Medical exercise therapy breaks the chronic pain cycle, even in the longer term, in patients with persistent anterior knee pain

In general there is a lack of long-term success in treating people with persistent musculoskeletal pain and long-term anterior knee pain or patellofemoral pain syndrome (PFPS), is no exception [1].  It is reported that approximately 25% of patients with PFPS continue to have pain and dysfunction one year or more after physiotherapy, the most frequently used conservative treatment for PFPS [2].

We evaluated the long-term effect of high-dose, high-repetition medical exercise therapy (MET) in patients with PFPS with respect to pain and functional outcomes in a multicenter randomized controlled clinical trial (RCT) with one year follow-up [3].

The original RCT evaluated two different therapeutic exercise regimens in patients with PFPS and revealed important (clinically and statistically significant) differences between treatment groups after a 12-week intervention period, indicating that high-dose, high-repetition MET is more efficacious than low-dose, low-repetition exercise therapy in this patient group. The differences between groups at post-test were −1.6 for mean pain (VAS: 0–10 cm) representing an effect size of 0.80, 6.5 for step-down test (numbers of completed step-downs in 30 seconds) representing an effect size of 0.81, and 3.1 for the modified Functional Index Questionnaire (FIQ: 0 points indicates maximal disability, 16points no disability) representing an effect size of 0.89. (Figure 1-3).

The term “high-dose, high-repetition” refers to the higher number of exercises, higher number of repetitions and sets and the inclusion of a substantial amount of aerobic/global exercise using a stationary bike in the experimental group. The exercises in the control group program was termed “low-dose, low-repetition” referring to the lower number of exercises, lower number of repetitions and sets, and the brief sequences of aerobic/global exercises. Dosage parameters in the control group were graded in accordance with traditional strength training principles, commonly prescribed for PFPS-patients [4]. For patients in both groups, load and range of motion were graded in order to make the program appropriate and achievable with as little discomfort as possible. The participants in both groups performed group specific and individually tailored exercises three times a week for 12 weeks, always supervised by the same physiotherapist. The number of exercises, repetitions, sets, and duration of aerobic/global exercises were kept constant in both groups throughout the study.

At one year follow-up the group differences are maintained and even increased with respect to pain and functional outcomes [5]. The results indicate a continuous improvement in the experimental group and a worsening in the control group between post-test and follow-up. In this period there was no intervention applied in the groups. The differences between groups at follow-up were −1.8 for mean pain representing an effect size of 0.9, 4.5 for step-down test representing an effect size of 0.6, and 1.1 for FIQ representing an effect size of 0.3. (Figure 1-3).

Figure 1

Figure 2

Figure 3

The long-term effects seen at one year follow-up draw increased attention towards central and psychological factors. This includes cognitive-behavioural factors, such as health beliefs, self-efficacy and fear-avoidance [6, 7] as well as stress mechanisms (including hypothalamic–pituitary–adrenal [HPA] axis activity), neural sensitization [8, 9] and motor learning [10, 11]. These are long-term mechanisms, some of which evidence suggests proved to be main predictors for treatment outcome on the longer term [6, 12] and to immediate individual reliable change in patients with persistent musculoskeletal pain [13]. There was however no instruments applied in the RCT or follow-up study addressing these possible mechanisms.

The apparent new state of healthy self-regulation occurring in the patients completing high-dose, high-repetition MET is valuable and cost-efficient on the individual level, but probably also to society. Measured as reduction in work absence costs, this is demonstrated in patients with long-term subacromial pain, finding high-dose, high-repetition MET to be more efficient than low-dose, low-repetition exercise [14]. Additonally, a presumed healthier state of self-regulation might make people more independent of treatment and health care services, as well as less dependent on social financial support. Although speculative, it is possible that several of the mechanisms behind the long -term clinical effects seen in this current patient group, could be relevant in other persistent musculoskeletal pain conditions. Long-term effects of high-dose, high-repetition MET have been demonstrated in patients with persistent subacromial pain [15]. However, the high-dose, high-repetition MET-approach might be most appropriate in certain rehabilitation phases in people with persistent musculoskeletal pain.

Future research is needed to explore the mechanisms behind the clinical effects as well as test the usefulness of these interventions more extensively.

