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Medical Exercise Therapy for patients with hip, knee and ankle pain ­ dysfunction of the lower extremity.

Tom Arild Torstensen B.Sc (Hons) PT, M.Sc., specialist in manual therapy MNFF Holten Institute, PO Box 6038, S-18106 Lidingö, Sweden. Email: [email protected] The Medical Exercise Therapy philosophy for treating lower extremity dysfunction is to use functional weight bearing starting positions while working through functional movement patterns and focusing on coordination and kinetic control. To achieve functional movement patterns, unloading or deloading principles are utilized in the early phase when the patient is experiencing pain, swelling, or decreased range of motion. An effective way of unloading the body in the Medical Exercise Therapy methodology is by using an unloading frame attached to a lateral pulley. The specially designed Medical Exercise Therapy equipment thus enables you to exercise patients in functional movement patterns as well as treat relevant anatomical structures in a functional weight bearing starting position. In 1982, Oddvar Holten (1,2) was invited to the USA by Bjørn Svendsen (3) and they introduced Medical Exercise Therapy, for the first time, to US based physiotherapists. Since then, Bjørn Svendsen has further developed methods and equipment in order to use the principles of unloading (3). Doug Kelsey (4) has also developed a new piece of equipment which is an unloading device combined with a treadmill. In an article in PT today, Lawrence W. Styles (5) addressed this new development using expressions such as "assisted exercise" in lower extremity rehabilitation and "maximum tolerable load" for that activity (MTL). Kelsey (4) uses expressions such as "load tolerance", "partial weight bearing activities", and Kelsey argues that it is of the utmost importance that the training program is designed to use appropriate load tolerance for particular tasks: "Ideally, rehabilitation should replicate activities of daily living as closely as possible. To do this, at least three factors must be considered: 1) the type of training: task specific (closed chain) vs. open chain; 2) the load tolerance of the tissue; and 3) the "optimal load zone" and the volume of training within that zone. A task-specific exercise exactly mimics the particular desired activity of daily living. For example, to improve stair-climbing ability, stair climbing must be practiced. Similarly, if improvements in running are desired, then running, not swimming, must be practiced. Task specific motor improvements depend on the manner in which tissue is trained due to neural adaptation.", (Kelsey 1994 (4)). Today, there is a bundle of scientific evidence in favor of closed kinetic chain exercises versus open chain in the rehabilitation of lower extremity dysfunction. Closed kinetic chain exercises have been found to be superior to open chain in regards to: 1) decreasing shear forces on the knee, 2) increasing proprioception, 3) increasing muscle group coordination. Today, closed chain exercises are viewed as economical, efficient, and as an effective means of rehabilitation with the ultimate goal of enhancing proprioception, thus gaining lower extremity joint stability (Bunton 1993 (6), Beynnon 1997 (7), Bynum 1995 (8), Escamilla 1998 (9), Graham 1993 (10), Jenkins 1997 (11), Yack 1993 (12), 1994 (13)). However, Beynnon (7) has performed in vivo measurements on the loading of the anterior cruciate ligament (ACL) during different exercises, concluding that open chain exercises do not put more strain on the ACL when compared to closed kinetic chain exercises. There are, of course, many good arguments for using closed kinetic chain exercises, but it is not always true that they strain the ACL less when compared to open kinetic chain exercises. The goal of a typical Medical Exercise Therapy program for any dysfunction of the lower extremity is, in an early phase of the treatment, to introduce seven to nine different exercises combining closed and open chain exercises. In most cases, the number of sets is three, and the number of repetitions performed in each set is thirty. Thus, the patients are doing three sets of thirty repetitions with a thirtysecond break between each set. With a warm up (15-20 minutes), the total number of repetitions during a one and a half-hour treatment session ranges from 1000 to 1500 repetitions. The theory behind using such a high number of repetitions is to stimulate healing processes of the injured structures through increased circulation and a biomechanical loading of the stress lines of the tissue. The high number of exercises and repetitions are also aimed at decreasing the pain experience, increasing range of motion, and improving stability, coordination and kinetic control. The exercise program should also have positive psychological effects on the patient, being a way to stimulate active coping strategies and to decrease fear about being active. Many patients say that they are surprised at how much they could exercise, and the key to this is choosing comfortable starting positions and then having them work through the available comfortable range with an appropriate repetition and weight dosage. When starting to exercise, the patient may only be able to do two to three exercises with fewer repetitions, but as the patient improves, new exercises are added and the "old exercises" are continuously upgraded regarding weight, repetitions and range of motion.

