Raise your hand if you’ve ever been in a conversation with a classmate or colleague or online about how you feel like you never really learned exercise prescription in PT school? Now, I find this to be more true with DPTs versus PTAs. Regardless if you’re a DPT or a PTA, if your hand is up, you’re not alone.
The dreaded “3 sets of 10” and “clamshells for everyone” have become inside jokes among PTs. Personally, I think the 3 sets of 10 gets over-demonized. I’ll even admit clamshells may have their time and place in certain situations. However, there is a little bit of an ugly truth to those jokes.
Dosing, exercise selection, and other aspects of exercise prescription could use a little work in our profession as a whole. I think most of us get A LOT better at it with experience. But you’d think we’d be better at it from the get go right? I mean it is a BIG part of what we do. In this post I wanna explore why we fall short, where we fall short, and how we can flip the script on exercise prescription.
Why We Fall Short
So why aren’t we better at exercise prescription? Well, it’s hard to be good at something you never really learned. I’ve discussed with classmates and co-workers and we all agree we wished we’d learned more about exercise prescription in school.
Did anyone else feel like the exercise piece was kind of an afterthought? For many DPTs, we remember ROM, MMT, special tests, manual techniques, and subjective interviews all being stressed in MSK labs. Then it was like the exercise piece just sort of got glossed over.
This trend seems to be continuing. Just in the last month I’ve seen at least three social media posts from SPTs talking about how their programs skim over exercise prescriptions. One of the posts even went on to explain that their teacher basically said “that’s something you’ll learn while you’re in clinicals.” While I’m sure whatever CI this student gets is more than happy to teach them, I’m also sure they’d prefer their student have some of the basics down.
The problem with this is then it becomes a blind leading the blind situation. PTs who already didn’t know the exercise prescription like they should have sometimes become the teachers. Then we have an entire profession who in their early years is just okay at exercise prescription when that’s at least half their job.
The other reason I think we fall short is unfortunately the way some practices are run. Yes, I’m talking about PT mills. If you want to know my take on PT mills I get real in depth on it here in a previous post. In PT mills, patients are left to their own devices. They’re by themselves doing exercises while their therapist is likely doing manual therapy on another patient.
Naturally, that means the exercises stay pretty general for everyone. Not necessarily specific to the patient’s deficits or well-picked for that patient’s abilities. Oh and what’s something easy for the patient to remember and count for how many to do? . . . Three sets of ten.
Where We Fall Short
Now that we’ve chatted about the why, let’s talk about the where. To me, there are two main areas we often fall short in exercise prescription – dosage and selection. Like I said before, dosing exercise for patients at 10 reps of everything is a little bit of a PT inside joke. Sometimes 10 reps isn’t a bad thing either! Actually, one could maybe argue most of the time it’s not. This podcast from Mike Reinhold actually had a great discussion on it.
While 3 sets of 10 doesn’t need to be demonized, it shouldn’t be the only dosage we use. For example, a lot of my patients will report to me, “It doesn’t hurt much anymore, it just gets tired easily.” That’s a scenario where I start to consider increasing that rep range to around 15 for more endurance OR I prescribe an exercise that plays on more time under tension. Which brings me to my next point – exercise selection.
In exercise selection I think we’re fine with picking exercises that strengthen the target muscle. When it comes to specific goals though, I think that’s where we fall short. When I first started working as a PT I was in LTC. Many of those patients’ goals were to stand or walk again. However, it sounded like they’d really only ever done a lot of seated exercise. So what did my co-worker and I do?
WE GOT THEM ON THEIR FEET. Even if it was just standing in the parallel bars, even if it was just for five seconds. For many, that five seconds became ten, then a minute, then lifting a leg, and before you knew it maybe they could at least do a transfer with an AD. We had results because we knew if they wanted to get better on their feet, we had to get them on their feet.
There is nothing inherently wrong with a LAQ or a clamshell. Sometimes maybe it’s where we need to start. I would challenge us however before prescribing those infamous “go-to” exercises to ask ourselves a couple questions. Does this exercise genuinely apply to my patient’s goals? And, is there a better exercise I can give that they’re able to do? I think if we start asking ourselves those questions we’ll find some of our exercise selections change our patients making progress a lot quicker.
Flipping the Script on Exercise Prescription
So how do we change the narrative? Well, to get the root of the problem we could start with education. Again, I think this is more a problem in the DPT programs versus the PTA programs. This is actually where I would note DPT curriculum needs to take a page from PTA’s. From what I’ve heard, most PTA programs have an entire class devoted to exercise prescription.
If you’re an educator or have some sort of role in curriculum building for DPT programs and this blog post somehow comes across your desk. . . I beg you. PLEASE. Make sure there is at least a unit, a week, SOMETHING more than one day devoted to exercise prescription.
I know some will try to say “there just isn’t time. Our main concern is preparing students for boards.” While I understand that concern, students need to get prepared for the clinic as well. They will also certainly be thankful you took the time to teach exercise prescription. Plus, let’s be honest, taking a little time outside the board curriculum isn’t going to make or break their boards, but it could have a big effect on those SPT’s future patients.
The other way we get to the root of poor exercise prescription in PT is to get rid of PT mills. Plain and simple. Their model breeds a slew of problems that ultimately leads to poor delivery of patient care. If we want to give a good exercise prescription, we have to be in an environment that sets us up for that and PT mills just aren’t it.
Now a lot of us don’t work in mills, but feel like we could improve on exercise prescription . . . but it’s also not like we can go back to school, nor would we want to. Actually, you couldn’t pay me to go back. If exercise prescription is something you think you need to work on, here’s a few tips to get you started.
A little exercise physiology review is always helpful. Remind yourself of reps, sets, and max percentages that coincide with strength, hypertrophy, power, and endurance. Again 10 reps may be appropriate in a lot of cases, BUT are you using enough resistance? Or based on the goal do you need higher or lower reps? Once you know those things it’s a lot easier to make adjustments
My next tip is going to make me sound like a broken record because I know I’ve said this in other blog posts, but you have to be goal specific. If their goal is to be able to squat, get them up asap. Don’t waste time on LAQs they barely feel. Figure out what their goal is or what piece they have the most trouble with. I guarantee you there is an exercise, activity, or drill you can come up with that will help versus just some cookie cutter mat exercise.
Lastly, scaling is key. A lot of times I think we make the mistake of completely stopping an exercise if it’s too hard or painful. However, most of the time I find the exercise is good, we just maybe need to adjust for patient tolerance. By scaling things like ROM, resistance, speed, etc. we can continue an exercise that might be really good for the patient instead of moving onto something less helpful.
One of my favorite examples is a modified RDL or modified deadlift. RDLs and deadlifts are great exercises, however not everyone tolerates the full ROM due to low back issues. Instead of going through the full range I’ll put a stool in front of the patient as their target to shorten it up a bit. Most of the time that’s enough. Gradually we work the height down and by the end of it they can go through a full ROM!
These are all just a handful of my ideas to improve how we prescribe exercise. How do you think we can flip the script on exercise prescription? Drop some ideas in the comments and let’s get a discussion going. Also what are your feelings on 3 sets of 10? Overused or over-demonized? As always, share with your friends and on social media. Don’t forget to hit subscribe to get new posts directly to your inbox.
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