About Berit Østerås

Berit ØsteråsBerit is a physiotherapist, Msc. and Associated Professor at Sør-Trøndelag University College, Faculty of Health Education and Social Work, Department of Physiotherapy, Trondheim, Norway.

Since 2004 she has combined her clinical physiotherapy practice with teaching and scientific work. In her clinical work she sees an increasing number of patients presenting with persistent musculoskeletal pain. Her scientific work and studies have addressed different patient populations in the long-term pain category.

References

[1] Davis IS, & Powers CM (2010). Patellofemoral pain syndrome: proximal, distal, and local factors, an international retreat, April 30-May 2, 2009, Fells Point, Baltimore, MD. J Orthop Sports Phys Ther, 40 (3) PMID: 20195028

[2] Piva SR, Fitzgerald GK, Irrgang JJ, Fritz JM, Wisniewski S, McGinty GT, Childs JD, Domenech MA, Jones S, & Delitto A (2009). Associates of physical function and pain in patients with patellofemoral pain syndrome. Arch Phys Med Rehabil, 90 (2), 285-95 PMID: 19236982

[3]  Østerås B, Østerås H, Torstensen TA, & Vasseljen O (2013). Dose-response effects of medical exercise therapy in patients with patellofemoral pain syndrome: a randomised controlled clinical trial. Physiotherapy, 99 (2), 126-31 PMID: 23219636

[4] Chiu JK, Wong YM, Yung PS, & Ng GY (2012). The effects of quadriceps strengthening on pain, function, and patellofemoral joint contact area in persons with patellofemoral pain. Am J Phys Med Rehabil, 91 (2), 98-106 PMID: 22248804

[5] Østerås B, Østerås H, & Torsensen TA (2013). Long-term effects of medical exercise therapy in patients with patellofemoral pain syndrome: results from a single-blinded randomized controlled trial with 12 months follow-up. Physiotherapy, 99 (4), 311-6 PMID: 23764516

[6] Piva SR, Fitzgerald GK, Wisniewski S, & Delitto A (2009). Predictors of pain and function outcome after rehabilitation in patients with patellofemoral pain syndrome. J Rehabil Med, 41 (8), 604-12 PMID: 19565153

[7]. Woby SR, Urmston M, & Watson PJ (2007). Self-efficacy mediates the relation between pain-related fear and outcome in chronic low back pain patients. Eur J Pain, 11 (7), 711-8 PMID: 17218132

[8]. McFarlaneAC. Stress-related musculoskeletal pain. Best Pract Res Clin Rheumatol 2007;21(3):549–65.

[9]. Riva R, Mork PJ, Westgaard RH, & Lundberg U (2012). Comparison of the cortisol awakening response in women with shoulder and neck pain and women with fibromyalgia. Psychoneuroendocrinology, 37 (2), 299-306 PMID: 21764519

[10]. Fu M, Yu X, Lu J, & Zuo Y (2012). Repetitive motor learning induces coordinated formation of clustered dendritic spines in vivo. Nature, 483 (7387), 92-5 PMID: 22343892

[11]. Kida T, Kaneda T, & Nishihira Y (2012). Dual-task repetition alters event-related brain potentials and task performance. Clinical Neurophysiol, 123 (6), 1123-30 PMID: 22030141

[12]. Meeus M, Nijs J, Van Mol E, Truijen S, & De Meirleir K (2012). Role of psychological aspects in both chronic pain and in daily functioning in chronic fatigue syndrome: a prospective longitudinal study. Clin Rheumatol, 31 (6), 921-9 PMID: 22349876

[13]. Asenlöf P, & Söderlund A (2010). A further investigation of the importance of pain cognition and behaviour in pain rehabilitation: longitudinal data suggest disability and fear of movement are most important. Clin Rehabil, 24 (5), 422-30 PMID: 20442254

[14]. Østerås H, Arild Torstensen T, Arntzen G, & S Østerås B (2008). A comparison of work absence periods and the associated costs for two different modes of exercise therapies for patients with longstanding subacromial pain. J Med Econ, 11 (3), 371-81 PMID: 19450093

