It is widely accepted that therapeutic exercise encompasses a majority of treatment techniques employed in physical medicine. Although many practitioners of physical medicine such as chiropractors and occupational therapist prescribe or employ physical means to advance and accelerate the rehabilitation process of their patients, the field of physical therapy has always been on the leading edge of exercise specific programs.

Today’s therapist has received instruction and information in general exercise science with emphasis in exercise physiology, kinesiology (the study of movement) and biomechanics (proper body mechanics). This general knowledge is enhanced by a unique clinical focus on disorders, dysfunctions and neurological problems and their functional representation.

Exercise prescription choices must continually represent the specialized training of the therapist through a consistent focus of the human function. Exercise used at the therapeutic level must refine movement, not simply create general exertion with the hope of increased movement tolerance.

Moore and Durstine state: “ Unfortunately, exercise training to optimize functional capacity has not been well studied in the context of the most chronic disease or disabilities. As a result, many exercise professionals have used clinical experience to develop their own methods for prescribing exercise”.

The following four principles for exercise prescription are based on human movement and the systems upon which it is constructed. The intention of these four distinct categories is to break down and reconstruct the factors that influence functional movement, and to stimulate reasoning behind the critical thinking needed to develop a therapeutic exercise progression. Hopefully, these factors will serve the intended purpose of organization and clarity, thereby giving due the respect to the many insightful clinicians who have provided the functional and substance for the construction of this practical framework.

The four principle considerations for the therapeutic exercise prescription are the following:

• Functional evaluation and assessment of the condition of dysfunction and impairment.
• Identification and management of motor control.
• Identification and management of osteokinematic (movement of bones) and arthrokinematic ( movement of the joint in the body ) limitations.
• Identification of current movement patterns followed by facilitation and integration of synergistic movement patterns.

The four P’s are actually four simple words starting with the letter “P” that represent the four principles previously mentioned. They serve as quick reminders of the hierarchy, integration, and application of each principle. The question of what, where, when and how with respect to functional movement assessment and exercise prescription are answered in the appropriate order.

• Purpose. Functional evaluation and assessment .
• Posture. Identification of motor control.
• Position. Identification of osteokinematic (movement of bones) and arthrokinematic ( movement of the joints of the body ) limitations.
• Pattern. Integration of synergistic (muscles that work together to perform the same movement ) movement patterns.

There are also five simple questions that are considered primary to a persons exercise program.

• What functional activity is limited?
• What does the limitation appear to be - a mobility problem or a stability problem?
• What is the dysfunction or disability?
• What fundamental movement is limited?
• What is the impairment?

The functional evaluation process should take on three distinct layers or levels. Each of the levels should involve qualitative observations followed by quantitative documentation when possible. The levels are functional activity assessment, functional or fundamental movement assessment, and specific clinical measurement.

Unilateral and bilateral comparisons serve to demonstrate the functional problem to the patient at each level. Until the physical therapy evaluation, many patients think the problem is symptomatic and structural in nature and have no example of dysfunction outside of pain with movement. Moffroid and Zimmy suggest that, “ Muscle strength of the right and left sides is more similar in the proximal (attachments that are closest to the joint) muscles whereas we accept a 10% to 15% difference in strength of the distal (attachments that are farthest from the joint) muscles... With joint flexibility, we accept a 5% difference between degrees of measurements of the right and left sides.

If you have any questions or concerns please feel free to stop in at APTA and ask for advice or a consultation.

* Information referenced from “ Posture Magazine” volume 1 #3
* Resource Gray Cook, MSPT , OCS, CSCS