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Exercise Prescription and the Lower Extremity

 

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Squat Leg Muscles

Exercise Prescription and the Lower Extremity

Alan Zhou, SPT

 

Background:

Prior to starting the physical therapy program, improving strength and conditioning, improving human movement, and optimizing performance were the driving forces that led me to my fascination with exercise and training. Outside of my personal history as a strength sport competitor, I have also previously helped coach conventional athletes, strength athletes, and recreational athletes. After starting the program and working with patients, I came to realize that many patients are chronically under-dosed in terms of exercise intensity1 and that is something I have taken on as my personal mission to try and address. I have always appreciated and admired how Athletic Trainers and Strength Coaches work with their athletes through the application of strength and conditioning. I believe that looking at physical therapy through the lens of a strength specialist allows physical therapists the ability to utilize unique methods of prescribing exercise parameters through evidence based methodologies.

Similarly, this Capstone project acts as another way for me to serve others within the program and explore my love for teaching and coaching. After being a teaching assistant for the Musculoskeletal II course for the 2nd year students, another opportunity to assist Dr. Mike Lewek and Dr. Jon Hacke with the 1st year students was too tempting to forgo. Teaching and sharing what little information I know not only gives me the opportunity to cement the knowledge for myself, but it also allows me to contribute back to a program that his given me experiences and opportunities I could not have gotten anywhere else. Creating a useful resource for students to use and reference with future patients is something that allows me to serve my classmates and community at large. The chance to interact with future UNC DPT graduates in this capacity and affect change (big or small) within the world of physical therapy is a privilege that seldomly presents itself. I had hoped to take advantage of the opportunity to try and honor the knowledge of those before me and to aid the ones after me.

For this project, I created a VoiceThread PowerPoint Presentation on exercise prescription for the lower extremity, taught the corresponding lab session, created an evidence table of current concepts with autoregulation, and created a quick reference handout for students and clinicians.

Statement of Need/ Purpose:

In the current UNC DPT curriculum, there seems to be a lack of clinically applicable content related to exercise selection and progression/regression. The current Exercise Prescription material gives a great theoretical background to the ideas behind the dosage of exercise, but many of the ideas do not immediately translate to clinical practice for some students. Due to the large variation in knowledge among students, it has also been noted that the challenge comes in bridging that vast knowledge gap between the hyper-experienced and the newcomers to exercise. There seemed to be a need for providing a framework for straightforward, practical application of strength and conditioning principles while also providing a novel, evidence-based methodology to the prescription of exercise.

Due to many clinical limitations and some of the inherent inaccuracies with traditional percentage based training,2–5 it seemed important to update the course with current evidence regarding the efficacy of autoregulatory training as an adjunct method of prescribing load intensity. I believed that the new course information should speak upon current concepts available in selecting loading parameters for patients along the continuum of care and provide tangible and immediately applicable skills for students going out on rotation.

Course instructors have also voiced that students seem to have trouble with exercise selection and determining how to increase or decreases the difficulty of the respective movements. Anecdotally, there appears to be a gap between UNC DPT students’ understanding of performance and physical therapy/rehabilitation. Bridging that gap, providing information, and understanding clinical application can be utilized for the betterment of patient treatment and care. WHO and the NSCA have released position statements in regard to resistance training6–8, so there is a need for students to synthesize those concepts and overlay the principles of strength and conditioning to optimally address patients’ functional deficits and impairments.

Products:

Final products/components are linked below, and were created/utilized to serve as an adjunct to the PHYT726 Exercise Foundations/Prescriptions course, in the Spring semester of the 1st year of the UNC DPT program.

Components include:

Evaluation:

I incorporated feedback from my advisors and committee members to modify and improve the presentation and lab components of the project. Zoom meetings and multiple e-mail conversations were utilized in order to discuss how to best modify the framework I envisioned into a student friendly presentation. Important reference information was also provided for inclusion into the presentation. The advice and guidance from my committee members was invaluable for the not only improving the quality of the presentation, but also my own personal knowledge and growth. They provided numerous suggestions regarding formatting changes for enhanced learning, tips for improving the aesthetics of the slide information, and identified areas in my material that required further discussion and elaboration.

