Guidelines
Medical Strengthening Therapy – MST

Preamble

The following Guidelines were drafted by a working group set up by GMKT, the Association for Medical Strengthening Therapy.  Following review by the GMKT Board, they were approved on 28 April 1999.

GMKT is an international professional association. Its aims are to disseminate information on the active rehabilitation of the musculoskeletal system based on scientific principles, facilitate the exchange of the relevant scientific and medical expertise and act as contact point for the media, paying authorities (public and private health insurers), patients, associations representing health professionals and any other interested parties. GMKT does not engage in profit-making activities and the production of these Guidelines was not sponsored by commercial interests.

The following experts have published reports on Medical Strengthening Therapy:

  • Professor Dr. G. Rompe and Dr. G. F. Finkbeiner, Berufsverband der Ärzte für Orthopädie (Professional Association representing orthopaedic specialists in Germany) 
  • rof. Dr. med. W. Puhl, Hauptverwaltung der Deutschen Krankenversicherung (Head Office of DVK, the German health insurer)
  • Prof. G. Tidow, University of Bochum.

These Guidelines are based on the “Consensus Guidelines for the Utilization of MedXTM Medical Testing and Exercise Machines in Spinal Rehabilitation Programs” compiled in 1997 by a steering committee of scientists from several universities and users of MedX systems in the United States.

In addition to drawing upon years of practical experience in the USA, these Guidelines also reflect experience from more than 40 practices offering Medical Strengthening Therapy in Switzerland and Germany.

The Guidelines are updated as and when necessary in the light of new scientific research and improvements in technology. The GMKT Board reviews them annually to ensure their validity.

1 Aims of Guidelines

Disorders affecting the back and spine – the so-called dorsopathies (ICD 720- 724) – are a major challenge both for the medical profession and those involved in health economics.

Reasons:

  • these disorders are extremely common
  • they often recur or become chronic
  • often, patients cannot work, require hospital treatment or take early retirement
  • the direct and indirect medical costs are high
  • the lack of mandatory strategies for prevention and treatment
  • the link between these disorders and patient lifestyle

There a clear scientific evidence of the link between weaknesses in the deep muscles stabilising the spine and chronic back pain. In many cases, targeted strengthening of autochthonous extensor muscles of the cervical/lumbar spine can reduce pain and improve function.

Since 1988, this scientific evidence has been applied in practice for both the diagnosis of spinal function and the treatment of associated disorders. Many Central European countries have established treatment centres that in some cases have changed both the methodology and equipment. The aim of these Guidelines is to provide a uniform standard that guarantees quality of treatment, a scientific approach and represents value for money. In particular, the standard includes the following:

  • selection criteria, indicators and contra-indicators
  • methodology and therapy protocols
  • qualifications and training
  • equipment and technical requirements
  • documentation
  • quality assurance

These Guidelines do not stipulate fixed rates for therapy. However, the criteria specified in the Guidelines mean that the cost of treatment must inevitably be within a certain range if both quality and value for money are to be guaranteed.  Agreements with patients and paying authorities should be within this price range. The price range can also be used as a basis for regional framework agreements.

Users of this therapy give a voluntary undertaking that they will comply with the Guidelines. In addition, before accreditation, potential users must complete a questionnaire on their use of this therapy and if necessary the answers to this questionnaire are checked by a site visit conducted by authorised GMKT representatives. The GMKT seal is protected by law and its use ensures transparency in the minds of patients and health insurers.

2 Treatment: aims and definition

Medical Strengthening Therapy is used for the safe and scientific diagnosis of spinal function and for the treatment of chronic spinal disorders. It is an outpatient treatment and requires the active cooperation of patients.

Its aim is to improve function and reduce pain by:

  • increasing the maximum strength and endurance of spinal extensors
  • reducing intra and inter-muscular imbalances
  • increasing range of motion and
  • strengthening the trunk and support muscles, e.g. abdominal muscles

These factors are documented before, during and after completion of therapy and provide objective evidence of its results. This process of data collection is an essential part of Medical Strengthening Therapy as defined in these Guidelines. Treatment may only be defined as Medical Strengthening Therapy (MST) if it meets the following criteria:

