Reflections of rehabilitation professional: exercise

The word exercise is used so freely nowadays that it may well be that our clients do not necessarily share rehabilitation professionals understanding of the word. I hasten to say that I am not an expert – I have always been spoilt by having a team of physiotherapists to support my work, but I have been encouraged to reflect on exercise this month, particularly as Covid-19 is likely to leave many fatigued and weak.  Exercise can simply be classified as:-

  • stretching
  • strengthening
    • isometric
    • isotonic
  • aerobic

Stretching structures helps prevent damage to the musculoskeletal system when the system is suddenly stretched. They may also be prescribed after surgery or when structures have tightened up for whatever reason (e.g. arthritis). If performed consistently over time, there will be elements of aerobic exercise (see below) and minimal muscle strengthening.

Strengthening exercises may be prescribed for specific parts of the body e.g. to strengthen protection for a specific structure, particularly when the muscles involved might have weakened due to lack of use, injury or illness. A classic example is strengthening of the quadriceps muscle which weakens when there is arthritis of the knees – whether inflammatory or degenerative.

On other occasions, a generalised exercise programme will be recommended e.g. with chronic fatigue. In this situation – likely to be seen frequently after Covid-19 – exercises must be started very gently and gradually built up – the so-called graded exercise programmes.

Many people don’t understand the difference between isotonic and isometric exercise – a good example of the difference is when strengthening the quadriceps muscle.  Sitting with one knee extended in front of the body without moving the knee joint is an example of an isometric exercise as the knee joint is not moved. If however, the knee is bent, then straightened and this is repeated, then this is isotonic exercise. Both are effective in strengthening the quadriceps, but the isometric exercise minimises strain on the knee joint which is an advantage if the joint is (or at risk of becoming) inflamed e.g. with any form of arthritis.

Aerobic exercise is any exercise which raises the heart rate consistently over time and its importance was first described in the 1950s when the rate of heart attacks in bus conductors and bus drivers were compared – this showed that bus conductors who walked up and down bus corridors and stairs suffered many fewer heart attacks than the sedentary drivers – research that is so famous that you can google it (find it here).

Those who prescribe or recommend exercises have to give thought as to why individuals do not perform them either in the short term or longer term. In the short term, individuals often do not comply with a programme as they are:-

  • afraid that exercise will aggravate their underlying condition. This fear is compounded if they notice clicking – usually arising from the joints with poor bony and large ligamental support – e.g. shoulders, neck and spine – such clicking can be explained as excellent as it means that the joint movement is improving!
  • feeling unwell – they should be advised to continue their stretching exercises and ease off their muscle strengthening exercises. If very sick exercises will have to postpone until improvement in health begins; and then gradually return to their programme as they get better
  • feeling too busy – can set their alarm clock a little earlier and/or reduce their number of repetitions – but some exercise should be done every day!
  • unable to pace their activities – all customers should be advised that they do not know the results of today’s exercise until they wake up tomorrow – so don’t rush into vigorous activities unless so advised by a professional.
  • expecting magical results which are not forthcoming – may not have been warned by a referring health professional e.g. that exercise for spinal pain may not be curative but that exercise will make it easier to live their pain.

It is prudent to explain to those whose exercises are not being professionally supervised that some discomfort is to be expected when beginning to exercise unused muscles. Patients should stop if there is sharp or increasingly severe pain. The concept of ‘the burn’ is not medical – in fact, it is harmful. If in doubt, patients can stop, review the situation next morning when the effects of the previous day’s exercise can be assessed and if not in pain the exercises can be gradually increased.

For those who are advised to exercise through walking – ensure they have trainers to walk in – or else advise the purchase of sorbithane heal pads from a chemist to place inside walking shoes. This reduces the shock absorption for those with spine or lower limb problems.

Long-term failure to exercise must be mostly due to laziness. For those who are to be prescribed exercises for life –e.g. for spinal pain or osteoarthritis (OA), this must be explained fully – e.g. exercise is the management for spinal pain which has been repeatedly proven to reduce the risk of recurrences. Sometimes a little fear can be beneficial. Thus, those with OA knees who benefitted from quadriceps strengthening exercises who were randomly advised that they would be reviewed in 3 months, to check that they were still doing their exercises, had less knee pain than those who were not so advised [1]!

For therapists who are supervising their patients, there are often opportunities to explore other aspects of their patient’s lives – particularly their emotional lives – which can be very therapeutic. For many patients, their emotional lives are kept secret due to perceived stigma so these opportunities are really important.

I enclose a copy of the programme I have used over many years in case it is of interest – it is homemade and was not prescribed by professionals! But starting with the neck always seems to be omitted and it shouldn’t be.


Regular exercise is a fundamental part of any rehabilitation programme but its importance fades in patient’s minds as they begin to get better. Rehab professionals should concentrate on how to encourage persistence with programmes prescribed in an effort to prevent recurrent illness.

Fear that exercise will make their condition worse is frequently seen and needs to be vigorously tackled.

I am happy to discuss any of the issues raised in these reflections with colleagues who can email me andrew.frank1 AT  and head the email VRA – professional reflections.


Andrew Frank

Trustee and Past-Chair, VRA.


  1. Chamberlain, M.A., G. Care, and B. Harfield, Physiotherapy in osteoarthrosis of the knees. A controlled trial of hospital versus home exercises. International rehabilitation medicine, 1982. 4(2): p. 101-6.


Appendix – a personal exercise programme

Stage 1 – upright

  • Neck stretching
  • Spine stretching including shoulders
  • Knees bends

Stage 2 – all fours – hands and knees

Stage 3 – supine

  • Pilates exercises – rotating flexed hips
  • Sit-ups with rotation to include obliques.