Retention of the lecture/VoiceThread material was assessed through a Google Forms quiz. Students were asked to take the quiz prior to watching the lecture and after watching the lecture. Of the students that submitted their responses, 90% increased their number of correctly answered questions by at least 2/10 questions. Additionally, I utilized the standardized UNC DPT presentation survey from Dr. Jon Hacke to assess the quality and effectiveness of my lab session. Students are able to provide a numeral assessment of the lab session while also providing free written comments/criticism. DPT1s completed and returned the survey. Of those that submitted feedback, the average score across the 9 categories was  >97%. Many students stated they enjoyed the Zoom lab session as it explained the VoiceThread information and allowed for practical application of concepts. Constructive criticism stated the clinical case instructions could have been more explicit and more time could have been provided in order to review the new course material.

Self-Reflection:

Looking back at this Capstone project, I feel that it has given me a great opportunity to re-examine my passion for human movement. It served as a reminder of why I chose physical therapy as a career and how I can continue to make changes in the profession. Although there are inherent struggles with being a DPT student, this teaching project provided many moments satisfaction when fellow students found value in the information I was teaching. Because of my project’s earlier than usual timeline, it also reminded me to be efficient with my schedule and taught me the value of appropriate work-life balance. Also, I have come to greatly appreciate the skills learned in regard to database searching, assessing literature quality, and synthesizing the most clinically applicable data from research articles. Without the wonderful lessons from Dr. Carol Giuliani or Dr. Charles Sheets, I would be lost in a sea of Boolean terms and psychometric data points. Lastly, this project has given me the ability and confidence to create and present professional material to clinicians and peers. This opportunity has enhanced my leadership capabilities and has not only improved my clinical understanding of exercise prescription but also my ability to teach and coach others.

Acknowledgements:

First, I would like to take this time to say that working with you all has been a pleasure and I am beyond grateful for the opportunity to speak with you all.

Dr. Mike Lewek and Dr. Jon Hacke, thank you for being my advisors and allowing me this opportunity to teach within your course. It was a wonderful chance to help my fellow students and explore my interest in teaching. You all provided me with invaluable insight, tips, and recommendations for improving my approach to teaching students of varying backgrounds. Thank you for always moving the project forward and helping me stay on track with the goals. It has been a pleasure being your student in and out of the classroom. Your expertise and advice are greatly, greatly appreciated. I hope to stay in touch with you all moving forward!

Dr. Madison Franek and Dr. Kyle Cooper, thank you both for allowing me to reach out to you to become committee members for this project on such relatively short notice. Thank you, Dr. Cooper for providing your thoughts on areas for emphasis with my presentation and being the contact point for other clinicians. Thank you, Dr. Franek for providing such great resources on exercise selection and kick-starting my brainstorming for the project. Your integration of various frameworks for exercise prescription was integral to my formulating of thoughts for 1st year students.

Finally, I would like to thank my UNC DPT family and classmates for their continued support throughout this program. Without the shared laughs and support, I am not sure I would be here at this point.

References:

