MET Article

[AJ Lievre]

Check out this article. Posted in Residency Shared “Medical Exercise Therapy for Treating Musculoskeletal Pain- A Narrative Review”
How have you incorporated MET into treatment? Where have you found it to be most effective?

[Kyle Feldman]

Great article after the Eric Kopp course AJ

I liked how it explained the cost benefit right off the bat for high dose ther ex. Great article to show insurance if they begin to question why we are only doing 4-6 exercises but billing so many units. It also explains why it is skilled care with the PT in the room and that each exercise is specific for the patient in front of you.

11 articles seems pretty good for this specific exercise type with most having 1 year follow ups

endogenous analgesia is a great term I have not used but something that would be great to explain why this much exercise is good and can help with pain by releasing opioids

Also great that they hit on the psychosocial component with the patients who suffer from depression and anxiety. This is more and more common as I have learned more about it

In clinic I had been using some of the MET principles and exercises but since the course with Eric I have a better understanding of why the more reps
Most of the routines I give have more reps to increase that pattern. I also am trying to do better with global and semi global exercises for each patients. At times I will focus so much on the area of the body (such as knee and hip for a knee patient) and not do as much core or full body work. I am working to be more balanced with every patient.

I have seen that MET is great for patients who are stiff or guarding because the more reps seems to calm down the tissue and allow the pattern to improve with the more reps. Also has helped well with patients with poor muscle activation or motor planning. More reps improves the form and muscle activation.

Overall I could see MET being the main principle that therapists use to program for patients.

[Aaron Hartstein]

I agree Kyle- definitely a great follow-up to Eric Kopp’s course and addition to Michael’s VOMPTI presentation.
I was first introduced to MET through the VOMPTI course series which I’m really thankful for and have found many of the exercise principles to be extremely helpful. I will say I have not done as good of a job utilizing the dosage aspect. For me, I think it’s been most challenging having a patient perform an exercise for 3×30. Usually the MET patient population I’m thinking of are not as highly motivated as I would like. However, I think much of this has to do with my inability to appropriately explain to them the importance of having a high dosage exercise which luckily this paper helps a lot with. The article did a great job of explaining how the patient can initially be involved at determining their own dosage to decrease fear while working up to the goal of 3x/30. Eric Kopp also provided a great way to explain to patients the importance of global exercise and to follow-up with his talk, probably my favorite part of the paper was the ‘Biological aspects of the medical exercise therapy approach’. Like Kyle, I really liked the use of the term endogenous analgesia. I think communicating this section of the paper in a patient friendly way will make a huge impact on how patients may view exercise and how it can have a positive effect on their pain.

[Aaron Hartstein]

I thought this was a great follow up as well after the MET course and I appreciated the language spoken in the article to assist me with day to day explanations of MET. Previously before the course, I did not prescribe high repetitions of the exercises, but did prescribe the type of exercise for functional impairments. After the Kopp course and reading the article, I believe MET is again another tool in the tool bag to use with patient’s who meet a certain criteria such as fear and avoidance of movement, and especially in large part psychosocial component to care. Overall, MET is to decrease the patient’ subjective pain experience, which entails performing exercises within in a pain free ROM and movement, and to instill self-efficacy, which is my overall goal for any patient. I have noticed my willingness to prescribe 3×30 since the course and to be able to justify my clinical reasoning in doing so. I also appreciate articles to refer to show patients the research behind this method and reasoning.

[Aaron Hartstein]

I agree with everyone else—definitely a great follow-up article following Eric Kopp’s course. I’ve also been trying to incorporate MET more frequently as part of treatment with appropriate patients. I have one patient that recently had his knee manipulated under anesthesia due to significant ROM restrictions s/p MFPL reconstruction from non-compliance. Even after the manipulation, his knee is still very stiff and presents with both capsular and soft tissue restrictions. I’ve been very aggressive with manual therapy to target knee flexion ROM (utilizing some of the new mobilization techniques with the belt from the Kopp course). As expected, the pt. has been sore so I’ve been alternating manual therapy with MET global and semi-global exercises throughout the treatment session and this seems to help with his pain level and mobility.