[15]. Østerås H, Torstensen TA, & Østerås B (2010). High-dosage medical exercise therapy in patients with long-term subacromial shoulder pain: a randomized controlled trial. Physiother Res, 15 (4), 232-42 PMID: 21110409

Comments

  1. Federico says

    Dear Tom,
    It is really interesting your article, and all comments. Wonderful to see how the approach to the same problem is different. In october 2013 I have been diagnosed with grade 3 chondromalacia and I am following the low dose, low repetition program with no results after 20 sessions. I am thinking in change to something “harder”. Do you now if in Barcelona there is any place when I can perform high dose, high dose, high repetition MET program?
    Many thanks in advance.
    Kind regards
    Federico

  2. John Ware says

    Tom,
    If your goal is to enhance the shift in the framing of MET from the biomechanical/biomedical model to one that is more consistent with the current science that is relevant to the lived pain experience (“biopsychosocial”, if you will), then I would refer to performing global and local “movements” rather than talking about “working” certain “muscles”. After all, people move with intention; under normal conditions, they don’t think about contracting a particular muscle. When the focus is on working specific muscles or muscle groups, then the implication is that weakness underlies the pain problem and then that circles back to ontological assumptions about the cause of pain, which I think the science has firmly refuted.

    I’ll repeat that I think PTs have made a prodigious mistake in attributing weakness as a cause of pain, and it will take considerable effort and self-discipline to undo it. A good start would be to use more accurate language in describing what it is we are doing with our patients. Perhaps some accuracy and uniformity in our language will by itself help to reduce some of the fear-avoidance and catastrophizing that we are trying to address with our treatments (see Benedetti et al’s 2007 review of nocebo re: the importance of language in interactions with patients with pain).

  3. I appreciate the thorough reply, thank you!

  4. John,
    thanks for your answer. Now, I can see where you are coming from. Over the last 15 years we have done many improvements of the medical exercise therapy (MET) model. One is dividing exercises into global, semiglobal and local exercises. Global exercises are exercises where you activate the whole body working large muscle groups. Semi global exercises are exercises where the patient work a kinetic chain like the upper extremity or lower extremity. Local or so called specific exercises are exercises where the patient work a few muscles over one joint. In MET, the goal is to combine global, semi global-, and local exercises so that the patient perform a large enough exercise dosage to activate the endocrine system and the pain modulating systems. As we have shown in our clinical studies, when this is done regularly over time, it results in interesting short and long term clinical improvements.

    One reason for this improvement, was our experience that exercising locally a few muscles in the painful area easily increased the symptoms. Thus, it is nice to use more global exercises to modulate the pain experience. We believe that such an exercise approach increases the patient´s level of self-efficacy, decrease negative beliefs about exercise and improve negative psychological factors like catastrophizing, hypervigilance, fear avoidance, anxiety and depression – MET is a biopsychosocial treatment.

    Before, it was more focus on using a global exercise as a warm up exercise and then use specific (local) exercises to treat single tissue structure like a muscle or a joint – MET was a biomedical treatment.

  5. Brian,
    In both studies (1-4) the low repetitive, low dosage group did 10 minutes warm up and then 4 different exercises each of 2 sets of 10 repetitions, taking approximately 20-30 minutes to perform. In the high repetitive, high dosage exercise groups the patients did 20 minutes pain modulation (global exercise like cycling), then 4 exercises each of 3 sets of 30 repetitions, then 5-10 minutes global pain modulation (cycling), then another 4 different exercises 3×30 repetitions and finishing with 10 minutes global pain modulation. Each treatment lasted approximately 70-90 minutes. All patients in both groups had 3 treatments for 12 weeks a total of 36 treatments. The difference between the groups regarding dosage is; 1) time doing global pain modulation, 2) number of exercises, 3) number of sets, 4)number of repetitions of each set and 5) total time exercising during each treatment. The method for testing and grading exercises was similar for all exercise groups. To be able to perform high repetition, high dosage exercises for the lower extremity, open chain deloaded knee extension, was performed three times during the treatment.

    In publication (1) you will find pictures of the exercises used for shoulder rehabilitation, and for long term anterior knee pain you will in publication (3) find a description of the exercise programs.