  1. Lee PG, Jackson EA, Richardson CR. Exercise prescriptions in older adults. Am Fam Physician. 2017;95(7):425-432.
  2. Richens B, Cleather DJ. The relationship between the number of repetitions performed at given intensities is different in endurance and strength trained athletes. Biol Sport. 2014;31(2):157-161. doi:10.5604/20831862.1099047
  3. Helms ER, Byrnes RK, Cooke DM, et al. RPE vs. percentage 1RM loading in periodized programs matched for sets and repetitions. Front Physiol. 2018;9:247. doi:10.3389/fphys.2018.00247
  4. Helms ER, Kwan K, Sousa CA, Cronin JB, Storey AG, Zourdos MC. Methods for regulating and monitoring resistance training. J Hum Kinet. 2020;74:23-42. doi:10.2478/hukin-2020-0011
  5. Helms ER, Cronin J, Storey A, Zourdos MC. Application of the Repetitions in Reserve-Based Rating of Perceived Exertion Scale for Resistance Training. Strength Cond J. 2016;38(4):42-49. doi:10.1519/SSC.0000000000000218
  6. Faigenbaum AD, Kraemer WJ, Blimkie CJR, et al. Youth resistance training: updated position statement paper from the national strength and conditioning association. J Strength Cond Res. 2009;23(5 Suppl):S60-79. doi:10.1519/JSC.0b013e31819df407
  7. Fragala MS, Cadore EL, Dorgo S, et al. Resistance training for older adults: position statement from the national strength and conditioning association. J Strength Cond Res. 2019;33(8):2019-2052. doi:10.1519/JSC.0000000000003230
  8. Bull FC, Al-Ansari SS, Biddle S, et al. World Health Organization 2020 guidelines on physical activity and sedentary behaviour. Br J Sports Med. 2020;54(24):1451-1462. doi:10.1136/bjsports-2020-102955

 

First image reference: https://barbellscholar.com/2019/01/07/top-10-barbell-squat-variations/

8 Responses to “Exercise Prescription and the Lower Extremity”

  1. Michael Lewek

    Alan,
    You have pulled together a nice bit of information to share with our DPT1s. I appreciate all of the work that you did to plan the virtual ‘lab’ experience and your flexibility to continue with things, despite the crazy weather.
    The work that you put together is an important component of building a plan for the patient. It built nicely on the previous coursework that was covered earlier in the semester and gave the DPT1s a great practical sense for how to load. I will continue to build off of this next year to ensure that these points continue to be emphasized.
    Thank you for your hard work and great insight into this project.
    Mike

    Reply

  2. Debbie Thorpe

    Hi Alan
    You did a nice job on all the “products’ for this project on LE exercise prescription! The voice thread that you created is evidence-based and very complete. I like your pre/post learning assessment to make sure your audience was retaining the content. Also your teacher/Scholar presentation evaluation should give you some good feedback related to your presentation skills. Did you receive feedback for your presentation? You might want to include the data from the pre/post learning assessment on your site from peers who completed it? You did a good job of managing the lab time and the video of the lab session was a unique contribution to this project and after viewing it , you should get some ideas of what went well and ways to improve your presentation skills. Overall, a very nice project! Good luck on the remainder of your clinical rotations!
    Best
    Debbie

    Reply

  3. Krista

    Hey Alan! I was immediately drawn to the topic of your capstone because of my personal interest in exercise strength and conditioning. Then when I saw Ryan’s and Brandon’s comments, I’ll admit I was bit intimated because you 3 are rockstars in terms of combing EBP and exercise prescription, especially in an athlete population. However, I think my hesitation only highlights the need for your capstone and educational materials. I agree UNC’s program could benefit from additional instruction on exercise selection and progression/regression. I think there is an assumption we will gain this knowledge in clinic, but that relies on CIs using up-to-date exercise prescription and providing the education. I don’t want to fault our program, as there’s only so much you can fit in 3 years. I just want to highlight the benefits of your products. It was great to see specific exercise examples- I was unfamiliar with the closed chain hip adduction exercise. I am excited to try it out myself. I also appreciated how you dropped in small practical tips throughout the presentation, like anchoring a TheraBand with contralateral foot during seated knee extension to keep it stable. Before your presentation, I was unfamiliar with the 3 types of periodization. It was also great to learn more about autoregulation after you peaked my interest with it in our Sports Medicine Elective. Your VoiceThread and Evidence table are extremely informative. The VoiceThread Handout is an excellent concise resource I am pleased to add to my repertoire. I am looking forward to watching your Zoom Lab Session when I have a little more time to set aside. You should be very proud of the products you created. Alan, I am grateful were in the same PT class so that I got know you and will have a competent friend and PT I can contact once we’re in the real PT world!
    -Krista

    Reply

    • Alan Zhou

      Hi Krista,
      Thank you for reading through my work and the super kind words! To even be mentioned with Brandon and Ryan in the PT same sentence is a big honor. I am glad I could provide something you felt was a value added. If you’re interested in more reading about RPE/RIR, the work of Helms, Hackett, and Zourdos are essential reads for autoregulation. I am glad I got to know you as well, and I am excited to know that another PT is hoping to apply S&C to PT. Please keep in touch!

