Review of First Class in Fellowship

This past weekend, I was fortunate to take my first class in the fellowship at Manual Therapy Institute, starting half-way through the program (due to having completed an APTA-credentialed orthopaedic residency). The first lecture in the fellowship portion is Medical Exercise Therapy. I had been told previously that this was one of the less exciting classes due to the obvious lack of manual therapy involvement, but that didn't mean it was any less important. Each day, we spent approximately 2-3 hours just reviewing old material and practicing skill. As with any skill, the key to developing better motor control is practice, practice, and more practice. Being able to consistently utilize the instructors with your assessments is incredibly beneficial. The real focus of the class, however, is on exercise prescription and dosage. Most of the first day is spent discussing exercise physiology and its relation to each tissue type. While it may seem trivial to some, think about how often you either see (or prescribe) "3 sets of 10." How often is this actually what is appropriate? If the exercise is for actual muscle strengthening and you actually prescribe the "3 sets of 10" based on comparison to a 1 Repetition Maximum, that may be accurate. However, if the focus of the exercise is more so for tendon, bone, or cartilage healing, 3 sets of 10 would be way off. There was a significant focus on discussing exercise to rest ratio's and exercise dosage based on tissue type and the relation to research.

The second day of the class was focused primarily on exercise prescription. We didn't review so much the different types of exercise, but more so different way to modify exercise. For example, there is an emphasis in the MTI program of unloading an overused joint in order to allow healing to occur. This includes using a lumbar unloader for treadmill walking (fowards, backwards, sideways) or a cervical unloader for the BUE, and cervical stabilization exercises. These are some of the more common ones, but we were also taught how to incorporate the idea of unloading to extremity exercises as well. For example, tissues like cartilage in the knee heal best at 20% body weight with thousands of repetitions. The treatment can be riding a bike or using a shuttle squat for 20 minutes. Of course you want to focus on other impairments that are involved with the movement impairment syndrome that lead to the injury, but you want to address the tissue as well.

Given some of the recent research around imaging and having recently read Explain Pain, I recognize there is a lack of consistent correlation between what imaging and tissue pathology reveal in relation to the patient's perception of "pain." What we perceive as pain is more associated with a hyperactive nervous system, which may or may not be appropriate given the presence of true tissue injury. With MTI's emphasis on Sahrmann's movement impairment syndromes, exercise prescription is designed to eliminate abnormal movement impairment syndromes and be performed in a pain-free range. Given my success utilizing repeated motions in my treatments (thanks to instruction provided by The Manual Therapist), I questioned the concern about repetitive microtrauma as the basis for Sahrmann's technique. I was pleasantly surprised by the instructor's response to my questions. He was aware that there is definite success with repeated motions, but he is resistant towards prescribing them himself due to fear of contributing to repetitive microtrauma that may lead to worse long-term outcomes. My surprise was that he acknowledged there is no evidence that supports his concerns, but that he holds to it based on his preferred practice pattern of utilizing the Sahrmann approach. I again recognized some awareness of the possible benefit of what some may perceive as "abnormal" practices for a manual therapist. Many clinicians, especially academians, may state there is no point in doing soft tissue work to the ITB since it is not muscular. As part of my IASTM training, we are taught that engagement of soft tissue can engage the nervous system to alter tissue mobility and pain perception. This is an effect the instructor recognized specifically. You will find many advocates of a specific school of thought to be extremely stubborn regarding any conflicting idea. It is refreshing to take a course by an instructor who is always open to differing approaches. I am already looking forward to starting my mentoring hours next month and taking my next class in November.

-Chris

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