The Myth of Exercise Prescriptions: Embracing Trial and Error

Having a clear answer to a problem before you begin is appealing, especially with exercise prescriptions that eliminate uncertainty. However, many therapists often ask their patients during follow-up visits, “How did those exercises work for you?” This highlights a common realization: things don’t always go as planned.

So, why do we view rehabilitation as prescriptive? Are we treating a condition, an outcome measure, or a unique individual with specific needs?

In my experience, rehabilitation is more about adaptability than rigidity. It should be a progressive and flexible process where we continuously adjust our approach based on patient responses. The intensity, frequency, and type of exercises can—and should—be tailored to individual requirements and goals.

Being comfortable with this adaptive mindset is crucial for effective movement-based interventions.

Assessment, too, is a refining process. As new information emerges, our understanding of the problem may shift, and our initial hypotheses might not hold true. Much of what we do involves informed trial and error.

The initial intervention serves as a starting point, a trial run to gauge effectiveness—essentially an educated guess. This notion of prescription often isn’t emphasized enough. It’s more of a suggestion than a hard rule.

Even in terms of physical adaptations, exercise is becoming less prescriptive. Research shows that adaptations can occur across various rep ranges and loads. The key factors for physical change often lie in effort and intensity—parameters that are frequently overlooked in rehabilitation research.

By embracing this flexible approach, we can better meet the diverse needs of our patients and enhance their rehabilitation journey.

Learning Process

Both therapists and patients should view therapy as a learning journey, not a sign of failure. The expectation that we must have all the answers from the start can undermine a therapist’s confidence and create unrealistic rehab expectations. Often, we need to experiment and navigate the balance between pain and functional improvement.

Data

Research data and clinical experience can sometimes feel blunt. It’s easy to assume that a patient’s specific condition, treatment, and outcomes will align perfectly with what’s reported in studies. However, the inherent variability in data means we often only understand its effects on our patients after applying it, not before.

A research paper may not accurately represent every patient’s unique situation. Studies typically sample only a fraction of the population, which is why we see confidence intervals. The real challenge in clinical practice lies in integrating data with individual patient experiences.

Roger Kerry’s insightful paper, “Expanding Our Perspectives of Research,” touches on this issue. We must also recognize that, with a modern biopsychosocial approach, we often lack clear prescriptions for many issues we encounter. One of my primary focuses is helping patients regain confidence in their bodies and activities. What’s the prescription for that?

Moreover, research papers frequently lack detailed methodology. Often, they refer to other studies or appendices that go unnoticed, leaving out crucial variables like intensity and rest periods. Consequently, being “evidence-based” in rehab isn’t always what people expect.

Clinical Practice as a Process

Unfortunately, clinical reasoning doesn’t capture attention like definitive treatment claims do. The complexities of practice often get overlooked, leading to bias and polarization. The real challenge is reconciling research with a patient’s individual presentation and personal beliefs.

This process is ongoing. Clinical reasoning and refinement should continue throughout a patient’s care, not just at diagnosis followed by a static prescription.

A thought-provoking comment from Twitter encapsulates this idea: “Evidence-based practice doesn’t mean throwing available evidence blindly at the patient; rather, it’s a delicate process of discovering the best-suited strategies for each individual.”

In my view, the best therapists aren’t those with the perfect plan but those who can adapt and respond effectively when things don’t go as expected. Flexibility and responsiveness to changing patient needs are what truly define great clinical practice.

Clinical Reasoning Framework

1. Clinical Reasoning
2. Research Data
3. Patient History
4. Physical Examination
5. Diagnosis
6. Application of Findings
7. Response Evaluation
8. Expected Outcomes
9. Timeframe for Results
10. Adaptation Strategies
11. Deciding to Stick or Twist
12. Identifying Necessary Changes
13. Conclusion

Key Insights

• Prescriptions as Suggestions: Understand that treatment plans are more like guidelines than strict rules.
• Refinement Through Response: Adjustments are made over time based on patient responses.
• Informed Trial and Error: The process is iterative, reflecting real-world variations in outcomes.
• Clarity in Research: Research often lacks clear directives regarding prescriptions.
• Skill in Adaptation: Adapting treatment is a skill that transcends simple flowcharts.
• Holistic Model: Emphasizing reasoning, response, and adaptation offers a more effective approach to patient care.

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