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Medical Exercise Therapy

Oddvar Holten - The founder of MET
By the founder of Medical Exercise Therapy Oddvar Holten,
Holten institute for Medical Exercise Therapy

Published in The Norwegian Physiotherapy Journal; Fysioterapeuten in 1968; Holten O. Treningsterapi. Fysioterapeuten 35(8):236-240.

Translated from Norwegian in 1999 by Tom Arild Torstensen, 
Holten Institute for MET,
                                           Lidingö, Sweden 

This form of treating/exercising patients was sanctioned in march 1957 by the Norwegian health authorities as a special therapeutic system with the following criteria;

”A branch of exercise therapy where the patient performs exercises in specially designed apparatus, without manual assistance, but being constantly monitored by the physiotherapist. The apparatus must be designed to optimally stimulate the relevant functional quality in question, neuro-muscular, arthrogenous, circulatory or respiratory. To obtain this effect, the patient carries out the exercises from a defined starting position, in a specific range of motion, against a graded load. Medical Exercise Therapy is based on a minimum of one hour effective treatment (excluding dressing, undressing, shower/bath, etc). Prior to the treatment, a thorough assessment is carried out based on; 1. Muscle tests, 2. Specific joint test, and 3. Functional tests. From the patient´s history and this assessment, a diagnosis is determined and an optimal treatment is established. The therapy also includes re-assessment and adjustment of the exercise program when required. A maximum of five patients in a group setting are treated for one hour”. 

The idea for starting a special physiotherapy clinic for exercise therapy and developing a methodology for this treatment was prompted by two concepts. The first was the increased knowledge of the importance of the use of physical activity to maintain good health in the general population. The second was a belief that it should be possible to develop a physiotherapy clinic satisfying the below criteria:

A picture from Holten Institute in 1967 showing the interior from the exercise room. On the picture you can see a neck exerciser, a multiple purpose bench, three incline boards and dumbbells.
A picture from Holten Institute in 1967 showing the interior from the exercise room. On the picture you can see a neck exerciser, a multiple purpose bench, three incline boards and dumbbells.

Criterium A
The aim of modern physiotherapy is to restore, prevent relapses and increase the patient´s work capacity. The tolerance for physical and psychological loading should be better after finishing the physiotherapy treatment compared to when the dysfunction/disease commenced.

Criterium B
Physiotherapy for the musculo-skeletal system is the treatment of joint connections, muscles and their ”servants”, which are the neuromuscular, cardiovascular and respiratory systems as well as the organs for energy production.

Criterium C
Modern methods for training/exercising are mostly associated with a high number of repetitions (500-1000) which the patient performs him/herself . It is not rational in in such cases that have one physiotherapist per patient.

Här övervakar Odvar Holten en stegövning för en patient med en knäskada. Genom att med armarna dra i dragapparatens stång avlastar han en del av sin kroppstyngd vilken möjliggör ett högt antal repetitioner och set ( 3 set ggr 30 rep). Övningen koordineras och rörelsen sker inom ett komfortabelt rörelseomfång. Detta är en av sammanlagt 7-9 övningar i träningsprogrammet. 

Criterium D
Physiotherapists should, if possible, try to objectively measure the progression of the treatment using objective measurements for dosing the treatment as well as for the outcome of the treatment.

Criterium E
The patient’s degree of motivation will influence the result of the treatment. Increased motivation is obtained when the patient is orientated to the prognosis and the progression of the treatment at all times. This is made possible when the work capacity in the exercise room is dosed and graded in relation to the maximal work capacity of the patient, using objective measurements. In addition, the exercise program is written down on an exercise card. Hence, the patient will objectively follow the scheme of treatment, the progressions of the exercise program, and the improvements in function and pain experience.

When planning my institute, I also had to consider other variables. Two of those were increasing patient motivation and their active coping strategy. In order to obtain this goal, the patients are working in a group setting where each patient has an individually designed exercise program for their movement disorder. The treatment gives the patient increased insight in how an exercise program can improve a painful condition.

Another important factor is the cooperation of the Norwegian Manual Therapy group and the implementation of an active exercise program in relation to pre and post manipulative procedures. Medical Exercise Therapy is integrated with the manipulative procedures to help maintain or improve the function of joints and their related structures after these procedures are performed.