    1) Østerås H, Torstensen TA, Haugerud L, Østerås B. Dose response effects of graded therapeutic exercises in patients with long-standing subacromial pain. Adv Physiother 2008, 1-11, iFirst article
    2) Østerås H, Torstensen TA, & Østerås B (2010). High-dosage medical exercise therapy in patients with long-term subacromial shoulder pain: a randomized controlled trial. Physiother Res, 15 (4), 232-42 PMID: 21110409
    3) Østerås B, Østerås H, Torstensen TA, & Vasseljen O (2013). Dose-response effects of medical exercise therapy in patients with patellofemoral pain syndrome: a randomised controlled clinical trial. Physiotherapy, 99 (2), 126-31 PMID: 23219636
    4) Østerås B, Østerås H, & Torsensen TA (2013). Long-term effects of medical exercise therapy in patients with patellofemoral pain syndrome: results from a single-blinded randomized controlled trial with 12 months follow-up. Physiotherapy, 99 (4), 311-6 PMID: 23764516

  6. John Ware says

    Tom,
    Indeed, my original exposure to MET was about 15 years ago during my fellowship training, which was fairly eclectic, but had a strong influence from the Norwegian manual therapy “school” (Kaltenborn and Evjenth). Bjorn Svensen was involved in teaching the MET material back then. I recall that he was also involved for some time with one of the few (if not the only) North American manufacturers of MET equipment. I’m not sure if he still is. In fact, I used to teach the MET approach when I was a faculty member for one of the AAOMPT-recognized OMPT programs.

    So, obviously, I have a bias about the nature of this exercise approach since I’m fairly well-versed in its origins and used it extensively at one time. I’m willing to change my mind, but since shedding many of the biomechanical boondoggles that PT has been so enamored with for so long, it would take quite a bit of coaxing to get me to resume having a patient with persistent upper quarter pain perform, for example, 3×30 repetitions of scapular retraction of 0.5kg with a strap placed proximally around the shoulder. This exercise may be sufficient to provide relief of the patient’s shoulder pain, but is it necessary?

    It’s taken me nearly 2 decades to pare down my “toolbox” to a manageable size and, ironically, my outcomes have improved. I’ll need more compelling evidence that MET is both efficient and effective before I’ll go back there again.

  7. Can someone give more specifics for what “high-dose, high-repetition” and “low-dose, low-repetition” was?

    Total sets, reps, exercises, intensity, etc. I tried accessing the article but I don’t believe the full text of this one is readily available.

    Thank you.

  8. John,
    I just got an e-mail from a colleague in Denmark who is following our blogging. He writes to me that he has the opposite experience to you using medical exercise therapy. That the graded exercise therapy make the patient focus on what she/he is able to do functionally focusing less on local tissue structure(s). That MET quickly increases the patient’s level of self-efficacy decreasing the level of catastrophizing. And that these positive effects often happen during or after the first treatment.

  9. Deano,
    I have no knowledge about the British military model of exercise therapy. You can e-mail me articles or refrences to my e-mail; tom.torstensen@holteninstitute.com

    You will find information about the exercises used for long term subacromial pain (1) and long term anterior knee pain (2) in the publications referred to below.

    1)Østerås H, Torstensen TA, Haugerud L, Østerås B. Dose response effects of graded therapeutic exercises in patients with long-standing subacromial pain. Adv Physiother 2008, 1-11, iFirst article
    2) Østerås B, Østerås H, Torstensen TA, & Vasseljen O (2013). Dose-response effects of medical exercise therapy in patients with patellofemoral pain syndrome: a randomised controlled clinical trial. Physiotherapy, 99 (2), 126-31 PMID: 23219636

  10. Tom,
    I do find your results and exercise models interesting and am eagerly researching elements I can apply practically. Are you aware of the British military model of exercise therapy that has been delivered in a medical setting since 1939?

  11. John, thank you for sharing with us your beliefs about pain, structure, exercise and in particular your beliefs about the use of medical exercise therapy.

    Regarding number of treatments within the USA health care system, my experience is that the insurance companies have become much more positive regarding the use of evidence based methods, like exercise therapy. If a patient is improving, and the physiotherapist can argue for more treatments to make the patient more functional, the insurance company listen. On a very positive note, the exercise models that we use in our research showing positive outcomes, can all be performed as home exercise programs.

