Evidence Based Physical Therapy Articles

Four Keys of Therapeutic Exercise, Part 1

Michael Rinaldi, PT, OCS

For a long time the adage: "No pain, no gain" has been thrown around more times than rookie bull-rider whose leg gets caught in a stirrup.   I remember a sign with such an adage proudly hung on a wall in a clinic where I once worked.  

But seriously, when patients come into therapy and recite that trite aphorism, we've got problems in the PR department...el grande style.   It means that we, as a profession, have done things on a less-than-professional manner.   If we exercise a patient's shoulder just to make sure we're covering all the bases, without rhyme or reason or relevance to importance, we're type-casting ourselves, not to mention doing the patient a disservice.

And in today's era of evidence-based medicine (EBM), some of us have learned to sleep with one eye opened if we're found out to practicing without the priniciples laid out by David M. Sackett, MD¹. 

But what should we be concerned with when using exercise in the rehabilitaion process?

Essentially, there are three noteworthy attributes of muscle function to which the evidence in rehabilitation points.  There is also one other area of rehabiliation exercise which is commonly overlooked, but of prime importance when attempting to resolve a painful affliction.

1. Amplitude of Contraction.

It should come as no surprise to any that the level of vigor in which a muscle or group of synergistic muscles contract is of great importance.  Ample research has been done that supports the clinical practice or restorative strengthening.  Consider that return-to-sport studies have shown with a degree of certainity that a player has a good chance of successful return to sport when quad and hamstring peak contraction is within a certain percentile of the non-afflicted leg. 

Post-offer, pre-placement job screeenings often include some measure of how much a person can lift.  (Not always reliable or even valid, but indicates that vigor/strength is a requirement for a particular job duty.)

In the use of therapeutic exercise, unless one is using a microfet or an isokinetic device, it becomes difficult to measure improvement of amplitude objectively.   The patient will generally say "I feel stronger" which is a good subjective indicator that physiologic change is occurring.   However, improvement of peak amplitude is only useful as it reverts functional weakness, say post-operatively, or addresses disuse atrophy or lack of adequate strength necessary to carry out a task such as lifting.

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