Patient clientele
As many as 75% of the patients treated at the Holten Institute are suffering from low back pain. Of the 75%, 60% are male and and 40% are female. The age range of the two sexes is equal +/-, 25% in the 35-50 year group. Of the patients with back pain most have posture anomalies and static related postural problems as well as postoperative cases.

The Holten Institutet
The Holten Institute consists of a reception area with an office, a changing room with a shower for the patients, assessment and treatment rooms and an exercise room, measuring approximately 170 square meters. Main focus is on the exercise room which size is approximately 100 square meters.

The patients’ journals and exercise charts (programs) are stored safely in the reception area. As patients come in for treatment, the exercise program for each patient is placed on a magnet wall.

Men and women are treated on separate days.

The treatment
The first appointment consists of an assessment and the design of a relevant exercise program. Information regarding body type, posture, past and present level of physical activity, type of work and physical loading at work is recorded. In addition to taking an accurate past and present medical history, orthopaedic tests are performed. Range of motion is recorded using an angle measure, and isometric muscle strength is recorded using Zadigs dynanometer. When the latter is not possible, ordinary manual muscle tests are performed (The Oxford scale 0-5).

All patients with neck and back pain are also assessed according to the Norwegian Manual Therapy system including specific testing at segmental levels.

Information from the assessment helps to determine if active exercise therapy should be used as treatment. The assessment also helps to determine whether to use stabilizing exercises or mobilizing exercises or a combination of both. Other functional qualities to consider when choosing exercises are; joint mobility ­ how to improve local/specific joints or more global joint mobility, muscle strength, muscular endurance, coordination and specific kinesthetic awareness. The above variables are the background for designing an individual exercise program.

The patient is then shown being instructed in the exercises and told the reason why the exercise(s) are used. Each exercise is then tested in order to establish the appropriate dosage. The dosage consists of the size of resistance applied, number of repetitions, number of sets, number of resting periods and the length of the resting period.

The first treatment lasts approximately 1 _ hours. Later treatments last approximately one hour, but some patients do have exercise programs that take 2 ­ 3 hours to finish.

Re-assessment of the exercise program is based on the patient’s reactions to the original design of the exercise program, including the patient maximum capacity when testing out the exercises. The patient’s pain experience and coordination with movement is continously evaluated and considered when regrading the exercises.

The apparatus
The primary criteria for the apparatus is that it should not, in any way, limit any type of exercise or the grading of such an exercise. Through the application of the apparatus, one should be able to stimulate the functional quality relevant for the patient.

The design idea behind the MET apparatus is taken from the American body building apparatus. However, great care has been taken to design a type of exercise equipment to meet the needs of patients. In addition, traditional weight training equipment is part of the MET system.

Treatment results
Since the institute has only existed for a short period of time and is still in its infancy, there are no statistical results showing the effect of this exercise methodology. However, this also applies to most other methods in physiotherapy.

The clinical experience so far is positive and gives good reasons to continue and further develop this exercise methodology.

There seems to be a general attitude that if proper muscle strength and endurance is good it prevents acute and hyperacute low back pain. Experience from patients with heavy bodily work functions shows the opposite, where good working technique seems to be important to avoid musculo-skeletal dysfunction and injuries.

Muscular strength, and endurance training shall give increased tolerance for loading (increased work capacity) making it possible to perform work and daily activities without developing muscular dysfunction and pain.

A well automized movement pattern with well developed muscular awareness (movement awareness) should prevent acute and local overloading.

The field where medical exercise therapy will be an appropriate treatment method will probably vary alot, but experience and research will as time passes on show which dysfunctions/movement disorders that will benefit mostly from medical exercise therapy. However, in addition to neuromuscular dysfunctions I would also like to mention respiratory and cardiovascular conditions as well as patients with rheumatic disorders as categories that usually benfit from the medical exercise therapy.

Medical Exercise Therapy is a new way of organizing the work place and work day to work effectively with exercise therapy. However, the treatment couch is still the most important place where the treatment takes place, but not the only place.

Holten Institute offers 4 different two-day basic courses on Medical Exercise Therapy; cervical dysfunction, back pain, upper extremity dysfunction, and lower extremity dysfunction. The participant will gain knowledge of how to apply graded exercise therapy for various patient categories.
Here you can read on our courses »

Exercise manuals, videos and CD-Rom (Holten Institute’s Resource Guides-RGs that allows you to make personal exercise programs for your patients) can be ordered from Holten Institute
Order here »

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