Journal of Bodywork & Movement Therapies (2015) 19, 352e356

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PREVENTION & REHABILITATION: EDITORIAL

Designing effective corrective exercise

programs: The importance of dosage

In this editorial, two papers that appear elsewhere in this they will improve on their knee pain or golf swing until they
issue, are reviewed. One repetition maximum bench press have seen a specialist who can identify the cause of the
performance: A new approach for its evaluation in inex- problem. When they do consult a specialist e perhaps a
perienced males and females: A pilot study, by Bianco manual therapist of some description and a Golf Bio-
et al.; and Muscle strengthening activities and fibromyal- mechanic, the individual can be assessed, the problem
gia: A review of pain and strength outcomes, by Nelson. identified and they move to the next stage and become a
Both papers, as is evident from their titles, discuss strength conscious incompetent e they now know why they are in
training and how it may be applied to populations of varying pain or playing badly.
athletic ability or requirements. The next step is to activate the correct muscles in the
In the design of an effective corrective exercise program kinetic chain, or to change the grip on the club, or the
(or indeed any conditioning program) an optimal outcome is stance, or the head position etc in order to create
PREVENTION & REHABILITATION: EDITORIAL

dependent on training the appropriate physiological pa- competence. This means that the patient or student has
rameters. In the rehabilitation field, for many years now, now reached the penultimate stage in the process by
there has been an over-emphasis on which exercise to do becoming a conscious competent; if they track their leg
and often also the technique, with little focus on the acute with biomechanical precision, their knee pain goes, if they
exercise variables familiar to strength and conditioning keep their head down and their grip correct, they strike the
coaches; the repetitions, sets, loads, tempo’s, rest-periods ball cleanly. but the challenge is building in the repeti-
and program periodization. The upshot of this situation is tions and, in particular, the appropriate loading parameters
that patients may be given exactly the “right” exercise, for to change the original behavior so that it becomes uncon-
the wrong duration to have the desired effect. Indeed, the scious e the person doesn’t even need to think about it. At
literature that has investigated the efficacy of motor con- this point a new motor engram is stored; they have reached
trol intervention may be skewed toward a negative the pinnacle of the model and can be considered an un-
outcome for this reason. conscious competent.
What this points to is the notion that the model of the The issue with motor control interventions to date, is
four stages of competence in behavioral change (see that an often inappropriate duration of loading, which
Wallden, 2013a,b) fails to reach its highest peak. For targets the wrong motor fibers (usually the more phasic,
clarity, when a patient presents at the clinic or a person type 2A fibers) is prescribed, meaning intervention out-
takes up a new movement skill, such as the golf swing for comes are likely to be ineffective.
example, they are rarely highly competent; instead they The issue here being that, while the type 1 fibers will
show a level of incompetence. Perhaps their knee is sore activate immediately, the dominant energy systems are the
because they have a descending pronation pattern through type 2 energy systems e in particular the type 2A system
their leg (see accompanying practical article titled: Don’t (For clarity, it is unlikely that a patient would get much
get caught flat footed e how over-pronation may just be a activation of their type 2b fibers unless the loading itself
dysfunctional model) or they keep topping, hooking or was very high). As can be seen in Fig. 1, the type 2A fibers
slicing the golf ball. will activate early and will be the dominant energy system
In these two examples respectively, they don’t know until the 3e5 min window, when the type 1 fibers become
why their knee is hurting, or why their golf drive is off the the dominant system. This is why even what some may
mark, so they are not conscious of what to do to put it consider very basic low-load exercises become fatiguing so
right. They are what could be defined as unconscious in- quickly e because anaerobic metabolism is being utilized in
competents (the base level of the model). It is unlikely the recruitment of type 2A fibers.

