MEDICAL EXERCISE THERAPY (MET) – HOLTEN INSTITUTE PROGRAM
The MET training pathway is composed by 3 MET – Medical Exercise Therapy courses (1 weekends each) + 1 CRT – Cognitive Rehabilitation Therapy training course (1 weekend)
Medical Exercise Therapy (MET) – criteria
MET – Medical Exercise Therapy is a scientifically and evidenced based form of treatment that is underpinned by the biopsychosocial model of human function. Oddvar Holtens MET criteria became accepted by the Norwegian Health Insurance and National Insurance Administration in 1967. Since this time, MET has been nationally subsidized by the National Insurance Scheme (C32 – MTT) with allowance of up to 5 patients per group.
“A treatment form where the patient trains with specially adapted exercise equipment. The equipment is designed to optimally stimulate relevant functional qualities related to various body systems such as the neuromuscular, artrogeni , circulatory and respiratory systems. To achieve this effect, training occurs from specially adapted beginner positions where movement occurs through defined movement ranges, or parts thereof, with the appropriately prescribed dosage of load. For MET to have effect, a minimum of 1 hours training is expected (excluding showering or change of clothes). Before beginning MET treatment, a thorough assessment is conducted based on the following areas 1) muscle testing, 2) specific joint testing and 3) functional testing. The physical assessment and the patient’s history form the basis for an optimalized and tailored individual trainings program. Throughout the treatment period, the patient will receive retesting and on-going assessment that will ensure any adjustments or progressions needed to the program are timely met. A maximum of five patients per treatment group is allowed”, Oddvar Holten (1967)
MET – from 1967 to present day
MET was originally a biomedical treatment form with a focus on specific trainings stimuli that aimed to effect changes in various soft tissue structures. Additionally, emphasis was placed on the importance of pain free training and the importance of doing exercises correctly with proper technique. Over time, these focus areas have undergone change, especially the focus on changing tissue structure. Beginning in the 1990’s, Instead of attempting to change or effect soft tissue derangements like arthritis, partial or full thickness tendon tears, proplapse or other similar conditions, the concept of “functional training” was introduced. Functional training instead placed focus on what the patient could actually achieve and the patient’s belief in their own abilities. Focused treatment on what the patient can actually achieve, rather than structural changes in the body is today an important part of MET.
MET – a biopsychosocial treatment
Tom Arild Torstensen, clinincal director of the Holten Institute, has developed MET into a biopsychosocial treatment method. The focus of MET is based still on original concepts but more increasingly today focuses more on the patient`s beliefs and attitudes. A patient for example with constant pain, even at rest, cannot exercise pain free! In this situation, the patient must accept a level of pain associated with the MET treatment. The pain experience however must not be interpreted as dangerous or threatening, causing anxiety. An exercise may be defined as being performed correctly based on the patients pre-existing condition despite the fact that the exercise may initially appear uncoordinated. Working within a biopshychosocial framework, you meet the patient where they are now and on their level. Correctly prescribed MET training will help the patient to take responsibility for their own symptoms, body and health.
MET – Continuous communication and guidance
It is very important that the physiotherapist is close by and on hand, creating a safe environment for the patient to exercise in. Oddvar Holten described back in 1967: “The treatment happens without assistance, but with continuous guidance of the physiotherapist”. The thinking back then even, was that the physiotherapist be on-site to ensure that the exercises were completed correctly. This is still important today. However, more importantly is the feeling the patient gets of a “safe” environment created by the physiotherapist simply by being on-site in the pain modualtion/exercise room. Questions can be answered immediately, uncertainty disappears and the patient knows that the exercise therapy is done in the correct way. When uncertainty and anxiety is reduced, pain becomes less. The physiotherapist also has the opportunity to grade exercises such that the patient is always progressing in their therapy. It is easier and more motivating to exercise when we know we can be successful. In the painmodualtion/exercise room, the therapist becomes the coach and the motivator, a knowledge bank where the patient can use and find support in to improve their level of function. This often reduces patient’s symptoms.
MET – Global, semi-global and local exercises
METs focus today is largely on the dosage of exercise therapy/training. It is the dosage that gives the desired treatment effect, and not the choice of specific exercises for individual muscles or other soft tissue structures. An adequate trainings dose is achieved through a combination of GLOBAL (whole body exercise), SEMI-GLOBAL (exercise with one extremity or kinetic chain) and LOCAL (exercises with a part of the kinetic chain for example one joint) exercises. A combination of GLOBAL, SEMI-GLOBAL and LOCAL exercises gives the optimal exercise dose for the patient. We at the Holten Institute strongly believe that it is the DOSAGE of training that gives the treatment effect and not how specific an exercise is. In particular, use of GLOBAL exercises repeated several times in a session is an exciting way to increase the exercise dose. When the dosage of exercise is increased, we activate our descending pain inhibiting system and thus hinder nociceptive input to the central nervous system.
