Medical Exercise Training: The New Modality

Medical Exercise Training
..... the Ne w Modality
Medical Exercise Training Institute
Managing Medical Conditions with Exercise
Michael K. Jones, PhD, PT
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.
Medical Exercise Training Institute | www.postrehab.com | 1.888.610.0923
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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 proce-dures,
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:
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
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.
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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
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
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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:
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
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.
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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.
Total Hip Replacement Flowchart
Doesn’t meet criteria.
Refer back to MD.
Low Back Pain Post Rehab Flowchart
Doesn’t meet criteria.
Refer back to MD.
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 condi-tions.
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
page 7
Total Hip Replacement
Protocol
Referral to
Physical
Therapy
Referral to Post
Rehab Training
Post Rehab Criteria:
No Open Wounds
Full Weight Bearing
Minimal Pain (4 or <)
DC’ed Physical Therapy
Medical Clearance
12 Weeks Post-Op
Post Rehab Assessment:
Medical History
MS Screening
Gait/Balance Assessment
Check Active Hip ROM
Lateral Step Up
Leg Press Strength
Leg Extension Strength
Leg Curl Strength
Hip Adduction Strength
Hip Abduction Strength
Hip Manual Muscle Testing
Harris Hip Scale
Precautions
Phase I
(Week 1 – 2)
Strength
Quad/Glut/Adductor Isometrics
Leg Press
Hip Bridging
Multi-Directional Leg Raises
Standing Terminal Knee Extension
Balance Activities
Endurance Training (Bike/Treadmill)
Phase II
(Week 3 – 4)
Strength
Continue with Phase I (Increase Intensity)
Wall Squats
Leg Extension
Hip 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 Ball
Circuit Training
Perform Harris Hip Scale Every 4 weeks
Obtain Medical
Clearance from
Operating Physician
and
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
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 Pain
Protocol
Referral to
Physical
Therapy
Referral to Post
Rehab Training
Post Rehab Criteria:
No Radicular Pain
Full Lumbar ROM
Full Motor Control of
Lower Extremities
Medical Clearance
Specific Lumbar Diagnosis
Post Rehab Assessment:
Medical History
MS Screening
Oswestry Scale
Spinal Stability Assessment
Abdominal Strength
Back Extensor Strength
Wall Squat Endurance
Leg Press Strength
Leg Extension Strength
Leg Curl Strength
Rowing Strength
Chest Press Strength
Lateral Raise Strength
Thomas Test
Ober Test
SLR Test
Fabere Test
Precautions
Phase I
Stretching of Lumbar/Trunk Muscles
Chest Press
Rowing
Leg Extension
Leg Curl
Lumbar Stabilization Level 1
Stationary Biking (recumbent)
Lateral Raise
Abdominal/Back Extension Strengthening
Aquatic Training (if available)
(Oswestry Scale every 2 weeks)
Phase II
Continue with Phase I (Increase Intensity)
Rotary Torso (controlled)
Back Extension
Phase III
Continue with Phase II (Increase Intensity)
Functional Training Activities (based on job site analysis)
Obtain Medical
Clearance from
Operating Physician
and
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
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
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
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
drmike@postrehab.com
www.PostRehab.com
page 8

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