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1360-8592/ª 2015 Elsevier Ltd. All rights reserved.
Prevention & rehabilitation: Editorial 353

At the high-end of performance, or even for those who

are attending a gym for the first time, it is useful to know
what the individual’s 1-rep max (1-repetition maximum) is
for a given group of exercises. In other words, the maximal
load that the individual can manage involving the pre-
scribed movement pattern (Bianco et al., 2015). This allows
the trainer, or strength and conditioning coach to be able to
prescribe exercise-loading parameters that will achieve the
desired response.
For example, if someone is learning a new exercise, or is
not well conditioned, or requires a strength-endurance
stimulus, a repetition range from 12 to 20 repetitions may
be desirable. To understand the approximate load required
to achieve effective adaptation, this can be calculated at
around 70% of the 1 rep max (or 1 RM) or 70% of the load
they could lift as a maximal one-off lift. If the maximum
load they could squat is 100 KG, then to target a strength-
Figure 1 Energy Systems: This classic diagram, redrawn from
endurance response between 12 and 20 reps, this should be
Telle (1995), illustrates how the 3 key energy systems, which
performed with 70% of that 1 RM e or 70 KG as load.
correspond with the 3 key fibre types, are utilized in perfor-
Reciprocally, if someone is trying to build power,
mance. This helps the clinician to understand how to effec-
without incurring too much hypertrophy stimulus then they
tively design exercise programs to target different muscle
may, for example, require a repetition range and load
groups and specific fibers within those groups.
which can be only moved between 3 and 4 times (see
Fig. 2). This range will tend to engage the faster twitch type
In order to train the type 1, or postural muscle fibers, it
2B fibers, important for speed or power athletes; but also
is key, then, that the total time under tension is a minimum
important in some activities of daily living and as part of a
of 3e5 min (see the accompanying practical article for an
thorough rehabilitation process, as outlined in Wallden
example of how this can be applied).
(2013b). To calculate these loads, it is useful to know the
Most motor control trainings or research studies do not
1 RM. Taking the same example of someone who can squat
take these acute exercise variables into consideration, so
100 KG as their maximum one-time lift (their 1 RM), they
the type 2A fibers become trained, but they also fatigue

PREVENTION & REHABILITATION: EDITORIAL

would now pick a load equivalent to 90% of their 1 RM e in
quickly (as shown in Fig. 1), so cannot effectively stabilize
other words, 90 KG e and this should be an effective
the joint(s) they span for more than a few minutes. The end
training stimulus to train them in the 3e4 rep max range for
result is an intervention that sees the patient reaching
power (Chek, 1995).
conscious competence, but never attaining unconscious
competence e or full recovery. Clinically these patients tend
to present with a typically “shifty” behavior, where they
fidget, lean against things, find their pain is better when
moving than when still, and that it is absent first thing in the
day, but comes on later when the fast twitch (or outer unit
musculature) has finally run out of compensatory capacity.

The science behind program design

By far the most common number of repetitions for a patient

to be given for a rehabilitation exercise is “About 10”. If
time-travel were possible and a clinic could be attended
100 years back, it is likely that the most common number
would have been “About a dozen”.
However, in the 21st Century, there is the advantage of a
huge body of literature around the effect of doing an ex-
ercise, just 10 times versus 20 times (the repetitions),
together with the effects of intensity, time-under-tension, Figure 2 Program Design Summary: This image encapsulates
number of sets, rest periods between sets, loading pa- some of the key tenets of program design; illustrating how
rameters, speed of contraction, motor sequencing, speci- there is typically an antagonistic relationship between repeti-
ficity and so on (Chek, 1995). It is known, for example, that tions and sets, between duration and intensity and so on, when
10 repetitions is a loading parameter that offers optimal designing effective conditioning programs; and the relationship
hypertrophy (assuming the load is sufficient, so that the to hypertrophy, which may, or may not be desirable. The
patient can only perform 10 repetitions before complete numbers along the base of the diagram indicate the repetition
fatigue), but that this number of repetitions creates a range the patient is likely to be working in, with 8e12 repeti-
lower capacity for motor learning, compared to 20 repeti- tions being the classic range considered optimal to induce a
tions, for example (see Fig. 2). hypertrophy response (Wallden, 2008).
 354 Prevention & rehabilitation: Editorial

