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1st Apr


The Importance of Specific Exercise Dosage

Although injuries to muscles are common in sports, the majority of painful musculoskeletal conditions stem from compromise of tissues such as tendons, ligaments, joint capsules, fascia, cartilage and underlying bone, spinal discs, and associated nerves and blood vessels. These tissues have low metabolism, limited nutritional supply, and take much longer to heal than muscles.

However, most exercise programs focus on stretching and strengthening of muscles, with little regard for what the underlying connective tissues need, in order to heal. Focusing the exercise solely on “tight or weak muscles”, can not only deprive the underlying strained or compressed tissues of needed stimulation to heal, but worse, easily compromise them further, delaying or preventing optimal healing.

Early in rehabilitation, it is important to avoid applying excessive stretch or compression to tissues. However, complete rest and immobilization deprives the tissues of energy needed to heal, and will delay the recovery. The type of exercise and dosage prescribed will depend on the tissues involved, and therefore a thorough evaluation is first required. Early on, exercises are chosen to reduce the pain, and whenever possible be performed with motion, to remove swelling and waste products, and provide oxygen and nutrients to the tissues, and be performed in the most comfortable positions. Movements often must at first be small, and repeated slowly to the breathing rate, with a large number of repetitions, often in excess of 30, which may be repeated several times per day. Increased pain and/or swelling over the next several hours to 24-48 hours may indicate excessive exercise dosage. Isometric exercises (contraction without motion) should usually be avoided at first, as they tend to cut off circulation and increase painful muscle guarding.

As light resistance may be added, coordination is emphasized to establish a normal movement pattern, through gradually increasing range of motion and speed of movement, and endurance training with high repetition exercise favors the deep stabilizing muscles, and improves capillary growth.

The next phase of rehabilitation exercise aims to increase the tissue’s tolerance to stretch or compression, to meet the demands of daily activities and/or sports. This now requires gradually progressed exercise to therapeutically stress the involved tissue. Weight bearing exercise now becomes more the norm, but caution must be exercised with e.g. arthritic joints, which must not be excessively compressed. Pain and swelling remain signs of over training. The exercise resistance may over time be increased to also promote increased strength, and joint protection. Functional movement patterns may now also be incorporated.

Tissue training is specific. Cartilage in joints, discs in the spine, bone, ligaments and tendons all require different training. Even muscles need specific training, depending on what they are asked to do with activities. Every condition and every individual is unique. Therefore, for exercise to have the optimal effect, and not be destructive, and to also help each person attain his or her goals, it is important to get the right exercise prescription.

One reason why there is such limited understanding of exercise to promote tissues’ tolerance to strain, including to a large extent within our field of physical therapy, is that much of the research performed in exercise science has been on healthy individuals. However, specific tissue training is the focus of methods such as Scientific Therapeutic Exercise Progressions (STEP), and Medical Exercise Therapy (MET), practiced by specially trained physical therapists around the world. We have been fortunate to get our orthopedic manual therapy training through the Ola Grimsby Institute, headquartered here in San Diego.

Best wishes for an enjoyable spring and continued good health,


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