      Reply

  4. Brandon Surber

    Hey Alan! First off, great job on this project as a whole. With all of the information that has started to make the leap to the forefront of exercise prescription conversations related to autoregulation, it is wonderful to see such a well thought out and executed project related to the topic. Similar to Ryan, challenging underdosing for patients with MSK related issues was something I explored in EBP II and is something I have had and continue to have an interest in. I have really come to appreciate the nuanced nature of this topic when we discuss specific physical capacity targets in training and rehab (hypertrophy, strength/force production, rate of force development, etc) and have realized the difficulty with underpinning the optimal dosage ranges for pain driven patient presentations. Similar to many, my original introduction to prescription was classic percentage based training cycles which I also struggled to translate into the volatile environment of rehab. Once I learned about the many, many autoregulation strategies at our disposal (APRE, DAPRE, RIR, RPE, etc), I realized that there are endless ways in which we can program and progress our patient’s exercise prescription.

    All of your materials are impressive, but I am especially drawn to the one page handout you made as it contains a ton of info in an easily digestible piece of information. This is something we set out to do in our project as well with the realization that some do not have deep backgrounds in S&C, but still need updated information on readily applicable strategies to improve the quality of rehab we provide. I believe RPE, RIR, and DAPRE are three of the most readily applicable strategies we can teach and utilize in rehab (compared to other strategies such as VBT) and you have covered them quite nicely here and have given an example of comparisons to the traditional method of percentage based markers. One thing I have been thinking about a lot lately and seeing discussions about within some of the AASPT chats is the role and potential benefit of training to failure in the rehab process (not pushing to a point of overtraining, but maybe 1-2 final sets of an exercise per week). I was wondering if I could get your opinion on this as it can be seen as a component of some autoregulatory approaches in practice? There seems to be information to support that it may help us to achieve a sufficient stimulus to drive adaptation forward, especially in a setting where we may only see an athlete or patient once to twice per week.

    Reply

    • Alan Zhou

      Brandon,
      I really appreciate the feedback and your comments! Our discussions always end up making me more curious and inspires me to become more proficient with S&C principles. If you’re impressed, then I am doing something right. As for the repetitions to failure in the rehabilitation setting, I think that it is a valuable checkpoint clinicians and athletes can use during the rehabilitation process. Testing a patient to a certain repetition max probably is not a bad idea occasionally in order to assess and build strength, endurance, and overall capacity along the rehab timeline. I think that challenging the patient appropriately with 1-2 sets to failure is likely a non-issue, especially with percentages of 1RM that are likely below 60% in the earlier phases of rehabilitation. Later phases will depend greatly on yearly calendar and programming, most likely. I think this all should be considered within the context of the particular training block for the athlete.

      In my opinion, single joint isolation exercises most likely can be done to failure with a recoverable amount of volume while large compound movements can be tested in the form of an AMRAP or back-off, if weekly tonnage is equated. Also, with a given injury, the athlete’s sense of failure may need to be “calibrated” depending on recovery timeline. As mentioned, using the sets to failure as a check, the stimulus may help to improve the athletes sense of perceived exertion. Zourdos, et al. published a paper about proximity to failure earlier this year (PMID: 30747900). To me, assigning low to moderate intensity and pushing them to near failure or failure aids in our assessment of program parameters. In theory, an injured patient could do dynamometry (if available) to get a baseline force output, utilize RPE training based on that information, test with a repetition max at a given RPE, and that repetition max number could be used to calculate a potential 1RM that can then be used along with autoregulation to adjust load prescription. I hope those thoughts make sense. Please let me know if I rambled too much and did not address the question adequately. There is a lot of “it depends” for this one, but the bottom line is “yes, I would likely use training to failure on occasion”. That question really helped with my clinical reasoning. Much appreciated again, Brandon!