I think the biggest obstacle with using MET more frequently in the clinic is time limitations, as I’m sure most clinicians would agree. It’s not always feasible to keep patients in the clinic for an hour, especially if you are treating another patient simultaneously that requires primarily manual therapy. For those of you that use MET on a regular basis, any suggestions for managing the treatment session or sequencing the MET exercises to make the most efficient use of treatment time?

[Kyle Feldman]

we have an aide which helps a ton so we can keep an eye on them but not need to be right by them and set up each exercise

[Aaron Hartstein]

Michelle, I’m glad you mentioned your case. I have had two similar patients recently- one who had a TKA this year and was recently DC by another PT and now is back in PT with me due to continued pain/loss of motion. The other had a TKA and manipulation in 2012 and still has extremely limited motion. For both, I have been doing a ton of manual to normalize range but then am using exercise following MET as Eric Kopp mentioned to both actively and passively use the new range. I struggled with the MET approach with them because if I keep the exercises pain free, I feel like they are not gaining motion, but then if I have them push into resistance, they are often achey after. Anyone else have any insight in using MET on chronically stiff capsules, particularly at the knee?

[Myra Pumphrey]

Casey, with chronically stiff capsules, you usually have some part of the movement that is resistance-free, then move into motion with resistance, then finally reach the limit of the motion. Often, you have a lot of motion where there is resistance, but no pain. Sometimes, you don’t have pain until you are at the very limit of the motion. It is my experience that if you work into resistance, but don’t push into pain, you can often make significant gains in motion without excessive soreness. You can use the same concept when setting the patient up for their MET for neuromuscular re-education in the motion you have gained with your manual techniques. Pushing into pain often results in spasm which increases resistance/movement limitation and causes more soreness.

[Aaron Hartstein]

Comments from Anisha (my current student)

“I found this article very interesting and think that MET would be a great approach for patients with chronic pain, especially chronic low back pain. I think that sequencing a treatment by breaking up more local exercises with global ones is a good idea to give the patient’s painful area a break, but also to give the patient the confidence to see that they can exercise for an hour while still being pain-free or close to it. I found it interesting that the patient helps determine the dosage and range of motion of the exercise. It makes sense that control over their treatment would help them, but I was unsure of how to approach this in the clinic. For giving a HEP in the past I have suggested dosage with a number of sets and reps but to use fatigue and their symptoms as a guide. How involved have your patients been in determining their dosage for MET or otherwise for you guys? Have you found it helpful to have more of their involvement?”

[Aaron Hartstein]

Thanks Myra, that explanation was really helpful!

Anisha- I like to tell patients what the goal is (for MET, for example, 30 reps pain free x 3). Then when I set them up, the instruction to remain pain free naturally makes them choose their ROM. I tend to start with a really light weight and monitor them with the instructions of “the goal is 30 reps, but rest before that if you experience excessive fatigue or form change”. Based on how effortful the first set was, I may modify the weight and allow them to choose reps again. If they know the goal of dosage (3 x 30) and of the exercise (with MET- to modulate pain, improve tissue healing… not hypertrophy of muscle, etc.), I think patients can often effectively pick dosage/ROM with your guidance. I think their involvement is critical becuase it encourages self-efficacy and better carryover both for an HEP and after DC, plus we need their input to see how they are tolerating an exercise.

[Kyle Feldman]

I am with Casey
I try to explain in the beginning what we are trying to achieve from the program and how they are using the body to help determine how much to progress
You give a guideline for the medicine but let them have some control of “how they are taking it”
Sometimes the HEP is tricky because you are throwing such big numbers at them. I have started using the statements Eric Kopp used in the lecture to make 30 reps about 45 seconds to 1 minute. So I will say to try to do the exercise for maybe 2-3 minutes with breaks as needed or 3 sets of 1 minute. The smaller numbers keeps the patients calm.
Just an idea

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