    Regarding exercise equipment, my experience is that most physiotherapists use different forms of exercise equipment to be able to grade exercises treating patients. Historically, pulleys have been around for more than a 100 years and when I did my basic training we used the famous Westminster pulley. We find pulleys useful to unload a part of the body putting less compressive/tensile forces on the tissue making it possible to start exercising with a high number of repetitions performing high volume exercise therapy. We hypothesize that this is an excellent way to stimulate the body´s pain modulating systems.

    The latest development within the fitness/gym industry show clearly that many fitness/gym centers now move towards rehabilitation, investing in exercise equipment more geared towards rehabilitation of patients with pain. The Italian company Techno Gym is one of many examples of this, and John, you can visit their homepage to see how they have designed exercise equipment to be able to grade and dose exercises to meet the need of the patient. However, being for or against using exercise equipment in physiotherapy I feel is beyond the scope of discussing results from a clinical study on the effectiveness of MET in patients with long term anterior knee pain.

    Your strong belief that MET is medicalizing the patient´s condition give me flash backs to discussions I had with colleagues some 10 to 15 years ago. John listen, we have moved on, and If you in USA are working in an environment where medical exercise therapy is stuck in the biomedical model , I can only agree with you. Changing physiotherapists beliefs and attitudes are difficult.

    What type of inference patients make using exercise equipment is difficult to make. I believe that there is a natural selection even before starting exercising. A patient who´s beliefs are more geared toward Pilates or any other body-mind movement therapy, probably seek help from a physiotherapist that offers such treatment. On the other hand, a patient that enjoy exercise using exercise equipment probably seek help from a physiotherapist that can offer such therapy. Research show that the beliefs and attitudes we have later in life is something we learn early in life from our parents and other people that are important for us. And there is of course always a genetic component to this too. John, your thoughts that some simple exercise equipment from Norway should make such huge behavioral changes are interesting.

    Finally, the studies we have done are all multi center trials, strengthening the generalization of our results. However, we hope that other colleagues and research groups will find our results and exercise models interesting. We are looking forward to replications of our studies.

  12. John Ware says

    Tom,
    Thank you for your very thorough response.

    Let me first address the issue of visit volumes in the U.S. outpatient physical therapy clinic setting. I’m sure there are exceptions, but it is generally rare to get that many visits approved by any insurance company for a condition like “rotator cuff tendinitis,” “impingement syndrome,” or “shoulder pain”. If it’s a patient with Medicare, and you work in a private PT practice, that number of visits including an hour of exercise (4 chargeable units) per visit would exceed the annual outpatient therapy cap by several hundred dollars. Additional hurdles would have to be overcome to get an exception approved by Medicare.

    I think it’s safe to say that nothing “works perfectly” in our current health care delivery system in the U.S. That is, however, no reason to dispense with a method that makes sense and is proven effective.

    I don’t doubt for a moment that performing graded, high repetition exercise under the watchful, earnest eye of a concerned therapist provides loads of both specific and non-specific beneficial effects for the patient with a persistent pain problem. However, I question two particular aspects of the MET approach. First, a considerable investment in equipment is necessary, including pulleys with weight stacks, benches, and various and sundry attachments. There are a fairly limited number of manufacturers of this equipment, the most prominent of which are located in Scandinavian countries. It’s not unusual to spend well over $10k on a single pulley module system. So, there is a significant monetary investment. If the evidence were more compelling that MET was superior to other methods of graded exercise for a variety of persistent pain problems, I could see where such an investment might be worth it. However, I don’t think the evidence is anywhere near that level. In fact, you, yourself, have been directly involved in most of the published research on this particular method. It begs replication by an unaffiliated research group.

    Secondly, and perhaps more insidiously, is the ever-present risk of medicalizing the patient’s condition. The highly choreographed nature of MET exercises tends to reinforce a biomechanical cause of the pain in the patient’s mind. I appreciate that you have made efforts to re-frame the exercises in a way that reduces this tendency, but I’m concerned that this type of exercise approach further ingrains this meme in the culture. Related to that concern is the ready association that patient make with pain and weakness- or lack of strength. A significant relationship between strength- or lack of it- and pain has never been established, and I think it was a fairly momentous mistake when the PT profession decided to run with that idea anyway. I don’t see how a patient undergoing an intensive program like MET can avoid making this inference.

