Medical Exercise Training: The New Modality

Medical Exercise Training InstituteManaging Medical Conditions with Exercise

Michael K. Jones, PhD, PTwww.PostRehab.com | 1-888-610-0923

Medical Exercise Training ..... the New Modality

Medical Exercise Training Institute | www.postrehab.com | 1.888.610.0923

Mandate for Change

Changes in the health care and insurance industries have mandated the use of exercise as a strong component of the medical management of chronic diseases. Though there is much research to support the positive influence of exercise on medical conditions – the actual integration of exercise protocols and guidelines into health care management is limited. This paper will provide a model for the integration of Medical Exercise Training into the medical management of common chronic conditions.

The statistics on the cost and occurrence of chronic disease are staggering. The American health care system is beginning to buckle under the costs and the numbers of individuals with chronic disorders and/or surgical procedures such as:

1) diabetes (DM) 2) hypertension (HTN) 3) osteoarthritis (OA) 4) total joint replacements (TJR) 5) low back pain (LBP) [spinal surgery including laminectomy & fusion]

Each of these conditions or procedures is positively impacted by exercise. These are only a few, but the most prevalent, of the chronic conditions that cost the health care system billions.

Wasted Billions

With costs in the billions, and rising, it’s obvious that something has to change.

• Diabetes affects some 25.8 million Americans at a cost of $245 billion, of which, 43% of these costs are inpatient hospital care. Type II diabetics are easily managed with diet and exercise guidelines.

• Hypertension affects 67 million Americans at a cost of $93.5 billion. Hypertension is another chronic condition that is managed with exercise and diet guidelines.

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• Low Back Pain – 80% of Americans will experience low back pain (LBP) at some point in their lives. The total cost of care related to LBP is estimated at $100 billion for 2010. The most frequent surgical procedures to manage LBP are: 1) laminectomy and 2) spinal fusion. For these two procedures, we can add $2.3 billion and $13.3 billion respectively to overall cost of LBP. Again, in many instances, a well-structured progressive exercise program can control some of these costs of LBP and associated surgeries.

• Osteoarthritis (OA) is another chronic disorder that can benefit from exercise. Annually, more than 409,000 hospitalizations occur due to OA, and some 27 million Americans suffer with arthritis. The majority of those surveyed with OA report primary involvement in the spine, hip and/or knee. Total annual cost associated with the treatment of OA is estimated at $89.1 billion. This works out to roughly $4603/person receiving treatment.

• Total hip and knee replacements are commonly performed for chronic OA. Loss of function is the primary reason for hip and knee arthroplasty. Estimates place the number of total hip and knee replacements annually at 450,000 and 720,000 respectively. The TJR client benefits tremendously from exercise using a structured protocol-based program.

Traditional Philosophy in Healthcare

The current standard treatment process for DM and HTN centers on drug therapy and diet modification. The research con-tains dozens of studies advocating the importance of cardiovascular and resistance training as part of the management for hypertension. The same is true for diabetes. Cardiovascular exercise and a simple resistance program significantly reduce blood pressure, blood glucose and A1c levels.

The standard treatment of low back pain, spinal fusion, laminectomy and total joint replacements includes drug therapy and short bouts of physical therapy or chiropractic care. These modalities provide temporary pain relief and restoration of low-level function. The level of function restored is not adequate for most patients to return to their pre-injury or surgery functional level. A structured protocol-based approach to exercise is an effective benefit for these procedures.

Passive modalities such as hot and cold packs, electrical muscle stimulation, and ultrasound are shown to be beneficial during the first 6-8 weeks of the acute and sub-acute stages following injury. After that period, exercise is clearly the most important modality to restore function. The Quebec Task Force study of January 1987 reported the importance of exercise as the key to long-term management of musculoskeletal conditions. Structured, proto-col-based exercise is essential after the initial period of chiropractic and/or physical therapy. Outcomes are significantly enhanced when lifestyle educa-tion is incorporated into the exercise program.

