How Often Should My Patient Do Their Exercises?

One of the most common questions I get asked, after “which exercise is best to fix back pain?” is….

“How often should my patient do their exercises?”

One of the things we have to remember is that “how often” or FREQUENCY is tied into the INTENSITY and EFFORT and therefore need for REST & RECOVERY, and the one thing under-discussed and often unreported in studies is intensity!! We could do 3×10 or 5×5 or whatever, but without the accompanying intensity, the sets and reps don’t really mean that much.

Intensity and effort often get used interchangeably, if there is a technical difference to discern then intensity is more about the objective measures we make e.g. heart rate whilst running, and effort is more how hard we perceive this to be, so rate of perceived exertion (RPE) would be a subjective measure with the Borg scale designed to relate to current working heart rate. So whilst technically not exactly the same, intensity & effort do have a strong relationship in my opinion and RPE can be used clinically as a simple, rudimentary measure of intensity.

This does not mean that all exercises have to be intense, it might need to fit the current sensitivity of the patient and this lower intensity can often be done more regularly, and for many just moving in a non-threatening way might suffice. But there may also need to be progression and this can be where lots of therapeutic exercise programs can fall down as they are looking for a single exercise/dosage.

Based on the current data with exercise my personal belief is that the dosing such as intensity and frequency are probably more important than the TYPE for some people!

I wrote about this a while back –  “Exercise dosing for pain is not he same as exercise doing for fitness”

What Is The Aim Of The Exercise?


Your clinical reasoning should really determine which exercise, how much, and how OFTEN!

Now there is a fair bit of discussion of whether ‘general exercise’ is better than ‘specific’ exercise whatever those two things are exactly, but my personal belief is we should always have some reasoning around WHY we are doing something. Unfortunately, although it’s a simple answer I just don’t really see “just do some exercise” as being THE answer to back pain for example.

So what is the aim? Well, we often have two main types, a more physical adaptation aim or a pain/function-focused aim.

Let’s start with the physical adaptation side of reasoning.


So strength and strengthening often get used interchangeably but might be different. Actually increasing force production or strength can require some intense exercise and higher effort levels. Sets and reps are often programmed but not the intensity as previously discussed. You could do strength programming variables but without sufficient intensity, and therefore you may not need the same rest as with more intense training but also might not get the same benefit. The load here should really dictate the reps as stopping at 5 reps with another 5 in the bank because the load is too light isn’t really going to cut it.

Our views of programming are changing with regards to strength and hypertrophy but intensity matters here and therefore frequency does too.

Load/Tissue Tolerance

This is a common aim, the concept of ‘strengthening’ an area to take a bit more load or activity.  A common mistake is to assume painful movement or being intolerant to an activity or load is CAUSED by excess load. Load is a very catch-all term and ANY painful movement or joint could be described as being load ‘intolerant’ if it causes pain, this would be a basic correlation NOT causation mistake.

Generally heavier loads are advocated and therefore higher intensities and lower frequencies although we really don’t know that much here, load tolerance I doubt is a solely tissue phenomenon.

In some cases a load tolerance approach might work by actually taking away load as much as a stimulus to increase tolerance, so addition by subtraction. We simply keep the body moving whilst taking away an aggravating load is a plausible rationale especially with exercises of limited intensity.

How does your exercise prescription also fit in with the other stuff the person is doing? This also should tie into your reasoning around frequency. With very active people, where volume might be an issue, sometimes LOWER intensity exercise performed more FREQUENTLY can also be of benefit.

The Spanner In The Works & Graded Approaches


It would all be so easy if therapeutic exercise was just about physical variables such as strength, but unfortunately, it’s not. We all know it’s great to get parameters to work with but anyone who has been in clinic knows that the real test is in how the person RESPONDS.

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It’s the interplay between intensity, frequency and PAIN that’s that really should guide us rather than theoretical parameters for fitness. And it’s not just pain as a sensation but the person’s beliefs and behaviours in response to and around pain in general that also need to be considered.

Graded activity and exercise are concepts that relate a bit more to habituating to pain and graded exposure to cognitive factors such as fear or catastrophizing. Here we don’t have ANY real parameters apart from those that are based around physical ability and pain tolerance. So frequency is really a thing that is tough to set BEFORE you work with someone. This is part of the inherent uncertainty in therapy that we have to get used to but can be guided by a thorough history of pain and exercise participation.