Similarly, hypertrophy may also be a desirable phase in variables, serum growth hormone levels can increase by as
both rehabilitation and performance conditioning (Wallden, much as 20-fold. Since growth hormone is key in entering
2013b) and, for this, training with loads at around 80% of the deep, restorative, delta-wave phase of sleep usually
the 1 RM is appropriate. These loads should allow the in- compromised in FM, it is entirely possible that the muscle
dividual to complete 8e12 repetitions which is right in the strengthening activities assessed by Nelson (2015) helped to
middle of the hypertrophy zone (see Fig. 2). drive GH levels higher. Similarly, Ratey & Hagerman (2008)
In the accompanying paper which describes a novel way explain that simply partaking in steady-state exercise, such
to assess the 1 RM in the bench press, Bianco et al. (2015) as cycling or treadmill running (classic “cardiovascular”
use a percentage of body mass to calculate the load an exercise) results in more of a catabolic effect, whereas
individual should lift (up to 25 repetitions) entered into an including some high-intensity sprints into the cardiovascu-
equation to help calculate 1 RM. This novel approach helps lar training (a form of interval training) increases growth
bodyworkers and movement therapists to safely and hormone secretion dramatically. Adding a single bout of
effectively predict their patient or athletes’ 1 RM. sprinting (high-intensity exercise) to a run or ride, for as
As Bianco et al. (2015) explain, this may have important little as 30 s, generated a 6-fold increase in GH. Poliquin
ramifications both for the athlete and for those inexperi- also describes how the release of cortisol with cardiovas-
enced in the gym, such as the patients with Fibromyalgia cular exercise tends to ramp up dramatically after 20 min of
(FM) as described in the Nelson (2015) paper. activity; inducing a fight-flight, catabolic state and, for
Nelson (2015) provides compelling evidence that, not those with breathing pattern disorders, adrenal fatigue or
only is exercise important, but specifically that resistance anxiety, an increased risk of exacerbation. Looking at it
training, or muscle strengthening activities can be of great from the opposite perspective, research into gym-based
benefit to the Fibromyalgia population. It is possible, functional movement assessment showed that Individuals
therefore, that patients with similar and related conditions who exhibited biochemical and biomechanical signs of BPD
may also benefit., chronic fatigue and post-viral fatigue. were significantly more likely to score poorly on movement
There may be many reasons why muscle strengthening screening tests (Bradley and Esformes, 2014). Overall then,
activities work well for the patient with Fibromyalgia. Just as it seems plausible and likely there may be a bidirectional
it’s more aerobic counterpart, muscle strengthening (or effect of exercise on breathing pattern and breathing
resistance training) can facilitates circulation, especially to pattern on exercise pattern; and since BPD may be both a
the working myofascial chains; it can improve breathing component of and causative in FM this may help to explain
pattern either reflexively through improved biochemistry why the results of Nelson’s (2015) enquiry into resistance
(described below) or with additional coaching e especially if based training interventions were so positive.
PREVENTION & REHABILITATION: EDITORIAL

this is worked on in recovery as a strong parasympathetic Indeed, in Fig. 2 this phenomenon is illustrated, showing
rebound after activity can facilitate the rest/digest abdominal how the higher the number of repetitions, the greater the
breathing pattern and can push the body into a repair mode hormonal (catabolic) stress. The lower the repetitions (and
(Chek, 1995). However, in addition to these benefits of general therefore heavier the load), the more the neural stress.
exercise muscle strengthening activities may have other Hence, for those in a state of fatigue, resistance training
benefits, which include increasing growth hormone output, programs may be very effective; and more-so the more
reducing circulating inflammatory markers, minimizing adre- they tend to stay towards the higher-intensity left side of
nal stress and, importantly, teaching the patient that pain is the diagram.
not always a negative indicator; that it can be a part of growth Since exercise can be effective in managing anxiety
and development, and that it will ease with time. (Ratey and Hagerman, 2008) and this can be effective in
It should be stressed that there are still many people e managing BPD (Chaitow, 2004) this could set up a positive
including bodyworkers and movement professionals e who feedback loop to also benefit patients with FM. Addition-
believe that resistance training is primarily for aesthetic ally, as Chaitow (2004) explains, the general deconditioning
gains and brute strength, but has no place in health. This often associated with BPD and with fibromyalgia (Nelson,
may be a view that is skewed by an era of fixed-axis ma- 2015) results in a lower aerobic threshold, meaning that
chine training, which probably caused more issues than it patients enter a state of oxygen debt sooner. This may
solved biomechanically. But functional exercises are those initiate a cascade of events resulting in anxiety, hyper-
exercises that serve the function for which they are ventilation and increased production of lactic acid, pyru-
intended; and for most people that would be exercise that vate and other waste metabolites within the muscles,
increases their sense of well-being, their performance ca- thereby increasing pain, soreness and the tender point/
pabilities and their overall health. Anyone in pursuit of such trigger point development that defines fibromyalgia.
an objective would, therefore, be likely to include muscle Beyond growth hormone, there is also evidence that
strengthening exercises as part of their program. higher intensity exercise increases ghrelin production in an
Nelson (2015) concludes her paper by stating that intensity dependent manner (Fathia et al. 2010) and that
“Future studies must provide explicit details with regard to low levels of ghrelin are associated with some of the
frequency, intensity, duration and type of muscle symptoms of FM (Tander et al. 2007).
strengthening exercise”, and he is right. One of the the-
ories behind Fibromyalgia has its basis in a dysfunctional You can only train as hard as you rest
interplay between growth hormone (Chaitow et al. 2005)
and other anabolic hormones, including IGF-1 and ghrelin
In athletic conditioning, the concept of over-training or
(Tander et al. 2007). Poliquin (2006) explains that if resis-
pattern-overload has been broadly accepted for some time;
tance training is conducted using optimal acute exercise
Prevention & rehabilitation: Editorial 355