  • a doctor determines whether therapy is indicated and also responsible for therapy management. The therapy itself is done under the one-to-one supervision of a therapist
  • isolation of the autochthonous spinal extensor muscles to be treated
  • effects of gravity compensated
  • dynamic concentric/eccentric training in accordance with physiological strength curves
  • isometric maximum strength test through entire range of motion
  • muscle-fibre type is identified by means of fatigue response (if particular concerns warrant this) 
  • functional diagnosis and strengthening of extensors of lumbar or cervical spine
  • test of net muscle strength that takes account of soft tissue tension
  • supplementary training for the muscles stabilising the trunk on machines of an appropriate technical design

3 Scientific principles

Research has shown that the spine of a recent cadaver with the stabilising muscles stripped out will distort at an axial load of just 2 kg. (Panjabi et al.; Spinal stability and inter-segmental muscle forces; SPINE Vol.14, No. 2, 1989)

In 1991, Manniche et al conducted a prospective controlled trial and found that maximum strength training of lumbar extensors can reduce the subjective pain of patients with chronic back problems by 70%. (Manniche et al.; Clinical trial of intensive muscle training for chronic low back pain; Lancet 1:1473-1476, 1988)

Lumbar extensors can only be strengthened if they are isolated as otherwise the load is taken by the superficial trunk muscles, ischio-crural muscles and gluteal muscles. At present, only machines using the MedX technology allow total isolation (Graves et al.; Pelvic stabilization during resistance exercise training; its effect on the development of lumbar extension strength; ARCHIVES OF PHYSICAL MEDICINEAND REHABILITATION, Vol. 75, Feb. 1994)

Research in 1992 showed that Medical Strengthening Therapy (MST) on a MedX lumbar extension machine significantly increased the strength of the back muscles of patients with chronic back pain. It also showed that in addition to increasing strength, MST reduced pain and improved physiological and psychological function. (Risch et al.; Lumbar strengthening in chronic low back pain patients; physiological and psychological benefits; SPINE; Vol. 18, No. 2, pp. 232-238, 1993)

In Minnesota, MST on MedX machines was given to 895 patients with chronic lumbar pain for a minimum of 2 years and on average 6 different treatments (including surgery) behind them. For 76% of these chronic and therapy-resistant patients, the outcome was good to very good. In a follow-up 13 months later, 94 % displayed equally good or even better subjective and objective outcomes compared with the end of therapy. (Nelson et al.; The clinical effects of intensive, specific exercise on chronic low back pain; ORTHOPEDICS, Vol. 18, No.10.1995)

In terms of neck muscles, it has been shown that targeted training can improve their strength and range of motion and significantly reduce pain. (Highland et al.; Changes in isometric strength and range of motion of the isolated cervical spine after eight weeks of clinical rehabilitation; SPINE, Vol. 17, No. 65, 1992)

46 patients identified as requiring cervical or lumbar surgery were given intensive Medical Strengthening Therapy. 12 months later, it was possible to review 38 of these patients and it was found that only 3 of them had undergone surgery in the meantime. Cost saving per operation between ,614 and 2,480! (Nelson et al; “Can spinal surgery be prevented by aggressive strengthening exercises? A prospective study of cervical and lumbar patients;” ARCHIVES OF PHYSICAL MEDICINEAND REHABILITATION, Jan. 1999)

A study of elderly residents (with an average age of 90 years) who completed maximum strength training of the quadriceps for 3 months found that strength increased by an average of 174 %. Muscle mass increased by 9 %, walking speeds improved and residents became much steadier on their feet. (Fiatarone et al.; High-intensity strength training in Nonagenarians; JAMA, Vol. 263, No. 22, 1990)

4 Selection criteria, indicators and contra-indicators

Selection criteria: Medical Strengthening Therapy has two specific applications and this affects the selection criteria: 

1) For functional diagnosis of lumbar/cervical spine:

  • used before therapy to identify indicators or contra-indicators
  • provides an objective check of therapy and its success
  • provides an expert opinion for third parties
  • identifies muscle fibre type and
  • acts as a screening tool  for scientific studies or studies relating to occupational medicine

2) For treatment:

  • for patients with chronic or chronic recurrent lumbar/cervical pain of varying aetiology, treatment is mainly conservative
  • treatment of sub-acute clinical syndromes of lumbar/cervical spine at least 4 weeks after initial manifestation
  • treatment of last resort prior to neuro- or orthopaedic surgery provided that no absolute indicators for surgical intervention or other contra-indicators are present
  • treatment for rehabilitation post surgery (after laminectomy/discectomy: minimum of 4 - 6 weeks post surgery, after spinal fusion at least 12 weeks post surgery)
  • for prevention with certain patients if there are substantiated risk factors or occupational exposure 