Graded Activity & Exercise

These are approaches that originally looked at improving chronic fatigue but are equally applicable to pain too. Again the intensity is important, if we are pushing the level of grading towards the more intense then longer rests and decreased frequency might be important. If more about building a movement HABIT then less intense and more frequent.

Graded Exposure

Graded exposure is slightly different in that it is more about cognitive factors such as fear and anxiety around moving than pain or actually than a physical change. But frequency is NO LESS important. True exposure sessions are mentally fatiguing and because of this physically and emotionally tiring. If we want to reinforce this with additional work at home we would have to consider this in terms of frequency and individual levels of fatigue.

Reasoning In Action


Here is how my reasoning might work with the two different aims. I like to use effort level as a guide to intensity as it is a simple subjective measure that is easy to use clinically across a variety of exercises/activities and I find rate of perceived exertion (RPE) is good for this. Now intensity and effort are NOT the same thing but generally the more intense an exercise the more effort is required especially the more of it you do.


Although the data around adaptation and reps/sets/intensity is definitely changing compared with what I was taught back in the 90’s, I still think that intensity is key for physical adaptation. With more intensity, we need more rest so frequency might only be 2/3 times per week. Bodybuilders were smart at training regions of the body on different days to maximize recovery whilst also getting in their overall training needs.

So we probably need at least a 7/10 RPE.  If you are looking for strength (force production) then I would say we should probably bias heavier mass to create that intensity too.

Tolerance might be different in that intensity could be created by a lighter load but you have to get in more reps to make the intensity. If we think about all the different activities and types of loads coupled with access to loading equipment then adjusting load and reps for intensity helps us a bunch. Remember that all this also ties in with their current level of sensitivity too and we often have to adjust this based on responses.


My reasoning here would be how can we build a HABIT of moving. HABITS are built more by frequency than intensity.

So let’s identify something that is going to be valued or ties into the values. We don’t always have to enjoy things but we do have to see a worth in doing them to continue to do them. Based on how someone’s pain behaves in terms of types of activities that trigger, severity of pain and how much it takes to do so (irritability) we can start to build a picture and reason a  dose of that activity.

So although we still have to be guided by the person’s RESPONSE, I would aim for intensity lower (3-5 RPE) and a frequency of daily or every other day, remember it does not have to be the SAME activity/exercise that is performed each time.

It is important to remember where you start with frequency and intensity should not be where you finish with it, but sometimes we need to start lower to get higher!

Key Points


  • Just go do some exercise might be why lots of exercise programs ultimately fail
  • Sets and reps also need intensity/effort
  • Intensity is relative to what you want to achieve and intensity dictates frequency
  • It’s often about trial and error
  • Get used to it!

Articles Of The Week September 26, 2021

Ever had a patient come in with ‘frozen shoulder’? Well, there’s some new research showing that maybe it’s not quite what we think it is.

Can the mind freeze shoulders? Five studies – Paul Ingraham

EDS can be a bit confusing for us to treat as it results in hypermobility. However, the more we understand we see it is a connective tissue disease that can be mistaken for others. So, the question remains, how can we help? Here are some options.

Ehlers-Danlos Syndrome: Does Massage and Physical Therapy Help? – Penny

We are big fans of implementing research to practice and adapting to the clinical guidelines set out in research. However, there is still an important part to all of this via the lived experience of the people who come to see you. Because THEIR experience is PERSONAL.

“Research Says” – And Why Lived Experience Matters – Bronnie Lennox Thompson

Remember in college when we were taught to do cross fiber frictions on a tendon? Well, turns out that’s probably the worst thing we can do for a tendon injury. However, progressive load…that’s where it’s at!

Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomised clinical trial – BJSM

Some of the good research that has been done on massage therapy shows how it benefits sleep (and who doesn’t love a great nights sleep?). A new study shows how using a sleep app in addition to therapy benefited compared to those who just had therapy alone.

Good sleep plus therapy works better than therapy alone – MedicalXpress

Articles Of The Week September 19, 2021



Reading research can be a daunting task, especially when it doesn’t really make sense to us how to read it. Here is a free course with small videos you can check out to up your research game!

Understanding Research Evidence – National Collaborating Centre for Methods and Tools

There is strong evidence that a therapist’s beliefs get passed on to patients and they adapt to a therapist’s beliefs. So, when we have a more biomechanical belief or explanation for our patients, this can lead to more disability for them. Here’s a great article with some advice on how not to do that.

Chronic Pain: It’s More Than Mechanical – Laura Baehr

“Based on high-quality research, nonoperative management of ACL injuries is a really viable option for some ACL injured patients.” However, there are factors to take into account and this article does a great job of showing where this would be applicable, and where not.

