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1st Sep

2013

Specific Exercise in Physical Therapy

The method of therapeutic exercise used at Mossberg and Associates Physical Therapy is termed Scientific Therapeutic Exercise Progressions (STEP), sometimes referred to as Medical Exercise Therapy (MET), on which it is based. This is an exercise method that is quite different than most exercise approaches used in physical therapy in the USA, however which has deep roots in Europe and Scandinavian Orthopedic Manual Therapy.

Whereas most traditional physical therapy exercise programs focus primarily on muscle recruitment and strength, STEP/MET incorporate known basic science on tissue pathology and regeneration as well as exercise physiology, to optimally affect both muscles/tendons and joint tissues with surrounding soft tissues. After all, the majority of patients seen in physical therapy have problems affecting tissues such as ligaments, joint cartilage and capsule, tendons or spinal discs. These tissues have very low metabolism with poor or no blood circulation, which therefore requires specific exercise dosage to target them.

It is also a precise method where calculations are made of exact number of exercise repetitions, range of motion, speed of motion, resistance, body position, and type of muscle contraction to have the desired effect. Traditional physical therapy more commonly include instructions with a set number of repetitions, e.g. 2-3×10 throughout the course of physical therapy, without specifically measured progressions.

So why does this matter? It matters because all tissues respond to the physical stresses we put on them, in a positive or negative way. Since we know what type of stresses help regenerate each type of tissue, we can apply that to effectively reduce pain, restore mobility and eventually restore our ability to tolerate desired activities.

As an example, a person who has pain from a spinal joint or disc, and who typically would also have painful muscle guarding, could lie down to take compression of the joint, and perform 30-50 slow and pain free movements in different directions, repeated many times per day as able. This will bring in oxygen as well as nutrients through the blood supply, to reduce the muscle guarding and stimulate cartilage and collagen fiber cells in and around joints to promote healing. If there is swelling, the movements also help transport such fluid. Frequent movements also send nerve impulses to the spinal cord and brain, to inhibit pain sensations and “reset” the threshold level at which we actually perceive pain.

To regain normal motion, we also have to restore or develop normal coordination. To achieve this, a minimum of 6000 repetitions, and for some tasks up to 50000 repetitions, are required. Therefore, movement coordination and establishment of permanent “muscle memory”, is one of the most important exercise qualities to develop, which other “low repetition” traditional exercise approaches cannot promote enough.

When we get hurt, we lose normal function of the short and deep stabilizing muscles, which may go into guarding, or simply atrophy and not contract as they should. They are primarily slow twitch endurance muscles, and therefore they first need to be trained with high repetition endurance exercise, e.g. in sets of 25-30 repetitions, daily or several times per week.

Once the pain level has come down and mobility has improved, the exercise program needs to be progressed for most people, to further toughen the connective tissues, and build support or stability around the joints. Now we typically train people in upright or weight bearing positions and with higher exercise intensity both with movement (dynamic exercise) and without movement (isometric exercise), and gradually decrease repetitions to 15-20 per set or for some down to 8-12 repetitions to build more strength- however this is in later stages of training. Both deep stabilizing muscles and superficial fast twitch muscles are exercised to restore normal function. People with arthritic joints or severe disc degeneration are typically not progressed to this level, as increased resistance also leads to greater joint compression.

STEP/MET is also often used to complement hands-on manual treatment to increase joint mobility wherever lacking, by performing exercise where a movement can be isolated to the restricted joint, which can be exercised actively, or with the body part assisted through e.g. weights, or with light resistance added, performed 30-40 times to full stretch, repeated several times per day whenever possible. This lubricates the collagen fibers in the tissues around the joint, and therefore improves mobility. Static stretches for 20-30 seconds can sometimes be added later on when the tissues are stronger and more pliable, to further increase mobility, but this should not be done too early when tissues are weak or irritated.

Just like the world class athlete applies science to design the most effective training program, STEP/MET does this to most effectively recover from injuries or pain, and restore long-term musculoskeletal health and mobility, and prevent recurrence.

Although some of this discussion has been a bit technical, I hope it gives you a better idea of what STEP/MET is. Please feel free to forward it to anyone who could be interested.

Best wishes for your continued good health,

Gunnar

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