Have We Given Up on Impairment Correction?

In July of 2017 the JOSPT published the updated clinical practice guidelines for neck pain 1. Interestingly, none of the interventions provided by rehab professionals for neck pain receive a level A – strong confidence in recommendation. Although the intervention of “therapeutic exercise” continues to receive B levels of recommendations, even this intervention is questioned by authors of systematic reviews for its efficacy. This should raise concerns as policy makers and payers will determine to further to pay for this intervention.

As rehabilitation providers, we should make the distinction between “general exercise”, of which the health benefits are well established, and “therapeutic exercise”.

Therapeutic exercise provided by rehabilitation professionals aims to improve, normalize and optimize the underlying impairments in addition to symptom moderation and functional improvements. The improvement in impairments should be measurable and significant. We should refrain from providing “sham” therapeutic exercises 2, i.e. exercises considered therapeutic but that do not obtain better outcomes than “general exercise” or the “staying active advice”. A study from Bartholdy et al 3 indicates that impairment corrections of 30 to 40% are required to have a meaningful impact on symptoms and function.Reduction in symptoms and improvements in function can occur without significant improvements in impairment and can be achieved by the natural healing process and/or with “general exercise” and education, provided by rehab and non-rehab providers.

Impairment correction is required for long-term positive outcomes, preventing relapse and chronicity. The efficacy of therapeutic exercise depends on the provider’s capability to assess the impairment correctly within the concept of the kinetic chain, its contribution to symptoms and function, and ability to design, dose and deliver the intervention appropriately and with precision. Modalities and manual therapy techniques should be utilized to facilitate the delivery of the therapeutic exercise intervention.

Over the last decades MET Seminars has developed a MET-odology for precision therapeutic exercise design, dosing and delivery in a value based healthcare system based on the principles of Medical Exercise Therapy.

The MET-odology or framework allows the clinician to optimize the exercise prescription and obtain consistent clinical outcomes. Appreciating the pressures and constraints of financial realities, operational and regulatory policies and procedures, the future of our rehab professions depends on delivering outcomes exceeding the ones obtained by “general exercises” and advice to stay active. As modalities are either proven to be ineffective or readily available, therapeutic exercise becomes ever more important.

References

  • Blanpied PR, Gross AR, Elliott JM, Devaney LL, Clewley D, Walton DM, Sparks C, Robertson EK. Neck Pain: Revision 2017. J Orthop Sports Phys Ther. 2017 Jul;47(7):A1-A83. doi: 10.2519/jospt.2017.0302.
  • Harris, Ian. Surgery, The Ultimate Placebo: A Surgeon Cuts through the Evidence. South Wales: University of New South Wales Press; 2016.
  • Bartholdy C, Juhl C, Christensen R, Lund H, Zhang W, Henriksen M. The role of muscle strengthening in exercise therapy for knee osteoarthritis: A systematic review and meta-regression analysis of randomized trials. Semin Arthritis Rheum. 2017 Mar 18. pii: S0049-0172(16)30172-X. doi: 10.1016/j.semarthrit.2017.03.007.

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