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New Standards in Exercise

Many patients are referred to fitness programs. Improvement with fitness programming is often measured in terms such as “feels better”, “more energy” or “better health”. One of the frustrations when referring individuals with medical condi-tions to fitness facilities is the ambiguity of outcome measures. Medical professionals need more specific information to determine if the fitness program is having a positive impact on the client’s condition.

Medical Exercise Training (MET) protocols establish a new standard containing specific staged exercises and functional outcome measures or “FOMs” for the delivery of exercise programs. These FOMs serve as measurable parameters that are periodically re-assessed to determine exercise effectiveness. The functional outcome measures used in MET include:

Physicians, physical therapists, chiropractors and Medical Exercise Specialists (MES) all understand the FOMs. Therefore, FOMs are universal and easily interpreted. Incorporation of FOMs into medical exercise training programs assures the ex-ercise sessions are targeted toward improving the client’s function specific to the needs of their condition. The MES com-municates with the medical professional to obtain FOM values. FOMs are measured and reviewed throughout the client’s medical exercise training program.

Utilizing FOMs as goals and yardsticks to measure progress is an essential concept in MET. The MET communication and documentation systems allow Medical Exercise Specialists to record and report the FOMs in a timely and effective manner. Every MET session is documented to ensure safety and program continuity. The use of FOMs and the MET communication/documentation system is unique in the fitness arena and allows Medical Exercise Specialists to truly partner with medical professionals and insurance carriers to enhance the health and function of clients.

MET Functional Outcome Measures

1. Glycosolated Hemoglobin (A1c) 2. Blood Pressure 3. Blood Glucose 4. Bone Density 5. Range of Motion 6. Muscle Strength Testing 7. Functional Assessment Scale 8. Cholesterol Levels 9. Pain Scale 10. Anthropometric Measures 11. Resting Heart Rate 12. Body Mass Index

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These areas are not addressed by standard fitness programming. Fitness programs at best are partially effective and do not truly assist medical professionals with the management of medical conditions.

The New Concept - Medical Exercise Training

All the components listed above are incorporated into a relatively new concept known as “Medical Exercise Training”. Medical Exercise Training or MET is the development of safe and effective, structured, protocol-based exercise program-ming specific to the client’s medical condition. MET programs focus on exercise techniques to enhance strength, flexibility, cardiovascular endurance, balance, and stability as well as FOMs. Clients with cardiovascular, neurological, metabolic and musculoskeletal disorders benefit from MET services. MET is also able to manage surgical conditions including total joint replacements, spinal, knee and shoulder surgeries as well as pre-surgical training to enhance post-operative outcomes. Each MET protocol monitors specific “functional outcome measures” to determine the effectiveness of the exercise.

MET is specific and directed toward resolving the client’s functional deficits that remain after discharge from physical therapy and/or chiropractic care. General fitness programs will not adequately address and manage the needs of medical-based clients. Fitness programs can be beneficial but the outcomes are limited and unpredictable. On the other hand, MET programs are specifically designed to improve functional outcome measures. MET programs are not designed to take the place of professional physical therapy or chiropractic services. These disciplines have well documented benefits for short-term management of pain and limited functional restoration – MET is the best long-term option. MET focuses on functional outcome

Fitness programming must adopt a new approach to include:

• Specific functional outcome measures to gauge progress and effectiveness

• Use a protocol-based approach containing specific exercise progressions and

documentation/communication guidelines designed for individual medical conditions

• Be finite and provide specific guidelines on frequency and duration

• Engage clients in home exercise and lifestyle education

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Medical Exercise Training is beneficial for the following conditions/procedures:

