Framework for exercise prescription (FEP)
The FEP (Fig. 1) uses chronological, but flexible phases to aid in understanding exercise prescription for patients throughout five stages of rehabilitation including the (1) tissue healing phase; (2) mobility phase; (3) performance initiation/stabilisation and motor control phase, (4) performance improvement phase; and (5) advanced skill, agility and coordination phase.
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(Anemaet & Hammerich, 2014)​
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ROM exercises can include;
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Passive range of movement (PROM) – indicated when patients lack an ability to perform AROM or a medical restriction. There is minimal mechanotherapeutic effect and therefore it is the least desirable form of ROM exercise, especially in later stages of rehabilitation as there is no voluntary muscle contraction to prevent muscle atrophy (Khan & Scott, 2009). It does however still provide some tissue stress so does have some benefit, albeit smaller than other ROM exercise options.
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Active-assisted range of movement (A-AROM) – indicated when the patient is permitted to contract muscles but lacks the strength to go through full ROM without assistance. During A-AROM, sensory feedback is offered and there is more stress placed on the tissues and circulation to the working areas is increased.
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Active range of movement (AROM) – AROM is desirable when patients are able to move through a range without external assistance as it enhances coordination and motor control because of the movement involved.
Muscle contraction
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The aim is not to increase strength but rather focus on increasing local circulation to improve tissue healing.
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Unloaded concentric and isometric exercises are ideal
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The frequency and intensity of muscle contraction should have an inverse relationship; frequency high and intensity low (20-30 per hour; ~25% maximum voluntary contraction (MVC).
1. Tissue healing
During this first phase, ROM and isometrics are the most beneficial types of exercise. It is important to understand that controlled and progressive mobility is indicated due to tissues remodelling along the lines of tensile strength (Prentice, 2011).
The timeframe at which tissue healing occurs depends on the type of tissue and the extent of the tissues damage.
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Inflammatory phase: What does this mean for exercise prescription at this phase?
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During the inflammatory phase following muscle injury, exercise aims to control the inflammation through muscle contraction, in a pain-free range of motion to help minimise fibrosis (Anemaet & Hammerich, 2014). If pain is reproduced in this stage, it may promote further tissue damage, which can promote further inflammation and nociception.
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This can be conducted in a PROM, AROM or A-AROM.
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It is important that muscle contraction is promoted to gradually increase stress on tissues, allowing mechanotransduction and Wolff’s Law to be employed; tissues respond to the stressors placed upon them. Additionally, Bayer, Magnusson and Kjaer (2017) showed that early muscle injury rehabilitation improves return to sport timeframes.
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Proliferative phase: What does this mean for exercise prescription at this phase?
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It must be remembered maximum strength hasn’t occurred during proliferation rather, the tissues integrity has been restored with type 3 collagen before it is replaced by type 1 collagen in the repair and remodelling phases. Therefore, ROM and strengthening exercises must be continuously monitored for aggravation of symptoms or signs of inflammation.
Repair and remodelling phase: What does this mean for exercise prescription at this phase?
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As the remodelling phase begins, more aggressive active range of motion and strengthening exercises should be incorporated to facilitate tissue remodelling and realignment along the lines of stress.
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Range of motion and muscle contraction exercises are valuable interventions, although the risk of further injury still exists and can ultimately delay tissue healing. Therefore, the intensity should be low, and the duration kept short, with continual monitoring of patient symptoms. A high frequency does however facilitate increased circulation and promotes collagen alignment along lines of stress, so progressively increasing intensity is still important.
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Using pain as a guide to drive rehabilitation can be useful (Prentice, 2011). Pain is usually quite high initially and typically subsides as the healing process progresses. If there are signs of increased inflammation or pain, the load may be too high for the current capacity of the tissues.
ROM exercises can improve circulation, assist with proprioception, lengthen tissues, enhance pain inhibition, or aid in applying stress to tissues, especially when completed actively (Anemaet & Hammerich, 2014).
ROM exercises include:
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active ROM
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active-assisted ROM
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passive ROM
Stretching exercises can be used to improve mobility and should be held from 6 seconds – 2 minutes. It is imperative that stretching exercises should be followed by actively using the new ROM to ensure that new ROM is maintained.