    The longer I do this the more convinced I become that the patients who succeed in overcoming these troubling mechanical pain problems become more comfortable in their own skin, both literally and figuratively. They need a wide birth to explore a variety of movements in a thoughtful way where the therapist acts as merely a catalyst in helping them discover the movements that bring about resolution. The MET approach seems to possess inherent constraints that might interfere with this process.

  13. Thanks John for commenting on our study on the effectiveness of high repetitive, high dosage medical exercise therapy in patients with long term anterior knee pain (PFPS).

    Over the years MET has been developed from a fairly strict biomedical exercise treatment to a bio psychosocial treatment. Today we have incorporated the latest knowledge from the pain sciences with special emphasis on the psychology and physiology of pain as well as knowledge from the behavioral sciences like cognitive behavioral therapy. We use new expressions like “exercise therapy as pain modulation”, using high repetition high dosage MET as a form of desensitization treatment or an antisensitization treatment. With the knowledge that we do not have pain receptors but nociceptors, it is inspiring to work with an exercise approach that focus on grading exercises so that patients can perform a high volume repetition program pain free or close to pain free. We are therefore making a clear distinction between exercise as pain modulation and exercise as strength training. Frankly, I cannot find one good argument to put a patient into a painful exercise program if simple grading can make the patient exercise pain free or close to pain free. Maybe the key treating pain using exercise therapy, is to apply an appropriate dosage to balance up the endocrine and immune system normalizing the function of the nociceptors in the body….. opening up the chemist shop in your brain!

    And finally John, even though I never have skinned a cat I too am sure there are many ways to do that. Something which I do have some knowledge about is designing exercise programs for patients, and from working clinically for 30 years and teaching for more than 20 years there seem to be as many ways to exercise patients as there are therapists. And I believe that this is a general problem for our profession, especially when we make no difference between strength training with a few repetitions in sets treating pain, compared to exercise as pain modulation focusing on the pain modulating systems of the body. I also think it is a problem for our profession doing research on the effectiveness of exercise therapy using 4-6 sessions expecting a positive outcome. These studies are excellent showing that exercise therapy used by physiotherapists is not effective and no better than placebo. Four to six exercise sessions, that is what you need to just getting used to moving. You also say that; “The days of seeing a patient with PFPS for 36 visits over 12 weeks are long gone here in the U.S.”, I know several clinics in USA that have implemented the MET approach using the MET principles described in our publications. They even apply 36 treatments over 12 weeks, and it works perfectly in the USA health care system. However, the reason why we in our studies have chosen 3 times a week for 12 weeks a total of 36 treatments, is the fact that we for many years have experienced clinically that this is the exercise dosage that is necessary for many patients to recover. Thus, it is common sense for us to also do clinical research on this exercise model.

    Clinically, treating one patient, it might of course look very different. Sometimes I might see a patient for only 6-12 treatments using MET. However, if improvements do not happen, I know that one of the reasons may be the number of treatments related to the dosage of exercise therapy. On a positive note for the exercise motivated patient, it is easy to give a full high repetitive high dosage MET treatment as a home exercise program. For me as an orthopaedic manipulative therapist it feels safe to use exercise therapy as pain treatment knowing that the effects are probably dose-response related, and when performed on a regular basis result in effects additional to placebo.

    Regarding cost effectiveness, we have published results from another clinical trial (1,2), with a similar two group exercise therapy design, looking at the effectiveness of MET in patients with long term subacromial pain. We found MET to be cost effective, suggesting that it might be worthwhile spending more time exercising and more treatments to obtain a successful treatment that have long lasting effects.

    The fact that pain is an output and that spinal control of nociceptive input is influenced by both external and internal mechanisms, we are moving towards a new paradigm shift better understanding how to exercise patients with pain. As a profession we need to look less at single tissue structures (3,4) and more at central mechanisms (5,6).

