The Physical Therapy Exercise Prescription Framework: 10 Observational Essentials

The following 10 observational essentials are what I apply to any patient during the evaluation, treatment, or rehabilitation portion of their program.

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.

2. Environment: The surroundings or conditions in which a person lives or operates. Examples can include indoors or outdoors, grass or dirt, flat or uneven surfaces, and quiet or loud. For the lunge example, are we lunging to the floor, to a BOSU, or to an Airex pad? A good starting point is lunging toward 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 try 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 plumbing, quadruped, and kneeling variations might be used. For a lunge, while half-kneeling, you are requiring more hip and ankle ROM, a more hip-than-ankle strategy for balance, an increased 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 on muscles, joints, and the neuromuscular system. An example of this is that by putting one leg more posteriorly during a squat, the posterior leg will have increased weight-bearing 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 driving during a lunge would be reaching down toward 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 that 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 an emotional driver would be fear. For a person who is afraid to do a movement such as a lunge due to previous experiences with injury, the lunge will most likely look different, have limited depth, have 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, 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. Lunging 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 on the knees and hips 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 on the knee while still maintaining range of motion.

7. Distance: The amount of space between two objects or things Horizontal coordinate. This can be measured in cm, inches, feet, or yards, or it can be classified as a 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 that 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 there are in 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 that 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 on 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 given length of time or the number of reps performed in that 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 explosion. 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 for which something lasts or continues. This can be the number of reps, the number of second holds, or the length of sets. Longer durations are typically harder, which is how to improve aerobic and muscular endurance. For lunge durations, it would be more difficult to hold the lunge in the loaded or 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.

There you have it: 10 items that we at Rehab United Seattle consider each time we apply any exercise, activity, or manual therapy technique to help our patients get back to an active life free from pain, stiffness, and medication.

I hope you enjoyed this blog post, and please leave comments if you have any questions.