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passive
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static stretching
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prolonged mechanical passive stretching
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active
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using autogenic inhibition
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reciprocal inhibition
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2. Mobility
Some patients can skip straight to this phase if signs and symptoms of inflammation and if initial proliferation stages have occurred. It is imperative that signs of inflammation have disappeared, is showing signs of decreasing, or are not worsened with the mobility activity for greater than 24hours. Exercises in this phase can include ROM exercises, stretching exercises, or even eccentric exercises for lower limb mobility (O'Sullivan, McAuliffe & Deburca, 2012).
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Determining which ROM exercise to use is dependent on patient irritability and what type of mobility impairment is present (Brody, 2012). For example, a patient may present with restricted range due to joint restrictions, pain, muscle or oedema, or hypermobility or joint instability. If there a mobility restriction, it should be determined if it due to an arthrokinematics limitations (how the joint moves - generally treated with a joint mobilisation intervention), or a osteokinematic limitation (how the bones move - generally treated using ROM exercises).
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Forcing joints through bony restrictions, recent trauma, acute inflammation or infection is contraindicated. Furthermore, mobility exercises are not required in all patients, e.g. patients with a spinal cord injury may not benefit from stretching of the hamstrings as they might utilise them for stability in sitting.
3. Performance initiation
Patients are able to proceed directly to this stage if signs of inflammation absent, are decreasing, or are not worsened with the introduction of these exercises for greater than 24hours. Patients should however be in proliferative or remodelling stages of healing. Full mobility is not also not required to begin this stage, but a pain-free range to exercise is essential.
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Exercises in this phase are completed daily, with a high number of repetitions and a low weight (<50%1RM for isotonic exercises OR 25-50%MVC for isometrics)
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When a patient is working at <50%1RM, it allows the body to maintain a predominately aerobic supply of energy and promotes less chance of injury.
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Improving muscle initiation; ​
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Successful muscle initiation requires neural, vascular, metabolic and muscular contribution and is concerned with the physiological sequence of events of a muscle contraction.
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Muscle contraction and initiation are essential to enable full tissue healing as they induce tissue adaptation, introduce stress and aid in joint stability and motor control for functional activities. Concentric, eccentric and isometric exercises can also be used in this phase. To distinguish their use between phases, the dosage parameters are manipulated.
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To decide the most appropriate muscle action, apply the principle of specificity – i.e. does the muscle need to act eccentrically/concentrically/isometrically? Does it need to work in an open-chain versus closed chain environment?​
This phase requires specific and accurate prescription dependent on the functional tasks that are required – this will include what components are most involved in this functional task. For example, strength, hypertrophy, power or endurance and muscle contraction type. This concept is further discussed here.
Then, consideration of the contextual factors of the patient is considered that can impact on exercise prescription – what environmental (i.e. work demands) and personal factors (i.e. unsupportive family, work ethic) are present in the patient’s life – do these positively impact or negatively impact rehabilitation? When these are contemplated, it allows the clinician to improve their exercise dosages to compliment these factors by adjusting for daily activity loads (Brody, 2012). Click here for definitions and the parameters best suited to improving strength, hypertrophy, endurance or power.
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While there is the crossover effect within these 4 types, it is important to apply the principle of specificity to the patient’s functional limitations to determine the training goal, as this will result in the best outcomes (Mangione, Miller & Naughton, 2010). For example, a patient may have sufficient strength to reach above head to do the washing, but may not have the dynamic endurance to complete a full load of washing or the quadriceps endurance to maintain standing. Another example may be a patient may have sufficient strength to ascend a step, but lacks the power to do so.
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Once the training goals component has been identified, the muscle action (concentric, eccentric or isometric), load, reps & sets, positioning, order, rest periods, velocity and frequency parameters are decided. Although there are variances between authors, similarities are present.
4. Performance improvement
5. Advanced coordination
Once patients have progressed through rehabilitation and have approached near-normal muscle performance without signs of tissue injury or mobility limitations, they begin to integrate components from previous phases to higher-level coordination and skill movements by adding plyometrics or manipulating body position, surfaces, resistance, agility or coordination.
NOTE: This stage is not solely for those returning to competition or sport.
For example, adding perturbations during single leg landing drills for those with balance deficits
Plyometric exercises
o Produce power through combining strength and speed which utilise the physiological properties of stretch reflexes and the musculotendinous-junction (MTJ) to increase motor unit recruitment and ultimately force production (Turner & Jeffreys, 2010). Plyometric exercises act as injury prevention, can improve joint ROM and flexibility and especially important for movements requiring a quick transition from concentric to eccentric muscle action.
