Article by: Doug Greenword, Clinical Lead – Exercise and Wellness Services
Clinical reasoning is the process by which the quality of clinicians shine.
It is the process of balancing:
- Diagnoses
- Functional deficits
- Pain reports
- Psychosocial factors
- Program goals (return to work, sport or life)
…to select what exercise, what dosage and what purpose at the stage of recovery.
Clinical reasoning is not about finding the perfect exercise – it’s a fluid process to determine the most appropriate treatment intervention at that moment.
Exercise prescription
Every exercise prescribed must answer three questions:
1) What exercise?
We must know the purpose for the exercise. Is it aiming to:
- Address an impairment, such as:
- Range of motion
- Strength
- Endurance
- Balance
- Motor control
- Build load tolerance
- Build functional capacity for a specific work-related task
- Address a specific pain mechanism, each with unique programming needs:
- Nociceptive – focus is on load tolerance and progressive overload
- Neuropathic – focus is graded exposure with pacing
- Central sensitisation – focus is on non-threatening movement and consistency to build confidence (R L Chimenti et al. 2018)
2) What dosage?
Here we can adjust different levers to achieve tissue adaptation, such as:
- Load
- Volume
- Tempo
- Range
- Rest
Dosage modification is how we progress but also make the exercise functional to the specific work-related task.
3) Why now?
This is because timing matters:
- Early rehabilitation – focus on improving confidence and load tolerance
- Mid rehabilitation – focus on progressive overload
- Late rehabilitation – focus on task specificity
What may be limiting function
We must form a strong, evidence-based hypothesis on what may be limiting function. We do this by asking ourselves, is the limitation due to:
- Impaired load tolerance?
- Manual handling/coordination?
- General deconditioning?
- Fear avoidance behaviours relating to pain?
For example, a client avoids lifting, not due to a strength deficit, but because of fearfulness behaviours relating to pain. Thus, in this case, a strong education and self-management plan are required, where maximising strength gains won’t fix the issue alone.
Exercise progression
Progression can be achieved through exercise selection and dosage modification, noting that this isn’t only achieved by increasing load.
Here it is important to convey to clients, pain reflects perceived threat, not damage. It is how the body communicates that the load is exceeding the current capacity of the tissue.
Progressive overload, ensuring recovery time and noting symptom patterns can all help to manage symptoms and exercise progression. Therefore, progression is driven by load tolerance, not symptom elimination.
Flare-up management
Symptom fluctuations are a normal experience when building load tolerance, however flare-up management plans can be set that are geared towards not losing momentum with functional progression. They are to focus on:
- Avoiding overreaction to pain spikes and unnecessary regression
- Modifying the dosage, not the intent
- Maintaining exposure to feared tasks
- Education around expected symptom fluctuation (Booth et al. 2017)
Red flags
Within a Functional Restoration Program, strong reasoning is required to determine when it’s safe to continue, modify the program, hold or refer. For example:
🚩Delayed onset muscle soreness is a normal nociceptive adaptation
🚩Unpredictable pain under low load warrants a modified approach focusing on central sensitisation-related education
🚩Progressive neurological symptoms warrant referral and medical attention (Low Back Pain Clinical Care Standard 2022)
References
- A Mechanism-Based Approach to Physical Therapist Management of Pain, Physical Therapy (Oxford Academic), R L Chimenti et al. 2018.
- Exercise for chronic musculoskeletal pain: A biopsychosocial approach, Musculoskeletal Care, Booth et al. 2017.
- Low Back Pain Clinical Care Standard, Australian Commission on Safety and Quality in Health Care, 2022.