Can All ACL’s be Managed Non-Operatively? – Mick Hughes

I love adapting movements for patients. This shows us some great ways we can adapt the ‘bridge’ exercise and simple progressions to suit your patient’s goals.

5 Ways to Adapt the Bridge Exercise to Suit Your Goals – Tom Goom

Quite often people come in for treatment because they want ‘injury prevention’. However, many times part of injury prevention could be because they’re scared of certain movements. So why not take an approach around building ‘wellness’? Here are some steps to do that.

Injury Prevention Through the Lens of Building Wellness – Richmond Stace

Podcast: Just Ranting About The Profession With Tristen Attenborough


On this episode we just basically rant about several things in our industry with our buddy from the UK Tristen Attenborough

Check out our upcoming live courses in October that can also be attended via zoom by clicking the link:


Are we the modality? A common denominator

The longer I exist in the world of manual therapy, the more I see little difference between styles of work or modalities. Despite claims of unique access to single tissues or pathologies, all manual therapy is performed in remarkably similar ways. What are the underlying qualities of each of the dozens (or hundreds) of seemingly unique brands of manual therapy that link their positive outcomes? I believe it to be the therapeutic relationship rather than the way one treats or the tissues one thinks they are accessing.

What thinks you?

Despite claims of tissue or pathology specificity, in the end, we are touching people. Can a specific style of stretch or input bias our ability to single out a specific tissue, structure, or supposed pathology to the exclusion of others?

Reflexology makes claims to access specific points in the foot reflecting on the general health and well-being, but can one remove from the interaction that the clinician is actively listening to the patient’s complaints or concerns and attending to those needs? Myofascial release claims domain over impacting restricted fascia by using long, slow, static holds throughout the body, but can one have certainty that is it fascia alone they are impacting and not muscle or, even forbid, skin? Massage typically uses a muscle-centric model to explain both the problem and the solution. Still, does using lotion and gliding on the skin assure us that muscles are the primary target?

Typically a messy argument ensues when such thoughts are posted to social media, as the tribalism of each modality or style of work creates angst among its many users. Having been indoctrinated to the mysteries of fascia and the lack of education on the part of physicians and others in healthcare on its importance, I can well relate to such tribalistic actions. But what is it that links the various manual therapy interventions that we all use?

Diane Jacobs and Jason Silvernail (1) wrote a paper many years back comparing the traditional way clinicians act in their roles. They viewed these traditional roles as one of the operator, where the clinician calls all of the shots, and the patient acts in a passive role. They compare this concept with a preferred alternative, viewing the clinician in the role of the interactor. Through this role, the clinician adopts a role that allows and requires decisions to be shared by both parties, allowing the patient’s values and expectations to be better represented. This view, and the views of many others (2-5), is moving the bar of manual therapy’s effects from clinician-driven tissue-based perspectives into interactional effects from a successful therapeutic relationship.

As I read therapists defend their modality or style of interaction regarding manual therapy, I was struck by the thought that instead of the modality being what is done to the tissues, the modality may be the clinician themself.

Few follow the rigid, pre-ordained protocols or historical narratives of any given modality without personalizing it to meet their way of treating or thinking or combining it with other styles. While therapists tend to see themselves as blending one modality to another as the situation demands, are they not in the role of creator, providing unique experiences to each individual patient? They are, hopefully, crafting the experience to meet the needs of the patient in an N of 1 fashion. Even when I thought myself an MFR purist I seldom sought out for my patient to unwind (though MFR training insists that such movement or emotional expressions come only from the patient; the clinician is simply the facilitator), seeing it as probably out of the scope of practice of a physical therapist as well as not representing what I was comfortable expecting of my patients. Sure, some clinicians are applying a routine to the patient that varies little from one patient to the next, but few would be accused of robotically applying exactly the same procure to each person. We personalize every session. Are we applying a modality? That would depend on how you define the term, and it is a very loosely defined term under the best of circumstances.