MET – Exercise therapy is pain modulation – a new concept in physiotherapy?
There exists today a large body of evidence and research that supports the thinking behind exercising and pain modulation with MET. The goal is to activate the descending pain inhibitory system through the production of endogenous opiates in the central nervous system achieving cognitive and spinal control of nociceptiv input. It is our belief, that the best way to achieve this is through many repetitions in series of an individualized program combined of aerobic (Global Exercises), semi-global and local exercises. When the patient is pain free, the use of known and common training principles within strength and conditioning can then be used.
MET – Baseline and gradual progression
Successful pain modulation training requires that the physiotherapist is on-site in the pain modualtion/exercise room, guiding patients and answering directly to any questions. This gives the patient confidence in knowing the correct way to perform the exercises avoiding nocebo effects. If the patient has to exercise with pain, there is now a larger chance for the patient to realize that it is not dangerous to exercise with pain or to sweat a little. Good communication between the physiotherapist and patient in the “pain modulating room” reduces the negative psychological factors that are associated with pain. The dosage of exercise therapy is initially graded to a level the patient can tolerate. Together in consultation with the patient, the number of exercises, load and range of movement steadily increases. To be successful with this method, It is fundamental to first establish a correct exercise baseline for the MET treatment. This reduces the negative psychological reactions with movement and training which can easily increase pain, the socalled nocebo effects. Through a specific test method, the patient themselves can determine the exercise dosage.
MET – 3 sets of 30 repetitions, 3-10 minutes
Why 3 sets of 30 repetitions? Why so many repetitions? Research says the following. “To activate the descending pain inhibiting system, the training must be either short and very intensive or low intensity over longer time”. Many patients find it easier with high repetitive and low load training. For patients with pain, it is often a nicer way to exercise. For many years we have applied the 3×30 model. 3×30 can be changed to three, four or even 10 minutes continuous dynamic training. A MET program that incorporates 9-11 exercises over 70-90 minutes is ideal for many patients. However, some patients may only tolerate 20 minutes or less initially. For the exercise therapy to have additional clinical effect to positive expectations efefcts (placebo), it is important that increases or progressions are prescribed gradually. We have completed many clinical studies that show our model of exercise therapy gives significant clinical improvements for various patient groups when compared to eexrcise dosages of only 20-30 minutes. When the patient begins to be symptom free, common principles in strength and conditioning training can and are further utilized by the therapist. We aim to introduce a new and exciting concept – “Pain modulation training”. It is very important to understand the difference between pain modulation training and strength training.
MET – exercise pain free or as close to pain free as possible
In modern MET, pain free or as close to pain free exercise therapy is still preferred, assuming that it is possible to find adequate exercises! Think about a pain scale from 0-10, where 0 is no pain and 10 is the worst pain imaginable. As good as pain free is equivalent to 1-2/10 on the pain scale. Patients with constant pain must of course move and exercise, but the pain must be acceptable. To understand what is acceptable pain, MET uses the “avoidance-endurance model”. In this model, the patient themselves decide how much pain he or she is going to exercise with. Cognitive techniques such as gradual exposure and acceptance is an important part of the exercise therapy for patients with constant pain.
MET – Group based treatment
MET treatment is group based, but each patient has their own exercise program. Each exercise program is individually tailored according to the patients needs using the biopsychosocial model. Group based exercise therapy is also very cost effective. 5 patients exercise at the same time, for a minimum of one hour and under continuous guidance of the physiotherapist or other qualified instructor. A group can consist of a diverse range of patients. One patient can previously have suffered a mild stroke, a second with long term pain, a third with pain after total knee replacement surgery, a fourth with an ankle sprain and a fifth with complex regional pain syndrome.
You can practice with MET and MET exercises without specially designed equipment
All exercises and exercise programmes we use can be performed without the need of specially designed exercise equipment. A home exercise program can easily be designed. A pulley apparatus for example, is just a rope that “hangs down from the wall” essentially. All exercises that are performed with a pulley apparatus can be replaced by a band with a knot tied on the end of it and then placed through the top of a door. MET also utilizes one’s own body weight as resistance, combined with simple aids such as hand towels and bands.