Tom Arild Torstensen B.Sc (Hons), PT, M.Sc., specialist in manipulative therapy MNFF. Holten Institute for Medical Exercise Therapy, Box 6038, 181 06 Lidingö. Tel: 08-446 05 57. Fax: 08-731 70 55. E-post: [email protected] Hemsida: www.holteninstitute.com

Over the last ten years, there has been an increased focus on the importance of using closed kinetic chain exercises to treat movement disorders of the lower extremity. Maybe this focus has gone too far? This author believes that there is an important place for open chain exercises as well. One just has to be clear regarding the purpose of the exercise. Open chain exercises can be used to treat a function on an impairment level, decreased range of motion for example, where a high number of repetitions and exercises with varied starting positions are done with controlled and coordinated ballistic movements which will result in a proper stimulus to gain range of motion. Open chain exercises can also be used to treat pain by finding a comfortable starting position and an acceptable range of motion, then performing a high number of repetitions in multiple sets. This kind of endurance training, performed "within the comfortable range of motion as close to pain free as possible", stimulates mechanoreceptors thus "blocking" the nociceptive stimulus. When tissues are overloaded or injured (trauma or surgery), an inflammatory process may follow with a release of substances that increase pain receptor sensitivity (Dubner 1992). The substances in question are cytokinin, bradykinin and prostaglandins. Both open and closed chain exercises, done in a high number of repetitions to increase circulation locally and globally, may change the chemical environment in the tissues causing a decrease in the release of the above mentioned pain stimulating substances. The graded exercises may also result in a release of the patient's own pain inhibiting substances, namely endorphins, both locally in the periphery and centrally in the brain. The exercises may also change the patients' beliefs about physical activity in relation to their dysfunction, making them believe that it is quite possible to do a lot of work. This gives them an active coping mechanism, which again will help modulate the pain experience. A usual comment from many patients arriving in pain and having to use a crutch is that they are genuinely surprised regarding how much they can do, even though they have a great dysfunction. They are surprised that they were able to perform many exercises with a high number of repetitions - and that afterwards it felt good. This intensive two day course covers the use of graded exercise therapy for clinical diagnoses such as hip and knee arthritis, total hip replacement, patellofemoral pain syndromes, ankle sprains, instability problems of the knee or ankle, sprained or strained muscles/soft tissue, Achilles tendonosis, rehabilitation after surgery to the knee (anterior/posterior cruciate ligament reconstruction, injury/surgery to the lateral/medial meniscus), and rehabilitation after fractures of the lower extremity. A live patient presentation will give you increased insight in the clinical reasoning process from taking up a detailed past and present history, performing clinical/functional tests ending up with an individual graded exercise program tailored specifically for this particular patient dysfunction. Scientific evidence will be presented showing that there is today good evidence for an active graded exercise program for patients with hip and/or knee arthritis (14,15,16)

References: 1. Holten Oddvar. Treningsterapi. Fysioterapeuten 1968;35(8):237-240. 2. Holten Oddvar. Medisinsk treningsterapi, Fysioterapeuten 1976;43(1):9-14 3. Olson J, Svendsen B. Medical Exercise Therapy: an adjunct to orthopaedic manual therapy. Orthopaedic Practice 1992;4 (4): 32-37. 4. Kelsey D, Tyson E. A new method of training for the lower extremity using unloading. JOSPT 1994;19(4):218-223. 5. Styles LW. New treatment approach. Assisted exercise in lower extremity rehabilitation. PT Today 1995, may 29: 14-22. 6. Bunton EE, Pitney WA, Kane AW, Cappaert TA. The role of limb torque, muscle action and proprioception during closed kinetic chain rehabilitation of the lower extremity. Journal of Athletic Training1993;28 (1):1020. 7. Beynnon BD, Johnsen RJ, Fleming BC, Stankewich CJ, Renström PA, Nichols CE. The strain behaviour of the anterior cruciate ligament during squatting and active flexion-extension. A comparison of an open and a closed kinetic chain exercise. Am J Sports Med 1997;25(6):823-829. 8. Bynum EB, Barrack RL, Alexander AH. Open versus closed chain kinetic exercises after anterior cruciate ligament reconstruction. A prospective randomized study. Am J Sports Med 1995;23:401-406. 9. Escamilla RF, Fleisig GS, Zheng N, Barrentine SW, Wilk KE, Andrews JR. Biomechanics of the knee during closed kinetic chain and open kinetic chain exercises. Med Sci Sports Exerc 1998;30(4):556-569. 10.Graham VL, Gehlsen, Edwards JA. Electromyographic evaluation of closed and open kinetic chain knee rehabilitation exercises. Journal of Athletic Training 1993;28(1):23-30. 11.Jenkins WL, Munns SW, Jayaraman G, Wertzberger KL, Neely K. A measurement of anterior tibial displacement in the closed and open kinetic chain. JOSPT 1997;25(1):29-56. 12.Yack HJ, Collins C, Whieldon TR. Comparison of closed and open kinetic chain exercises in the anterior cruciate ligament-deficit knee. Am J Sports Med 1993;21(1):449-452. 13.Yack HJ, Riley LM, Whieldon TR. Anterior tibial translation during progressive loading of the ACL-deficient knee during weight bearing and non weight bearing isometric exercise. JOSPT 1994;20(5):247-253. 14.Dieppe P. Osteoarthritis: Time to shift the paradigm. BMJ 1999;318:1299-1300. 15.Mangione K et al. The effects of high intensity and low-intensity cycle ergometry in older adults with knee osteoarthritis. J Gerontol A Biol Sci Med Sci 1999;54:M184-190. 16.Van Bar ME al al. Effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee. Arthritis and Rheumatism 1999;42:1361-1369

Tom Arild Torstensen B.Sc (Hons), PT, M.Sc., specialist in manipulative therapy MNFF. Holten Institute for Medical Exercise Therapy, Box 6038, 181 06 Lidingö. Tel: 08-446 05 57. Fax: 08-731 70 55. E-post: [email protected] Hemsida: www.holteninstitute.com

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