MST indicated if following criteria met:
  • Findings and diagnosis following examination by doctor reflect ICD 9
  • Symptoms result in a significant functional impairment for patients in their daily life or there is a significant risk of this
  • Painful symptoms persisting for a continuous period of at least 6 months or recurring for at least 2 years
  • Treatment is indicated medically and there are no contra-indicators
  • Patient must be sufficiently motivated to handle what is an active and strenuous treatment and it must be reasonable to expect patient to tolerate it
  • Individual therapy aims must be formulated for each patient
  • It would be impossible to achieve these therapy aims permanently with non-specific physical treatment or medication or if the symptoms have so far been resistant to treatment.
  • At the time of the initial functional diagnosis, the patient must display at least two of the following primary criteria or one primary criterion and two secondary criteria (except if functional diagnosis contra-indicated)

Treatment criteria following functional diagnosis of cervical or lumbar spine:

Primary criteria:

Range of motion (ROM) is reduced by more than 10 % with no clinical cause (spinal fusion, previous fractures) or anatomical reasons such as marked obesity.

Strength is reduced in flexion; recorded deficit in maximum possible flexion exceeds 15% of the norm corrected for age, gender and weight.

Strength is reduced in extension: recorded deficit in maximum possible extension exceeds 15% of the norm corrected for age, gender and weight.

Secondary criteria:

Intramuscular imbalances: the strength curve in the tested ROM deviates by 20 % or more from the physiological curve at a minimum of 2 test angles.

Strength is reduced in a mid test position: recorded deficit at a position between maximum possible extension and flexion deviates by 15% or more from the norm corrected for age, gender and weight.

Indicators:

Chronic or recurrent disc-related pain in the cervical/lumbar spine:

  • local cervical syndrome
  • cervico-cephalic syndrome
  • cervico-brachial syndrome
  • cervico-radicular syndrome
  • local lumbar syndrome
  • lumbar facet joint dysfunction
  • lumbo-radicular syndrome

  • spinal stenosis

  • post-traumatic spinal condition involving chronic or recurring pain:

  • consolidated fracture of vertebral body
  • post-traumatic cervical syndrome (whiplash-type injury to cervical spine)
  • post-surgical condition of spine following neurosurgery or orthopaedic surgery:
  • 4-6 weeks post disc surgery or laminotomy
  • 12 weeks post spinal fusion surgery (if bone material used to fuse bone not until bone has consolidated)
  • for disorders of varying aetiology such as:
  • spondylolysis, spondylolisthesis
  • spinal deviations (e.g. scoliosis)
  • osteoporosis

Contraindicators

Absolute contraindicators:

  • spinal neoplasm or metastasis
  • acute or non-consolidated/unstable spinal fractures
  • spinal infections
  • cauda equine syndrome, radicular and medullar syndromes with progressive neurological deficit
  • aorta aneurysm
  • eye or abdominal surgery 6 weeks prior to start of MKT
  • deterioration in general condition if patient suffering from chronic consumptive disorder or systemic malignant disorder
  • spinal surgery in the early post-operative phase


Relative contraindicators:

  • advanced osteoporosis or osteomalacia
  • acute nerve root syndrome
  • inflammatory, rheumatic disorders in acute active phase
  • conditions that prohibit an increase in intra-abdominal pressure
  • psychosis and claustrophobia
  • pregnancy
  • serious non-stabilised cardio-vascular disorders  (hypertony, CHD, arrhythmia)
  • serious pulmonary disorders (bronchial asthma, COPD)
  • lack of motivation on part of patient.

5. Therapy protocol

In order to guarantee maximum benefit for patient, the use of standard methodology and terminology is essential. They are also required for scientific evaluation and quality assurance purposes.

For this reason, all MST staff must be competent to do the following:

  • daily calibration of machines
  • use computer hardware and software and ensure the security of patient data
  • secure individual patients in machine and make the necessary adjustments
  • calculate and adjust the head/upper-body counterweight
  • test and adjust range of motion (ROM) and then improve it
  • determine training duration and appropriate training weight
  • supervise training and tests and provide effective instruction to patient
  • evaluate and interpret results
  • instruct patients on use of machines in supplementary programmes

Isometric maximum strength test

  • pre-test (test after warm-up with low weight for 60 - 90 seconds)
  • post-test (test after maximum /sub-maximum load)

Each test is performed over the maximum possible ROM:
  • lumbar extension: every 12°, 7 test positions up to a maximum possible of 72°
  • cervical extension: every 18°, 8 test positions up to a maximum possible of 126°

Other angles can also be tested if there are particular issues. Normally, one set of test is done for each therapy series although there are exceptions, e.g. conditions corresponding to an absolute or relative contra-indication for MST. Only one test may be done on any given therapy day. The norm data is already gender-specific and the norm data for lumbar extension is also age and weight-specific. The norm data is based on figures calculated by the University of Florida, Center for Exercise Sciences. The Strength Index (SI) is the area below the interpolated strength curve. It is automatically calculated by the computer and correlates positively with the strength recorded at individual measuring points and the range of motion.