Communication about pain (CRT)
Cognitive Rehabilitation Therapy – Communicating about pain.
Communication about pain is communication about feelings. However, it is a big challenge for the therapist to explain this to patient, and especially for the tissue/structure oriented patient, easily feeling stigmatized. ”What! Are you telling me that the pain I am experiencing is in my head? No, my pain is in my muscle, my tendon, my ligament, my intervertebral disc, etc. I am not a psycho!”
Using pictures and text with a humorous tone is a new way to avoid the problem of patients feeling stigmatized. When the patient recognizes him/herself in the pictures the patient often start to talk about what the picture means to him/her. Now the therapist can guide and add information in relation to what the patient is telling. Guiding insted of explaining, is a biopsychosocial way of incerasing the patients knowledge about the patients pain.
Cognitive Rehabilitation Therapy (CRT) is founded in and based on explanatory models of pain psychology and pain physiology combined with physical activity to modulate pain. These explanatory models are adapted and applied practically through exposure and graded exercise terapy that is integrated in Medical Exercise Therapy (MET).
The aim of CRT is to increase a patient’s knowledge and allow them to gain better control of their symptoms. CRT is a form of exposure therapy where the main goal is to decrease fear, decreasing different psychological reactions to pain. Furthermore, CRT aims to improve a patient’s functional level and increase confidence in their own abilities.
Why CRT and not CBT (Cognitive behavioral therapy)? CBT is a clearly defined and evidenced based method for certain behavioral conditions that is generally applied by a psychologist. To avoid confusion, I call the method presented Cognitive Rehabilitation Therapy which incorporates certain components of CBT like exposure.
The chemist in your brainMost agree on this: Our treatment methods relieve pain. However, the treatment technique is not the most important key to pain relief. Research has shown and taught us something interesting. Paradoxically, merely increasing ones knowledge about pain reduces pain. Thoughts and feelings can increase or decrease nociceptive input to and in the central nervous system. Simply put, the patient’s own thoughts and feelings can either increase or decrease pain. Importantly, it is the patients understanding and own explanations together in communication with the therapist that are very important factors in treatment – possibly the most important. Communication relieves pain.
We have no pain receptors, only nociceptors.
The health and medical world is in the midst of a big challenge. The normal and pre-existing understanding for what pain is must change. We must take on a new model of pain and communicate this to our patients. That an acute tissue injury like spraining the ankle, causes pain is no big surprise for anyone. However, it is more difficult to understand why it continues to hurt 8-12 weeks later, when the swelling has subsided and all the tissues (ligaments, tendons) in the ankle have theoretically healed. Now the pain experience do not sit primarily in the tissues, but rather is a result of changes in the nervous system. More related to different feelings, or more specifically an experience, that is first processed and further produced by different areas of the brain.
Under x-ray, MR -, and ultrasound scanning we can see various soft tissues. When we see a change or degeneration in one or more tissues we might be quick to think that here is the reason for the pain. This is erroneous. The continuum between seeing tissue changes on x-ray, MR-, and ultrasound scanning pain and function is very long and there often exists no connection. The reason for this is that we don’t have any pain receptors. This knowledge has existed over more than 40 years. Instead, the body has high tolerance nociceptors for sensing mechanical load, heat, cold and chemical reactions, that might be dangerous for us. Unfortunately, over a long time we have wrongly associated nerve impulses from nociceptors as pain signals.
A tissue injury or a sprained ankle for example, reduces the firing threshold for various nociceptors. They send nerve impulses to the spinal cord and further on to various areas of the brain. If the brain interprets the situation as dangerous (or threat value for your survival) you will experience pain. Thus, pain is an OUTPUT and not an INPUT. The pain you feel is also context related. Meaning that a tissue injury to a finger feels much more painful or dangerous for a professional violin player who is dependent on fine coordinative movements of his fingers to play his instrument compared to a person that has a type of occupation where this function is not that important. This knowledge about pain gives us a great opportunity to treat pain. We get a better understanding on how it is possible to have a prolapse of an intervertebral disc in the back, knee osteoarthritis or other structural changes and still be symptom free. When you realize that pain is closely related to feelings, an interpretation, it becomes easier to understand how close psychological factors can affect discomfort and pain.
Communication is difficult
Communication is also complicated. When explaining something to your patient, the patient will forget 25 percent of what you explained straightaway. Out on the street are a further 25 percent forgotten. The last 50% the patient interpret depending on beliefs, feelings, mood and day. You want your message and concepts to be understood. It is decisive that you get the patient to “mirror” your information and concepts.