Osteoarthritis Diabetes Hypertension

Lumbar Disc Herniation Total Hip Replacement Total Knee Replacement

Achilles Tendon Rupture Plantar Fasciitis Cervical Strain

Laminectomy Spinal Fusion Osteoporosis

Shoulder Impingement Rotator Cuff Tear Meniscal Tear

Shoulder Dislocation Cerebrovascular Accident Carpal Tunnel Syndrome

Rheumatoid Arthritis Parkinson’s Disease Lateral Epicondylitis

Medial Epicondylitis Thoracic Outlet Syndrome IT Band Syndrome

Tibial Plateau Fracture Closed Head Injury Ankle Fracture

Ankle Sprain AC Joint Separation Bicipital Tendinitis

PCL Rupture MCL Sprain LCL Sprain

Spondylolethesis Ankylosing Spondylitis Brachial Plexus Strain

ACL Rupture/Reconstruction Greater Trochanteric Bursitis Cervical Disc Herniation

Piriformis Syndrome Patello-Femoral Syndrome Spinal Stenosis

Lupus Erythematosus Frozen Shoulder Patella Tendon Rupture

Cerebral Palsy Myocardial Infarct Obesity

Patelloectomy Total Shoulder Replacement Cancer

measures.MET does not use any physical therapy modalities such as ice, heat, EMS, traction, and/or joint mobilization/manipulation. The sole modality used in MET is “exercise”. Lifestyle management training is also incorporated into MET programs. Life-style management provides client education, defined wellness strategies and independent exercise guidelines to hasten functional improvement. MET also utilizes the services of registered dietitians to provide a full range of medical exercise services.

“Exercise is the key to long-term management of most medical conditions”. Several studies in recent years support this statement. The most important of which, is the previously mentioned “Quebec Task Force” study. The study clearly sup-ports the focus on exercise to enhance function after the initial 6-8 weeks of physical therapy or chiropractic care. Other studies, further support exercise as a primary modality once the client has moved past the acute and sub-acute stages of treatment.

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New Health Care Professional – Medical Exercise Specialist

MET provides an economical option once physical therapy and chiropractic care are complete. MET promotes active par-ticipation by the client in the exercise and educational programs. The dependence on physical therapy modalities is not part of the MET model. MET services are provided by “Medical Exercise Specialists” (MES).

The MES is not a “personal trainer”. The MES has extensive training in medical exercise management and a clear under-standing of his or her role. Each MES is trained in the management of medical conditions using a protocol-based approach to exercise. The MET protocols are the basis of every aspect of MET services. The protocols allow a standardized approach with measurable outcomes and specific exercise selection and progression. The MES is trained in assessment techniques and documentation procedures. The role of the Medical Exercise Specialist is to:

Medical Exercise Training Model

The ideal MET client is 25 – 80 years of age with a “medically-stable” chronic medical condition that may range from obe-sity to a total joint replacement. The client has a referral from a physician or other medical professional. MET clients are usually seen 2 -3 times per week for 8 – 12 weeks. Each session consists of strength, cardiovascular, stability, balance and flexibility training specifically tailored to the client’s condition.

Medical Exercise Training options include one-on-one training, small group training and/or MED-FIT educational classes. MET requires a “referral” from a medical professional to begin the program. The client’s program is developed based on the MET assessment conducted during the first session and the appropriate MET protocol.

During the first session the MES completes a thorough medical history on the client followed by the “musculoskeletal screening”. The client is then put through a regional MED-FIT Assessment. Goals are also established for the client. The FOMs are part of the program goals. The results of the assessment and a summary of the MET program are communi-cated to the referral source and insurance carrier in a one-page assessment summary. Every 30 days a progress report is forwarded to the medical professional and insurance carrier to provide client status updates. Every MET session is docu-mented and recorded in the client’s file. The data gathered from the improvement in FOMs allows the MES to develop more effective guidelines and protocols.

