Therapeutic Exercise: Is It “Therapeutic”?

DeLateur defined therapeutic exercise as the prescription of physical movement aimed at correcting a deficit, improving musculoskeletal function, or maintaining good physical condition. These exercises may range from selective activities targeting specific muscles or body regions to general, vigorous activities that can elevate an individual to optimal fitness levels.

Goals of Therapeutic Exercise

• Mobilization

• Improvement of stiff muscles, tendons, and fascia

• Joint mobilization

• Enhancement of circulation

• Improved respiratory capacity

• Better coordination

• Reduced stiffness

• Improved balance

• Promotion of relaxation

• Increased muscle strength and, where possible, attainment and maintenance of maximal voluntary contraction (MVC)

• Improved exercise performance and functional capacity (endurance)

The last two goals reflect overall physical fitness, characterized by good muscle strength combined with endurance. Regardless of the initial exercise type prescribed for treating a specific condition, the ultimate goal of rehabilitation is to achieve an ideal fitness level at the end of treatment whenever feasible.

Medical Assessment

Before beginning an exercise program for fitness or therapeutic intensity, patients should undergo a medical evaluation by a physician, including full medical history, detailed physical examination, and adequate laboratory testing. In cases with cardiac history, it is important to exclude valvular heart disease, ventricular hypertrophy, dangerous arrhythmias, and benign hypertension.

Approach Theories

Therapeutic exercise aims to achieve and maintain physical fitness and falls into the following major categories, each with a specific objective:

• Endurance exercise

• Resistance exercise

• Flexibility exercise

Endurance Exercise (Aerobic Training)

Three variables define endurance training: frequency, intensity, and duration. According to the American College of Sports Medicine (ACSM):

• Frequency: 3–5 days per week

• Intensity: 64/70–94% of maximum heart rate (HR max), or 40/50–85% of VO₂ reserve (VO₂R) or heart rate reserve (HRR)

• Duration: Continuous or intermittent aerobic activity for 20–60 minutes (minimum total of 10 minutes in bouts throughout the day). Lower-intensity activity requires longer duration (≥30 minutes), while higher-intensity activity calls for at least 20 minutes. Moderate-intensity, longer-duration activity is preferred for non-athletic adults, as full fitness is better achieved with longer sessions and lower risk compared to high-intensity workouts.

Application in Healthy Individuals

Exercises that engage large muscle groups, generally aerobic, and performed continuously are recommended. Examples include walking, jogging, dance, stair climbing, cycling, swimming, rowing, skating, jumping, aerobics classes, and cross-country skiing.

Maximum heart rate is estimated as: HR max = 220 − age

A session should include:

1. Warm-up (~10 min): combining stretching and progressive aerobic activity to raise HR toward prescription

2. Endurance exercise (20–60 min)

3. Cool-down (5–10 min)

Application in Patients

High-risk patients, especially with cardiac or respiratory conditions, should engage in a less intense program—heart rate should not exceed 50–60% of VO₂ max. In absence of testing, a maximum HR limit of 130 bpm is prudent. For elderly or at-risk patients, intensity, frequency, and duration should be individualized based on clinical evaluation.

Progression should be built into the program to ensure continued gains—either by increasing duration or intensity.

Resistance Exercise

Resistance training increases strength, walking speed, endurance for stair climbing, balance, lean body mass, and decreases regional and total fat mass. It positively affects risk factors in coronary artery disease, osteoporosis, diabetes, and cancer. It may also reduce low back pain and occupational back injuries.

Forms of resistance training include:

• Isotonic (dynamic movement with constant load)

• Isometric (static contraction without joint movement)

• Isokinetic (controlled speed exercise via specialized equipment)

Typical prescription:

• Untrained individuals: resistance sessions 2–3 days/week full body

• More advanced: 4–6 days/week focusing on 1–2 muscle groups per session

Types of Resistance Exercise

Isotonic Exercise

Dynamic exercise combining continuous load with unconstrained speed; movements occur through ranges as muscles shorten or lengthen. Typical in weight training. Repetitions combine concentric, eccentric, and stabilizing isometric contractions.

Isometric Exercise

Static muscle contraction without joint motion or muscle length change. Examples: pushing against immovable objects or holding static poses. Effective for static muscles and useful when joint movement is contraindicated. Caveat: increases blood pressure and heart rate rapidly.

Isokinetic Exercise

Movement controlled at a constant angular velocity, with variable resistance. Performed using specialized machines (e.g., Cybex, Nautilus), providing maximal tension across the range. It requires high motivation and is limited by cost and availability.

PNF (Proprioceptive Neuromuscular Facilitation)

A framework of resisted muscle contractions aimed to maximize strength. Suitable for patients with upper motor neuron lesions and spasticity, and also to initiate muscle activation in partial peripheral nerve injuries.

Flexibility Exercise

These exercises help improve and maintain range of motion in one or multiple joints. They should be performed slowly and progressively into stretch, with gradual progression. Three main techniques:

Static Stretching

Muscle is stretched to mild discomfort and held for 15–30 seconds. Features: low injury risk, shorter duration, simple to perform. Most commonly used form.

Dynamic Stretching

Involves controlled bouncing movements. May cause muscle strain or injury if improperly performed.

PNF Stretching

Alternating contraction and relaxation of agonist and antagonist muscles through a series of movements. Delivers maximal flexibility gains but typically causes some muscle soreness and requires a trained therapist and time.

Stretch recommendations:

• 2–3 times weekly

• 2–4 repetitions per stretch

• Static holds: 15–30 seconds; PNF: 6-second contraction followed by 10–30 seconds assisted stretch

• Integrate into warm-up and cool-down

• Warm-up should (pre‑stretch) elevate muscle temperature

• Yoga, tai chi, and Pilates are options for improving flexibility

Range-of-Motion Exercises

Active-Assisted Range of Motion (AAROM)

Used when patients have weak muscles or pain limits movement. Avoid forcing joints or tissues past pain threshold.

Passive Range of Motion (PROM)

Used when patients cannot move actively. Involves slow manual or mechanical stretching to prevent joint stiffness and muscle contracture. PROM is typically part of warm-up or cool-down in motion-limited patients.

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