and in clinical practice, its counterparts repetitive strain stress causing controlled damage, which initiates a healing
injury and cumulative trauma disorders (Check, 2000; response for that tissue to re-grow stronger. Too much
Solomonow, 2012) are also well-established phenomena. positive stress (overtraining) can result in too much damage
In 2003, this author proposed a model to help explain (the rate of trauma has exceeded the rate of healing) and
why some people with poor posture, or poor technique, or an inability to recover, injury or illness may ensue. From
poor lifestyle choices (as examples) may seem to get by just this perspective, the rest between training sessions is
fine, while others seem to fall prey to such minor, but important to consider; as well as the resting of certain
repeated, misdemeanours (see Fig. 3). This model proposes movement patterns or muscle groups.
that the cumulative stressors on the system (biomechan- Beyond this, the rest periods utilized between the sets
ical, biochemical or limbic emotions) naturally increase as of any given exercise will also dictate the effect that the
the individual passes through life; but that these stressors exercise has. Fig. 4 illustrates how the 3 core fiber types
are always responded to by the healing rate, which typi- (there are many more than 3, but there are 3 accepted
cally starts high as a child, but declines as we age. For “general” fiber types) react to work.
example, according to Poliquin (2006), growth hormone
levels decrease by 14% per decade from the age of 20 years  The fast twitch type 2b fibers react to work by fatiguing
onward. The stressors are manageable largely by optimizing very rapidly e indeed within around 8 s their capacity is
the biomechanical profile e and other lifestyle choices, to all-but spent, which is why it is said the fastest sprinter
some degree. The healing rate, is manageable primarily across the 100 m finish is not the athlete who is accel-
through lifestyle choices, but also through optimizing erating fastest, but the athlete who is decelerating
biomechanical function. slowest. These muscle fibers require a minimum of 5 min
The role of the rehabilitation specialist is to optimize to recover.
both the healing rate (which means encouraging what can  The fast twitch type 2a fibers react to work by fatiguing
be done to increase it) and the damage rate (which means within 60e120 s of work (depending on intensity and
encouraging what can be done to decrease it). It is only conditioning level), but will recover quicker e within
when the rate of damage exceeds the rate of repair that 2e3 min in general.
the tissue (or organ) will fail.  The slow twitch muscle fibers (those most targeted in
This understanding can be useful in getting clarity on the early-phase rehabilitation) will recover very rapidly e
subheading of this section; You can only train as hard as you almost fully within 1 min.
rest. The purpose of training is typically to create a positive
The key difference in training these muscle fibers is

PREVENTION & REHABILITATION: EDITORIAL

that, in general, to target the faster muscle fibers, suffi-
cient rest periods are required. But in order to target and
condition the slow twitch, type 1 fibers, insufficient rest is

