Exercise prescription: Physiotherapy's most important and least standardized skill.

BACKGROUND: Exercise is a nearly ubiquitous recommendation in musculoskeletal (MSK) physiotherapy (PT), yet confidence, consistency, and clarity in how prescription decisions are made and communicated remain limited. Inconsistent reporting of exercise parameters obscures whether interventions are delivered at therapeutic intensities, while opaque prescription reasoning limits clinical practice translation. Current approaches often emphasize prescription outputs rather than longitudinal reasoning that links patient assessment to prescription, progression, and modification. Existing efforts have advanced exercise prescription by highlighting the complexity of mechanisms, specifying targets, and proposing region-specific models. Yet, no shared language or systematic processes allow exploration and explanation of the often-implicit reasoning strategies used to justify our prescription decisions across MSK presentations. High-quality exercise prescription is an iterative, progressive process that requires individualized integration of biopsychosocial patient factors into actionable and specific parameters. PURPOSE: The purpose of this Professional Practice paper is to establish the rationale for a shared exercise prescription framework in MSK patients and to briefly introduce a novel Exercise Decision Making Framework. IMPLICATIONS: Greater standardization of the reasoning process, rather than prescription itself, may improve our ability to appraise exercise prescription and identify warranted, individualized practice from unwarranted variation. A clearer framework for how exercise is selected, dosed, progressed, and modified according to the patients' biopsychosocial profile may strengthen clinical reasoning, improve translation of research into practice, and better prepare graduates for contemporary MSK care. As PT continues to define expertise around movement, improving how we prescribe exercise should be a priority.