Instead of seeing ourselves as a follower of a model or educator, might it not be more accurate to see ourselves as the provider of a unique service? Our training, education, and experiences all form who we are, but we allow ourselves to be branded under the label of one person’s line or brand…and we do it quite willingly? Enthusiasm for a certain work can cause us to take on that branding. We are told that it is good for business, as it allows the public to find you, that special someone, in a sea of mediocre clinicians (sale-pitches like this are common in the continuing education field!). There is nothing wrong with this, but mightn’t it be better advertising to promote ourselves, instead of the person who taught us? The same positive impacts can be seen from seeing a professional who promotes causative ideas relating to dehydration, gluten intolerance, sugar overload, insufficient protein/fat in the diet, lack of vitamins, etc. Somehow, people are helped by all of these interventions and beliefs. Does that person just so happen to find their way to the expert who specializes in the exact thing that is deficient or problematic in your tissues, or are there aspects of relationship-building that can be credited with at least some of the positive impacts?

What is the common denominator that makes all of us successful, that allows us to help patients no matter what intervention we use? I see much of this fall to the therapeutic relationship that we build with the patient. As an observer on this ride of ours through life, I’ve made it a hobby to observe how clinicians treat, how they engage patients, how they speak to them, and how they include (or not include) the patient in the decision-making process. Like it or not, there are remarkable similarities to what all of us do. While binds us together?

The therapeutic relationship is complex. We see ourselves as the giver of knowledge and techniques. Our patients see us in a similar light and hope that we are the person who knows exactly what to do to help them. Often they switch clinicians regularly, as when one doesn’t help them, they assume that there must be someone else who can. Often they the past clinicians as not having the special training or knowledge that the next one will when it is possible it was that the past therapist didn’t have the right ability to form a successful relationship like the next one does.

These are fuzzy concepts and ones that are easy to pick apart. Picking apart is often what we do when our beliefs are challenged, and I am guessing that I have seriously challenged some core beliefs in readers. I mean no disrespect to what you’ve learned and experienced, as those experiences are strong glue that binds us to our beliefs. I might ask you to reflect on how it is that we all find ways of helping others when what we do and believe is so vastly different? Are there common denominators? Might we, and the relationships we build, be the modality?


  1. Jacobs, D. F., & Silvernail, J. L. (2011). Therapist as operator or interactor? Moving beyond the technique. The Journal of manual & manipulative therapy, 19(2), 120–121. https://doi.org/10.1179/106698111X12998437860794
  2. Bialosky, J. E., Beneciuk, J. M., Bishop, M. D., Coronado, R. A., Penza, C. W., Simon, C. B., & George, S. Z. (2018). Unraveling the Mechanisms of Manual Therapy: Modeling an Approach. The Journal of orthopaedic and sports physical therapy, 48(1), 8–18. https://doi.org/10.2519/jospt.2018.7476
  3. Geri, T., Viceconti, A., Minacci, M., Testa, M., & Rossettini, G. (2019). Manual therapy: Exploiting the role of human touch. Musculoskeletal science & practice, 44, 102044. https://doi.org/10.1016/j.msksp.2019.07.008
  4. Bishop, M. D., Torres-Cueco, R., Gay, C. W., Lluch-Girbés, E., Beneciuk, J. M., & Bialosky, J. E. (2015). What effect can manual therapy have on a patient’s pain experience?. Pain management, 5(6), 455–464. https://doi.org/10.2217/pmt.15.39
  5. Anjum, Rani Lill; Copeland, Samantha; Rocca, Elena. (2020). Rethinking Causality, Complexity and Evidence for the Unique Patient. 10.1007/978-3-030-41239-5

Articles Of The Week September 12, 2021

There is many a narrative that needs to change in our profession. One such narrative is the theory of “myofascial slings” and in this Facebook post it helps us understand why this theory isn’t really useful for us.

Can Myofascial Slings Transmit Stretch From One Body Part To Another? – Raphael Bender

I remember a teacher in college telling me that some people will come in for treatment just to experience human touch. This has perhaps never been more important than during this pandemic where people have been isolated and lack the normal human touch they are used to.

Touch Deprivation Post-Covid: A “Tsunami Of Need” For Massage – Doug Nelson

Trigger points (TrPs) are a common source of discussion and debate on social media and even though most of us were taught about trigger points in school, the research has long been updated. We need to pay attention to that.

A Trigger Point Review – Eric Purves

One of the other articles we cited talked about interception, this article refers to this as: “your brain’s perception of your body’s state, transmitted from receptors on all your internal organs.” This plays some interesting roles in both physical and mental health.

Interoception: The Hidden Sense That Shapes Wellbeing – David Robson

We really like analogies around here, so this one really resonated. When we look at someone dealing with pain we have to be careful around causation. There are too many factors that contribute to a pain experience to narrow it down to just one thing.

Understanding Causation, A Coffee Mug Analogy – Modern Pain Care