL, Coogler CE. The effect of Tai Chi quan and Wolf SL, Barnhart HX, Ellison GL, Coogler CE. The effect of Tai Chi quan and computerized balance training on postural stability in older subjects. Physical computerized balance training on postural stability in older subjects. Physical Therapy 1997 Apr;77(4):371-84.Therapy 1997 Apr;77(4):371-84.

Wolfe SL, Coogler C, Xu T. Exploring the basis for Tai Chi chuan as a Wolfe SL, Coogler C, Xu T. Exploring the basis for Tai Chi chuan as a therapeutic exercise approach. Arch Phys Med Rehabil 1997 Aug;78:886-92. therapeutic exercise approach. Arch Phys Med Rehabil 1997 Aug;78:886-92. NoteNote

2) University of Illinois: Kinesiology Department: ttp://kch.illinois.edu/Research/Labs/ECRL/

3) Greenman, Philip. Principles of Manual Medicine. Lippincott Williams & Wilkins; Third edition (October 17, 2003)

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