The Physical Therapy Exercise Prescription Framework: 10 Observational Essentials

Have you ever wondered how your physical therapist decides what exercises to prescribe for your plan of care?

In this video blog series, we’ll be discussing the “10 Observational Essentials,” which are considerations for any movement or task analysis, or exercise prescription. Learning these ten essential concepts and “tweaks” can improve the variability of movements and exercise to help people prevent injuries, rehabilitate, and improve performance.

There’s no such thing as a bad exercise, only poorly-prescribed exercises. I think modifying and tweaking these ten components is what sets Applied Functional Science (AFS) apart and makes it different and unique. When rationalizing exercise prescription, the answer shouldn’t be, “I saw it online, it’s on the protocol, it looked cool," but instead using these 10 tweaks to create the desired chain reaction to improve function. The first of these observation essentials is the action.

1: Action: The desired movement pattern related to a fundamental task or skill. The movement pattern that is being performed. Examples include squatting, lunging, walking, reaching, stepping up or down, throwing, or swinging. For exercise prescription, the action should look similar to something the person needs to do for their sport or ADLs, or something that the person is having pain or dysfunction with. The action is going to be different for each person. For example, a healthy, active young adult probably shouldn’t be performing light, open-chain band exercises, whereas a sedentary, severe pain elderly patient most likely isn’t doing box jumps. For most of these videos, we will be using a lunge as the action. Other action variations include a static lunge versus a dynamic lunge.

2. Environment: The surroundings or conditions in which a person lives or operates in/on. Examples can include indoors/outdoors, grass or dirt, flat or uneven surfaces, quiet or loud. For the lunge example, are we lunging to the floor, to a BOSU, or Airex pad? A good starting point is lunging to a flat firm surface and progressing from there. If a soccer player wants to return to soccer, it is important to train them on uneven surfaces, on grass or turf, and trying to mimic their practice or game environment.

3. Position: A place or location where someone or something is located. Positions include: supine, prone, side-lying, quadruped, sitting, tall kneeling, half-kneeling, or standing. The positions can add variability and specificity. For ground-based sports or occupations like jiu-jitsu, or a plumber, quadruped and kneeling variations might be used. For a lunge, while half-kneeling going to a lunge, you are requiring more hip and ankle ROM, more hip than ankle strategy for balance, increase quad load of the back leg and increased patellofemoral compression. Stance positions are another tweak that can be used. For squatting, each squat position creates a different chain reaction and creates different demands to muscles, joints, and the neuromuscular system. An example of this is by putting one leg more posterior during a squat, the posterior leg will have increased weightbearing demand, load, and ankle DF ROM. For a horseback rider, squats may be performed in a wide stance position for sport specificity.

4. Drivers: Drivers can be mechanical, physical, or emotional. Drivers create, facilitate, or transmit motion to other areas. Anatomical drivers can include the arms, feet, pelvis, or eyes. Biomechanical drivers can be gravity, ground reaction force, mass, and momentum. Non-tangible drivers include fear, pain, encouragement, or confidence. An example of arm drivers during a lunge would be reaching down towards the floor while lunging. This reach is driving more hip and trunk flexion, increased posterior chain loading, and increased glute load. You can drive motion all the way down to the feet with arm drivers. An example of that is by standing and turning your trunk to the right, you will notice your right arch might get higher. Now use both arms to swing to the right and you will notice more motion occurring at the foot. An example of emotional drivers would be fear. For a person who is afraid to do a movement such as a lunge due to previous experiences of injury, the lunge will most likely look different, have limited depth, limited knee flexion, etc.

5. Direction: A point to or from which a person or object moves. An angulation coordinate. A lunge can be forward, backward, lateral or medial, or anywhere in between with increased variability being better. You might notice that you don’t always lunge perfectly straight. Think about when you are picking up a child’s toys from the floor...depending on the location of the toy, the lunge will look different. Also, think about lunging down to unload a dishwasher and then lunging in a different direction to put the glass in the cabinet. Lunging narrow versus wide changes the amount of foot eversion or inversion. For some pathologies where you might not want more foot pronation and eversion, a wider lunge might be less painful than a crossover lunge.

6. Height: A point to or from which a person or object moves with a vertical displacement or coordinate. Lunge to a box can be easier in rehab due to less mass and momentum whereas lunging from a higher box is more demanding on the lunging leg due to more ground reaction force from increased mass and momentum. The height of a reach can also be tweaked. Lunging with a forward shoulder height reach is less demanding to the knees and hips rather than a floor reach and requires less trunk and hip flexion ROM. This can be beneficial early on after surgery and can mimic the WB demands of being in the water. With aquatic therapy, the joints are unweighted which is less demanding. Lunging to a box creates similar effects to the knee, while still maintaining range of motion.

7. Distance: The amount of space between two objects/things. Horizontal coordinate. This can be measured in cm, inches, feet, yards, or can be classified in small, medium, or end range of motion. For a squat example, the distance would be small, medium, or end range for depth. Considerations might be if someone has patellofemoral pain syndrome and subpatellar pain, you might want to start at a small or medium range of motion to decrease the amount of patellofemoral compression. For a lunge, the longer the lunge the more mobility demands there are in the stance leg and the more momentum and force to the front leg. A person might want to perform lunges in a wider stance position to increase the base of support and balance.

8. Load: the amount of work done by a person or machine. This is often the weight or amount of resistance. In most situations, an increase in the load makes an exercise harder. This is one of the more common ways that exercises are progressed. The easiest answer is always to add weight, but might not be the most beneficial for that patient. For a lunge, you might increase the load by adding a medicine ball. You can also modify loads to muscles or specific joints during exercises by modifying other components like drivers. To increase the glute load during a lunge, you might add an arm driver to add trunk rotation to the same side.

9. Rate: the speed with which something moves. The rate can be the amount of distance covered in a length of time or the number of reps performed for time. The rate can make an exercise harder or easier. An example of increased rate becoming easier would be a marching single-leg balance exercise─the slower you are, the longer you’re on one leg which is the hard part. For the lunge example, faster lunges with quicker transitions are good for plyometric training and decrease the time between the load and explode. A higher rate could be more specific to running or other fast-twitch movements, whereas a slower rate might be harder to focus on eccentric control with longer lengths of time in the lengthened muscle phase.

10. Duration: the time which something lasts or continues. This can be the number of reps or the number of second holds or the length of sets. Longer durations are typically harder and is how to improve more aerobic and muscular endurance. For lunge durations, it would be more difficult to hold the lunge in the loaded/lower phase to turn it more into an isometric exercise, whereas if you have a runner, you could rationalize that running is similar to repeated single-leg hops. So if you’re going for tissue loading, a high duration of lunges would be more specific. Three sets of 10 reps (3x10) of an exercise will not guarantee a person can run one mile which involves around 1,500 strides.

For student physical therapists and other practitioners, I hope that this video blog series serves as a good refresher crash course on exercise prescription.

For patients, we hope that this series has provided you with a lot of insight into the methodology behind your physical therapist's prescription of exercises. We hope that the context provided in this video will enable you to better understand and be more successful in your plan of care.

Jason Averilla, PT, DPT, FAFS, OCS, CCI, is a Doctor of Physical Therapy from SDSU's inaugural class. He is a Board-Certified Orthopedic Clinical Specialist, Fellow of Applied Functional Sciences, and teaches in the DPT programs at San Diego State University and the University of St. Augustine. He is passionate about teaching and takes multiple students per year. In his free time, he likes to spend time with his family and 1-year-old son, kayak fish, golf, and play sports.

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