I’ve had plenty of patients come to me with very low expectations of what strength training in physical therapy actually involves. More often than not, they imagine endless rubber band exercises, an infinite loop of bridges, and “strength training” with the tiniest pink dumbbells.
But here’s the problem—what’s missing from that picture is intensity.
If you’ve read our blog 10 Principles of Neuroplasticity in Stroke Recovery: How the Brain Rebuilds After Injury, you already know that intensity is a critical driver of brain change. It’s what signals the nervous system to form the new connections that support real neurological recovery.
Unfortunately, one area I see consistently underdosed—especially in neuro rehab—is strength training. Far too often, patients with neurological conditions are given watered-down programs that don’t challenge them enough to create meaningful change.
Just recently, I saw a patient who initially came to me as a fill-in while her regular therapist was away. Interestingly, she ended up switching to more frequent sessions with me—even though her other PT had more availability. Later on, her occupational therapist told me, “She really likes that your sessions feel like a workout.”
My first thought? Woohoo! I’m thrilled she feels like she has to work hard—because ultimately, that’s the goal for every patient I see.
My second thought? Why are we still afraid to appropriately dose strength training in neuro rehab? After all, these are the patients who need it most.
With that in mind, let’s talk about some of the ways I determine appropriate dosing of strength training in neuro rehab.
Reps in Reserve
The National Academy of Sports Medicine (NASM) defines Reps in Reserve (RIR) as the number of repetitions you could still perform before reaching technical failure—in other words, the point where you can no longer complete the movement with good form.
For instance, let’s say you complete 10 squats with a 5 lb. weight and say, “I could’ve done 5 more before I had to stop.” That’s 5 RIR.
When it comes to building muscular strength, I typically aim for 2–4 RIR with my patients. This range, based on NASM’s recommendations, strikes a balance:
On one hand, it ensures I’m not maxing out patients on every set. On the other, it helps us avoid the kind of underdosing that leaves people wondering if they’d have gotten a better workout on the couch at home.
So next time you finish a set—whether in PT or at the gym—ask yourself:
“How many more reps could I have done before my form broke down?”
Admittedly, getting good at estimating your reps in reserve takes practice. However, it’s a powerful tool for dialing in your intensity and leveling up your results.
Repetition Maximum
When a movement is repeated consistently throughout your physical therapy plan of care, repetition maximum (RM) testing becomes a valuable tool. Specifically, it helps us ensure we’re applying enough resistance to actually stimulate strength gains.
For example, let’s take the leg press—because who doesn’t love strong, healthy legs?! If we plan to use it regularly, I might ask you to load 50 lbs and perform as many reps as you can.
Let’s say you hit 10 reps and say, “I can’t do any more.” Heck yes! That’s awesome. Nice work.
At that point, we can use a calculator (linked below) to estimate your 1 repetition maximum (1RM)—the amount of weight you should be able to push for a single rep. In this scenario, it’s about 67 lbs.
So why does your 1RM matter? It helps us determine the minimum resistance needed to maximize your strength gains. Especially if you’re newer to resistance training, starting with 10+ reps at 60% of your 1RM is a solid approach.
Even so, this isn’t a one-size-fits-all formula. Strength improvements can happen even at lower loads, and your capacity can vary day to day depending on sleep, stress, nutrition, and more.
Therefore, always let your physical therapist know if your program feels too hard or too easy—we’re here to adjust and make sure it works for you.
Relative Perceived Exertion
Relative Perceived Exertion (RPE) is one of my favorite ways to gauge intensity during strength training. It’s similar to the “reps in reserve” concept, and I like to use this chart from the folks at Barbell Rehab to help guide the conversation.
After you complete a set, I might show you the chart and ask, “What was your RPE on that lift?”
In response, you might take a look and say, “I could’ve done two more reps, but no more—so probably an 8.” Perfect. That’s right in the zone we’re aiming for.
On the other hand, if you say, “That felt like warm-up weight,” I’ll likely increase the resistance for your next set and check back in with your RPE afterward.
In general, I aim for patients to stay in the 7–8 RPE range during sessions and in their home programs. This range tends to strike the right balance between challenge and sustainability.
At RPEs of 6 or less, we’re likely getting plenty of reps—which is great for neuroplasticity—but the intensity may be too low to drive meaningful strength gains.
Conversely, at RPEs greater than 8, we’re hitting the intensity target—but probably not getting enough reps to support the repetition needed for neuroplastic change.
If this all feels too complicated to manage of your own, just know…
YOU DON’T HAVE TO.
I’m here to help you navigate these tricky calculations and maximize your recovery. Your job is to work hard and give honest feedback—so I can adjust your program to meet your goals.
Questions? Ready to get started?
Reach out anytime—I’d love to help you move forward with clarity and confidence.
📍 Cortex Rehab
431 N. 7th Avenue (inside Access Fitness)
Bozeman, MT
📧 Email: info@cortexmt.com
📞 Phone: (406) 763-7779
🌐 Website: www.cortexmt.com
📱 Instagram & TikTok: @cortexrehabmt
Resources
https://strengthlevel.com/one-rep-max-calculator
Schoenfeld BJ, Grgic J, Van Every DW, Plotkin DL. Loading Recommendations for Muscle Strength, Hypertrophy, and Local Endurance: A Re-Examination of the Repetition Continuum. Sports (Basel). 2021 Feb 22;9(2):32. doi: 10.3390/sports9020032. PMID: 33671664; PMCID: PMC7927075.
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