Figure 3 Cumulative Microtrauma Model: Cumulative

microtrauma, by its nature, accumulates throughout life.
However, it is always competing with the body’s ability to
repair. When the rate of damage exceeds the rate of repair,
this is when the tissue, organ or system fails. Ideally, this oc- Figure 4 Fatigue & Muscle Recovery Times: This image,
curs only at the end of the individual’s genetic potential. redrawn from Telle (1995) illustrates how rapidly the 3 key
However, if biomechanics are compromised (such as length- fiber types reach fatigue and how long it takes for them to
tension relationships), the rate of cumulative microtrauma recover from this point. This can inform the clinician in
will increase and may exceed the body’s ability to repair itself designing conditioning programs. In general, the rule is that
earlier than the genetic potential (dashed line). This would be faster twitch fibers must be given the time to fully recover
common in the patient base. If the nutrition & lifestyle habits (otherwise the body defaults to slower twitch fibers e
of the patient are compromised, the repair rate will drop defeating the object of training), whereas slow-twitch fibers
sooner, meaning that tissue break-down would occur even should not be allowed the time to recover fully, in order to
sooner (dotted line) (Wallden, 2003). create a training stimulus (Chek, 1995).
 356 Prevention & rehabilitation: Editorial

required. Of course, there are myriad nuances and per- those specializing in biomechanical rehabilitation, but
mutations but, as a basic rule in rehabilitation and condi- those working with more complex and chronic health
tioning, this is worth bearing in mind. conditions.

Conclusion References

Understanding the possible applications of acute exercise Bianco, A., Filingeri, D., Paoli, A., Palma, A., 2015. One Repetition
variables can be complex and, like any field of specialty, Maximum Bench Press Performance: a New Approach for its
can be taken to great depths of exploration. The program Evaluation in Inexperienced Males and Females: a Pilot Study.
Bradley, H., Esformes, J., 2014 Feb. Breathing pattern disorders
design summary slide (Fig. 2 above) was created to help
and functional movement. Int. J. Sports Phys. Ther. 9 (1),
condense some of the key tenets of strength conditioning 28e39.
into one diagram. Looking from the left, the triangle (col- Chaitow, L., 2004. Breathing pattern disorders, motor control &
oured red in the digital version of the journal) running from low back pain. J. Osteopath. Med. 7 (1), 33e40.
left to right of the illustration shows how when exercise Chaitow, L., Baldry, P., Domemerholt, J., Honeyman Lowe, G.,
intensity is high, it’s counterpart e duration e tends to be Issa, T.S., Lowe, J., McMakin, C., Watson, P.J., 2005. Fibro-
low. When load or speed are high, the volume is low. In this myalgia Syndrome e a Practitioners Guide to Treatment, second
instance, rest periods need to be high, the number of sets ed. Churchill Livingstone, Edinburg.
of the exercise performed should be high, and the key Chek, P., 1995. Program Design e Choosing Reps, Sets, Loads,
stress is neural. Tempo & Rest Periods. C.H.E.K. Institute Correspondence
Course. C.H.E.K. Institute, CA, USA. [Link].
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Chek, P., 2000. Pattern Overload. Published 01/09/2001. http://
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an exercise is high, the intensity (in strength conditioning (accessed 10.02.15.).
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speeds are typically low. For this kind of exercise the rest Garakania, E., Saghebjooc, M., 10 December 2010. The effect
period between sets should be kept short e perhaps as little of exercise intensity on plasma and tissue acyl ghrelin concen-
as 30 s to prevent full recovery between sets. The repeti- trations in fasted rats, 165 (2e3), 133e137.
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potentially an exception to this rule) and therefore the sets gia: a review of pain and strength outcomes. J. Bodyw. Mov.
are low. This kind of exercise tends to be more stressful to Therapies.
Poliquin, C., 2006. German Body Comp Program. Publisher, Poliquin
the hormonal system e in particular increasing cortisol
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table are 1e6 repetitions; often considered the “power” component insight into the disorder. J. Bodyw. Mov. Ther. 16.
zone, where hypertrophy gains are relatively small (as Tander, B., Atmaca, A., Aliyazicioglu, Y., Canturk, F., 2007. Serum
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Resistance training and, specifically, the acute exercise
variables is often poorly understood in rehabilitation field, Matt Wallden, DO
yet its application could benefit many patients; not just E-mail address: matt@[Link]