Case based exercise prescription

This session applies topics from this and other modules to prescribing exercise to treatment case
studies. The exercise programmes can be informed by elements of anatomy, types of muscle
contraction, types of training and exercise specificity. You may make use of lecture notes or other
resources and use any available equipment to design and demonstrate exercise selection. For each
of the cases below:
Part 1
1. Write a problem list
a. Use the headings - impairments, function, participation

Part 2
2. Design an exercise programme to:
a. Restore range of motion
i. Select exercise(s)
ii. Dosage – intensity, duration, frequency, sets, reps, etc
b. Restore muscle strength
i. Select exercise(s)
• Passive/assisted/active
• Types of contraction - isometric, concentric, eccentric
• Open/closed chain
• Single/multi joint
ii. Dosage – intensity, duration, frequency, sets, reps etc
3. Consider how to progress the exercise and programme
a. Dosage
4. Other considerations
a. Pain
b. Tissue healing
c. Psychological factors
d. Others
Part 3
5. Tailor exercise programme to return to previous or desirable level of function and activity
i. Functional exercise - specific tasks and skills
ii. What other types of training might be useful - endurance, power?
iii. How to train these parameters?
6. Consider how to progress the exercise and programme
a. Dosage
7. Other considerations
a. Pain
b. Tissue healing
c. Psychological factors
d. Others
Notes

For each case, part 2 is intended as a detailed look at designing exercises to improve range of motion
and strength at a specific joint and muscle group.

Part 3 is meant to be more open ended and a chance to consider other types of training and how to
address the points raised during part 1.

Take home from the session

• How to select exercises

• How to train different fitness parameters - types of exerices and dosage to target
• Starting to think about adapting these to different patients
Case 1: A 26-year-old elite female football player is partial weight bearing 12 weeks following an
internal fixation (intramedullary nail) of a left tibial fracture. The patient has reduced range of
motion at the ankle joint and weakness of the left leg, particularly affecting the plantar flexors.

Case 1 - Part 1

1. Problem list - could include

Impairments

• Reduced ankle DF, PF, Inv, EV ROM

• Reduced proprioceptive function at ankle
• Reduced strength …
• Reduced power…
• Reduced endurance…
• Reduced standing balance

Function

• Unable to FWB, walk, run, jump, hop, sprint, kick

• Unable to stand in shower to wash
• Difficulty climbing stairs to her fourth floor flat

Participation

• Reduced socialisation and integration at work (pro- football)

• Unable to play football
• Impact upon identity
Case 1 - Part 2

Flexibility

• Stretches of the plantar flexors - eg pulling toe towards body in seated position
• Consider, weight bearing/non-weight bearing, single/multi-joint - knee angle, static vs
dynamic, PNF
• Target dosage (from lectures) – need to stretch to max ROM ‘beyond available length’/ as
strong as possible, at least 4-8 weeks training, once a day, 4-6 stretches/session, at least
30s/stretch
• Could also consider total time under stretch vs reps*duration

Progression –

• ↑ dosage parameters, particularly intensity, duration, reassess endpoint

• Possibly move towards doing more active/dynamic stretching

Strength

• Patient could have generalised weakness of the left leg, but for this part concentrarte on the
plantar flexors
• Exercises of the plantar flexors, eg resisted toe pointing, heel raises, possibly step ups, etc
• Other points/prompts –
o types of contraction (eg possibly begin with eccentric or isometric - lower loading)
o single/multi-joint/open/closed chain
o Types of resistance (manual, body weight, therabands, adding weight etc)
• Dosage (from lectures/ACSM) ≥4-8 weeks’ training, 2-3 days/week, intensity - deconditioned
40-50% 1RM, 60-70% novice/intermediate, 80%+ advanced, reps/sets 8-12*1-3, rest
between sets
o Related question - how to define 1-RM in this patient?

Progression –

• ↑ %1-RM, fewer reps/more sets, reassess strength during training

• Intensity could be increased by removing support/adding manual resistance, adding weight,
using more body weight etc
• Possibly increasing range of exercise

Other considerations

Potential issues

• Pain around the ankle joint may initially limit stretch/contraction tolerance
• Tissue healing/deconditioning – risk of injury with more intense stretching or contraction
• Bone may not initially be strong enough for intense exercise
• Frustration, catastrophising, self-efficacy etc

Management

• Possibly start within ROM and move to stronger stretching

• Possibly Start at deconditioned intensity 1-RM
• Possibly 1-RM defined within limitation etc initially
Case 1 - Part 3

Specific skills needed and how they might be trained

• Kicking, running, sprinting, jumping etc

• Functional exercises for these

Power training

• Use of fast contractions at moderate intensity, multiple joint exercises, plyometrics

• Moderate loading, 0-60% 1-RM, 3-6 reps, 1-3 sets, 2-3 min rest for more intense