    Finally, it is of course necessary to perform more clinical trials on the effectiveness of MET as well as looking at different mechanisms that can explain the positive clinical effects from high repetitive, high dosage MET.

    References:
    1) Østerås H, Torstensen TA, Østerås B. High-dosage medical exercise therapy in patients with long-term subacromial shoulder pain: a randomized controlled trial. Physiother Res Int. 2010 ;15:232-42.
    2) Østerås H, Torstensen TA, Arntzen G, S Østerås B. A comparison of work absence periods and the associated costs for two different modes of exercise therapies for patients with longstanding subacromial pain.
    J Med Econ. 2008;11:371-81.
    3) Torstensen TA, Meen HD, Stiris M. The effects of medical exercise therapy on a patient with chronic supraspinatus tendinitis. Diagnostic ultrasound – tissue regeneration: a case study. J Orthop Sports Phys Ther 1994;20:319-327.
    4) O’Sullivan P. It’s time for change with the management of non-specific chronic low back pain. Br J Sports Med 2012;46(4):224-227.
    5) Mannion AF, Caporaso F, Pulkovski N, Sprott H. Spine stabilisation exercises in the treatment of chronic low back pain: a good clinical outcome is not associated with improved abdominal muscle function. Eur Spine J 2012;21(7):1301-1310.
    6) Steiger F, Wirth B, de Bruin ED, Mannion AF. Is a positive clinical outcome after exercise therapy for chronic non-specific low back pain contingent upon a corresponding improvement in the targeted aspect(s) of performance? A systematic review. Eur Spine J 2012;21:575–598.

  14. Thanks Julia for commenting on our study on the effectiveness of high repetitive, high dosage medical exercise therapy in patients with long term anterior knee pain (PFPS).

    Medical exercise therapy (MET) was developed during the early 1960s in Norway by Oddvar Holten and he first named the approach “treningsterapi” which I think I can translate to “training therapy”. However, to make clear that this form of exercise therapy was to be used within the health services for patients with pain and decreased function, he decided to rename it to “medisinsk treningsterapi” translated to English as medical exercise therapy (MET)”. He was also asked by the Norwegian health authorities to define this form of exercise therapy publishing the MET criteria in 1967 in the Norwegian Physiotherapy Journal;
    The MET criteria:
    1) The physiotherapist is present in the exercise room to monitor and coach the exercising patient(s);
    2) Specific exercise equipment is used to grade exercises according to the need of the patient;
    3) Starting positions, range of motion and loading is defined for each exercise;
    4) The therapy lasts or a minimum of 60 minutes;
    5) The assessment of the patient is the basis for designing and grading an exercise program;
    6) MET is group therapy where up to 5 patients are treated during that one hour. Each patient has his/her own individualized exercise program. The group could consist of a patient with neck pain, a second patient low back pain, a third after a stroke and a fourth with knee OA etcetera,
    7) The exercise program for each patient is continuously reassessed/regraded.

  15. John Ware says

    Medical Exercise Therapy is based on the exercise physiology concepts advanced by Odvar Holten going back several decades. These exercises were conceived originally as supplementary to manual therapy techniques that were designed to address loss of joint arthrokinematic glides (as described by Freddy Kaltenborn in his popular text). Many of the exercises, through the intricate use of pulley angles, are designed to assist in the reproduction of the arthrokinematic motion while the patient performs high-rep, low weight “osteokinematic” movements- typically in very specific planes. I suspect Holten, who was a Norwegian PT, wanted to differentiate this type of exercise designed for patients from strength and conditioning by using the term “medical”.

    I think it’s abundantly clear that these biomechanical concepts are flawed when it comes to patients with a pain problem, but I can see how performing a ba-zillion repetitions of a non-threatening movement of a painful body part might be beneficial (as opposed to higher load- low rep, which I suspect are more likely to produce nociception and then pain).

    In any case, I think there are probably more efficient and cost-effective ways to “skin that cat”. The days of seeing a patient with PFPS for 36 visits over 12 weeks are long gone here in the U.S.

  16. Julia hush says

    A well-designed and conducted study with results showing worthwhile benefits. However I am unclear why the exercises are described as “medical” when they have been designed by a physiotherapist, supervised by a physiotherapist and the study leader is a physiotherapist.