The Role of the Medical Exercise Specialist

• Deliver safe and effective exercise• Effectively communicate to report client progress to medical professionals• Provide recommendations on exercise to clients and medical professionals• Document client functional outcomes • Provide wellness and lifestyle education

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Medical Exercise Specialists follow a protocol to progress their clients. These MET protocols are specific to clients’ medical condition and provide assessment and progression guidelines as well as MET criteria. The MET criteria minimizes the possibility of an “acute or subacute” client entering the program. MET protocols are available for 60 medical conditions.

MET sessions are designed to not only to improve the client’s strength, flexibility, endurance, balance and stability related to their medical condition, it also provides lifestyle education. MET picks up where physical therapy and chiropractic care leave off. MET recognizes exercise plus education, produces positive functional outcomes for clients.

Medical Exercise Training Options

MET programs usually have duration of 30 – 90 days. Clients are recommended to participate 2-3 times per week. Based on their needs, clients can participate in one-on-one sessions, small group training and/or Med-Fit education classes.

• One-on-One MET sessions are available for all conditions. Condition specific sessions are delivered in a private setting and are either 30 or 60 minutes in length. For those who want schedule flexibility and need more personalized attention, this is an ideal program.

• Small group MET (SGMET) is the most economical option. SGMET is particularly useful in managing clients on a fixed income. SGMET is available for clients with similar conditions. SGMET sessions consist of 2 to 4 clients.

• “MED-FIT” training classes are available for low back pain, diabetes & hypertension, osteoporosis and total joint replacements. The classes are the “lifestyle” component of MET services. These classes are delivered to groups of 8 to 10 participants. MED-FIT sessions consist of 45 minutes of condition-based exercise and 15 minutes of lecture on a point of importance related to the condition.

Back School Total Joint Replacement Diabetes, Hypertenstion & Obesity

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Total Hip ReplacementProtocol

Referral toPhysicalTherapy

Referral to PostRehab Training

Post Rehab Criteria:

No Open WoundsFull Weight Bearing

Minimal Pain (4 or <)DC’ed Physical Therapy

Medical Clearance12 Weeks Post-Op

Post Rehab Assessment:

Medical HistoryMS Screening

Gait/Balance AssessmentCheck Active Hip ROM

Lateral Step UpLeg Press Strength

Leg Extension StrengthLeg Curl Strength

Hip Adduction StrengthHip Abduction Strength

Hip Manual Muscle TestingHarris Hip Scale

Precautions

Phase I(Week 1 – 2)

Strength

Quad/Glut/Adductor IsometricsLeg Press

Hip BridgingMulti-Directional Leg Raises

Standing Terminal Knee ExtensionBalance Activities

Endurance Training (Bike/Treadmill)

Phase II(Week 3 – 4)

Strength

Continue with Phase I (Increase Intensity)Wall Squats

Leg ExtensionHip Adduction (do not cross midline)Hip Abduction (do not cross midline)

Stationary Biking (Adjust seat to avoid excessive hip flex)

(Lateral Step Up (3-4 inch step)Perform Harris Hip Scale Every 4 weeks

Phase III(Week 5 – 6)

Functional Strength

Continue with Phase II (Increase Intensity)Unilateral Wall Squats

Lateral Step Up (Increase to 4 inches)Watch for signs of Patello-Femoral Syndrome

Phase IV(Week 7 – 8)

Functional Conditioning

Continue with Phase III (Increase Intensity)Lateral Step Up with Hand Held Weights

Mini-Squats with Swiss BallCircuit Training

Perform Harris Hip Scale Every 4 weeks

Obtain MedicalClearance from

Operating Physicianand

Physical Therapist

• Avoid combined hip flex > 90o, hip add X mid-line & int rotation

• Avoid excessive mvt into hip flex, hip add or hip int rotation

• Avoid sitting on low chairs or low seats

Doesn’t meet criteria.Refer back to MD.