Cardiorespiratory endurance

• At least 4-8 weeks training

• 3-5 days a week could do more for low intensity
• Light to moderate intensity in deconditioned, progress to moderate to vigorous
• 20-60 mins/session depending on intensity
• Possibly start unloaded (exercise bike, swimming), progress to walking and running

Muscular endurance

• Higher reps (15-20+), light-moderate load <50% 1-RM, shorter rests 1-2 min

Progressions

• Similar to last section ↑ dosage

o Power - probably increase intensity (easier to standardise), velocity, more advanced
power training could include more combination of intensity/velocity
o Cardiorespiratory - increase duration/intensity
o Endurance - probably increase reps primarily + increase intensity

Pacing

• A lot of these might be potentially more dangerous

• Begin after/during initial rehab of target muscle group
• Too much too soon etc
Case 2: A 71-year-old retired male with osteoarthritis of the right knee joint. The patient has reduced
range of motion and strength around the affected joint. He has a BMI of 30kg/m2 and reduced
physical activity due to pain in the affected limb.

Case 2 - Part 1

1. Problem list - could include

Impairments

• Reduced knee ROM

• Reduced KE/KF strength
• Knee pain
• Reduced power
• Reduced endurance/general deconditioning

Function

• Difficulty climbing stairs

• Difficulty standing from chair
• Difficulty walking more than short distances

Participation

• Reduced social activities

• Reduced voluntary work
• Identity - feeling older, frailer
• Avoidance of activities

Note also the potential for other comorbidities, CVD etc

Case 2 - Part 2

Flexibility

• Stretches of the knee flexors and extensors – eg straightening leg in lying/seated position,
toe touches, knee extension, quadriceps stretches - possibly lying on side/off chair with
towel
• Consider single/multi-joint hip angle, static vs dynamic, possible use of PNF
• Target dosage (from lectures) – need to stretch to max ROM ‘beyond available length’/ as
strong as possible, at least 4-8 weeks training, once a day, 4-6 stretches/session, longer
stretches >30s may be better for older adults
• Could also consider total time under stretch vs reps*duration

Progression –

• ↑ dosage parameters, probably start lower and work towards the target dosage above
• Possibly move towards doing more active/dynamic stretching

Strength

• Exercise of the knee extensors and flexors - knee extensions/flexions, squats, step ups, chair
rising
• Other points
o Types of contraction (eg possibly begin with eccentric or isometric)
o Single/multi-joint open/closed chain
o Range of exercise (stick to pain free range, or target range to support joint?)
o Types of resistance/assistance
• Dosage (from lectures/ACSM) ≥4-8 weeks’ training, 2-3 days/week, intensity - deconditioned
40-50% 1RM, 60-70% novice/intermediate, 80%+ advanced, reps/sets 8-12*1-3, rest
between sets
• Target lower intensity for older adults 40-50%, higher rep ranges (10-15) may be effective
o Related question – how to define 1-RM in this patient?

Progression –

• ↑ %1-RM, fewer reps/more sets, reassess strength during training, increase variety - types
of exercises, contraction, speed etc
• Intensity could be increased by removing support/adding manual resistance, adding weight,
using more body weight etc
• Possibly increasing range of exercise

Pacing

Issues

• Pain around the knee joint may initially limit stretch/contraction tolerance
• Deconditioning – risk of injury with more intense stretching or contraction
• Frustration, catastrophising, self-efficacy, fear etc
• Potentially slower healing/adaptation at older age
• Risk of falls

Management
• Begin within ROM and move to more intense stretching
• Possibly begin strength training in mid-range and extend as flexibility improves
• Possibly progress more slowly given patient’s age
• Start with easier/supported exercise, standing from chair vs full squats etc, step ups with
handrail etc
Case 2 - Part 3

Specific skills needed and how they might be trained

• Chair rising, stair climbing, walking moderate distances

• Functional exercises

Power training

• Faster contractions, functional movements/multiple joints

• 20-50% intensity, similar to younger
• Very fast movements, plyometrics etc become more difficult at older age

Cardiorespiratory endurance

• At least 4-8 weeks training

• 3-5 days a week could do more for low intensity
• Light to moderate intensity in deconditioned, progress to moderate to vigorous
• 20-60 mins/session depending on intensity
• Possibly start unloaded (exercise bike, swimming), progress to walking, possibly jogging
• Level of function targeted - short walks at moderate pace?

Muscular endurance

• Lower weight, more reps, shorter rests etc, similar to younger adults
• Higher reps (15-20+), light-moderate load <50% 1-RM, shorter rests 1-2 min
• Might be useful to support affected joint during prolonged activity

Progression

• ↑ Dosage
• Ways to progress different parameters similar to case 1, but at lower target range.

Pacing

• Some improvement in joint ROM/strength may be needed before these can be initiated
• General deconditioning/older age may benefit from slower progression
• Risk of increased pain further limiting activities
• Fear avoidance etc