      Reply

  5. Ryan Brooks

    Alan, thank you so much for putting this capstone project together. I actually looked at the same topic during my EBP 2 course last semester and thought that autoregulation offers a wonderful alternative to traditional percentage-based loading. One unanticipated aspect of this project that I felt was a really nice addition to the autoregulation information was the daily force demands as well as the WHO activity recommendation guidelines. I think these are super important to be familiar with to 1) assess the demands our patients may need on a day-to-day basis and 2) to inform patients on how much exercise they need to perform each week for general wellness. Considering the education we receive regarding exercise and movement in a doctoral level program, I feel understanding these should be the requisite. I appreciated your conversation regarding periodization as well as I feel this is a foundational concept to understand progressive overload of patients over time.

    The reason I feel autoregulation (RPE, RIR, etc.) is such a wonderful option vs percentage based is due to being unable to adequately assess tissue capacity in clinic especially post-surgery or during tissue is healing. The related pain, tissue integrity, and psychological factors a patient experiences really limit the clinician’s ability to test true tissue capacity; also risk of re-injuring the patient outweighs the benefit. This is where autoregulation can be a perfect alternative as you have perfectly described throughout your materials. My biggest reason in exploring this topic myself last year and in listening to/viewing your capstone material is that I felt like I saw arbitrary loading in clinic frequently and never understood how the PT knew that they were getting the desired tissue adaptation. I feel autoregulation offers a more objective way to assess this (even though it is based on a subjective measure) as it can be used concurrently with arbitrary weights using “guess and check” initially with a patient to determine the optimal load for the patient at that point. My big question for you and one I grapple with on this topic is that do you feel this can accurately be used in injured populations? As you stated, RPE/RIR become less accurate with more repetitions but more accurate with less repetitions. However, typically when we first see patients and initiate the motion/strength phases, the patient performs high repetitions with low weight. I know this is a difficult question, as I don’t remember seeing many autoregulation papers in resistance training and injured populations when exploring this myself, but I would love to hear your thoughts. Is this appropriate early on in building foundational strength or something that may not be effective to use until later when the athlete is lifting within the 1-6 repetition range? Thanks so much for this wonderful information again!

    Reply

    • Alan Zhou

      Ryan,
      Thanks for the comments and taking the time to read through my project! Thank you for the kind words as well. To jump into your question, the real answer is I am not sure if autoregulatory training is the most optimal or most accurate form of dosing intensity with injured patients. However, I do think it is one of the best tools we have at this point given the circumstances. In my opinion, the RPE rating is relative at various stages of healing. Initially, post-injury/surgery, the patient’s tissue will only be able to tolerate so much. Whether that is mechanical precaution or a fatigability issue, I think it that finding appropriate dosing becomes a moving target. Because there is no research currently out there for autoregulation for injured athlete’s, I would assume that the subjective feeling of repetitions left in reserve is still fairly accurate (based on previous performance research). Although it is not as accurate at lower percentages, the repetitions rating generally only vary by 2-3 repetitions. I think that taking RPE and applying it in the early phases of tissue healing is one of the few ways we can judge intensity of loading. I see things like RPE, simple clinical linear progression (“guess and check”), pain, and healing timeline all coming together help us to select load in this “grey area.” Once the tissue is safe to be loaded, then I think the RPE/RIR system will sort itself out. Like with a standard linear progression, I would think that the lower intensity and higher repetition phases would just be extended at the front end of the injury. I look at that timeline being something similar to going from -5 to 0 to 5, with the negative number being the time needed to reach a general baseline. I hope that makes sense. We can definitely chat more about this if you would like.

      Reply

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