Total Hip Replacement Flowchart

Progression Guidelines:

1) Each session must include hip abduction exercise

2) Glut max is very important to gait

3) Begin Leg Press with ¼ to ½ body weight

4) Ultimate goal is unilateral leg press with equiv. of body weight

5) Discomfort the next day determines exercise intensity

Low Back PainProtocol

Referral toPhysicalTherapy

Referral to PostRehab Training

Post Rehab Criteria:

No Radicular PainFull Lumbar ROM

Full Motor Control ofLower ExtremitiesMedical Clearance

Specific Lumbar Diagnosis

Post Rehab Assessment:

Medical HistoryMS Screening

Oswestry ScaleSpinal Stability Assessment

Abdominal StrengthBack Extensor StrengthWall Squat Endurance

Leg Press StrengthLeg Extension Strength

Leg Curl StrengthRowing Strength

Chest Press StrengthLateral Raise Strength

Thomas TestOber TestSLR Test

Fabere TestPrecautions

Phase I

Stretching of Lumbar/Trunk MusclesChest Press

RowingLeg Extension

Leg CurlLumbar Stabilization Level 1

Stationary Biking (recumbent)Lateral Raise

Abdominal/Back Extension StrengtheningAquatic Training (if available)

(Oswestry Scale every 2 weeks)

Phase II

Continue with Phase I (Increase Intensity)Lumbar Stabilization Level 2

Rotary Torso (controlled)Back Extension


Phase III

Continue with Phase II (Increase Intensity)Lumbar Stabilization Level 3

Functional Training Activities (based on job site analysis)


Obtain MedicalClearance from

Operating Physicianand

Physical Therapist

• If radiating pain or numbness/tingling develop

discontinue exercise

• Avoid uncontrolled trunk rotation and flexion

• Each session must have cardiovascular training, lower

extremity strengthening and spinal stability training

• Spinal stability training includes instruction in lifting,

pushing, pulling and carrying

• Decompress the spine by removing axial loading

• Gluteal strengthening is vitally important

Doesn’t meet criteria.Refer back to MD.

Low Back Pain Post Rehab Flowchart

Progression Guidelines:

1) Discomfort or pain the night after exercise indicates exercise intensity is too high

2) With each 10% increase in Spinal Stability score, increase exercise intensity

3) Lower extremity strength will outpace trunk strength gains

4) Low back pain is directly correlated to limited lower extremity strength

5) Begin teaching lifting, pushing, pulling & carrying immediately. Do not allow progression if

client is unable to find and maintain neutral.


All of the options above allow the client to receive the maximum benefit from MET.

Upon discharge, the client is provided with a home program. The client may opt to perform the exercise independently or enter a medical membership program. The medical membership provides access to the MET facility and 30-day checkups with a Medical Exercise Specialist.

Integration of Medical Exercise Management

The importance of exercise is abundantly clear. Regretfully, the integration of exercise into medical management has been slow to occur. MET is designed to work in conjunction with medical professionals. The use of strength, cardiovascular, flex-ibility, balance and stability training positively impacts a wide range of medical conditions. The unique components of MET include:

The MET components make it perfect for partnering with medical professionals in the management of chronic disor-ders. MET will have an immediate impact on health care costs, patient outcomes and overall wellness. As you can sur-mise from this discussion, Medical Exercise Training is a key to long-term management of chronic medical conditions. MET can have a significant impact on the lives of those with chronic disease. Introducing MET to sufferers of chronic disease; medical professionals, employers and insurance carriers will make a tremendous difference in the outcomes of these dis-eases and produce huge savings.

For more information on Medical Exercise Training, Certifications, Guidelines and Protocols, please contact:

Dr. Michael K. Jones, PhD, PT 22136 Westheimer Pkwy #349 Katy TX 77450 1.888.610.0923 [email protected] www.PostRehab.com

MET Components:

1) Specific MET protocols & progression guidelines

2) Utilization of functional outcome measures as yardsticks for program effectiveness

3) Communication and documentation systems to assure optimum results for the client

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Medical Exercise Training: The New Modality

Healthcare

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