Dynamic concentric/eccentric training (dyn. max)

Training is done:

  • over maximum possible pain-free range of motion (ROM)
  • until local fatigue of lumbar/cervical extensors
  • in anaerobic range
  • with measurement of time under load
  • minimum interval between sessions 3 days, e.g. Monday and Thursday or Tuesday and Friday
  • sub-maximal at first therapy session, i.e. not to local fatigue of lumbar/cervical extensors (= dyn. sub-max)

Fatigue Response Test (FRT)

A Fatigue Response Test uses the response of muscles to fatigue in order to identify the patient’s muscle fibre type. For example, where patients are not making progress, it can be used to determine the right training duration and training interval. No FRT is done for cervical extensors as these muscles almost always display a slow-twitch dominance.

Dynamic training to local fatigue is done with a weight equal to 50 % of the maximum strength of lumbar extensors measured in the pre-test.

Comparison of strength index (SI) recorded in the pre- and post-tests:

  • difference less than 10%: slow twitch dominance (ST)
  • difference 10% - 30%: mixed fibre type
  • difference greater than 30%: fast-twitch dominance (FT)

 

Supplementary programme

In addition to specific exercises to strengthen spinal extensors, each MST session also includes accompanied strength training for trunk and support muscles.

This includes:

  • a personal training programme
  • training of a minimum of 5–6 major muscle groups
  • supervision of supplementary programme by a therapist
  • written record of machines, settings and training duration

Follow-ups (F 6/ F 12)

6 and 12 months after completion of therapy, patients are invited back for a follow-up so that the results of therapy can be checked. This process is also important for the data collection required for the evaluation of therapy gains and the long-term effects of MST.

The follow-up session consists of the following:

  • subjective assessment by patients of their condition: questionnaire
  • range of motion: ROM tested
  • maximum strength test /strength index (SI): isometric pre-test
  • strength endurance: dynamic training: dyn. max

MST in conjunction with other therapies

MST should only be used on its own, i.e., other treatments should be completed before MST started e.g.

  • physical treatments (e.g. heat, ultrasound, electrical therapy)
  • physiotherapy
  • medical baths and massage
  • chirotherapy and neural therapy
  • acupuncture, etc.

However, in individual cases it may be appropriate to use targeted pain therapy, e.g. chirotherapy or a local anaesthetic in order to support MST or make it possible in the first place.

6 Medical Strengthening Therapy

For patients with chronic back problems, the ideal outcome of MST is unrestricted or significantly improved spinal function and elimination or reduction of painful symptoms. The strength of autochthonous spinal muscles has normalised, mobility has improved and patterns of movement and load have normalised. Objective evidence exists for outcomes and gains remain after completion of therapy. Patients have learned how to deal actively with their problem.

Duration of MST

For over 90% of patients, 12 - 18 therapy sessions should suffice. It is extremely rare for patients to need more than 24 sessions and any number in excess of this must be medically justified and scrutinised carefully by the paying authority.

After MST

An important aim of therapy is to encourage patients to take personal responsibility for their health after completion of MST.  The therapy itself is done under medical direction and instruction by a therapist. However, during therapy patients learn that they can subject their back to a load and in fact that they must do this in order to consolidate therapy gains. There are 3 options for what happens after MST:

  1. Patient trains once or twice per week in a well-run strength training centre on high-quality machines after careful instruction. A doctor recommends an optimum training programme. Experience has shown that in most cases therapy gains can then be maintained for many years. This is an attractive option as it benefits the general health of the patient, the cost/benefit ratio is good and it requires only a minimum amount of time.
  2. Studies have shown that the strength of the isolated autochthonous muscles can be maintained if patients do a dynamic training session every 3 or 4 weeks for lumbar muscles or every 2 weeks for cervical muscles. This is an attractive option in terms of time but the benefits are restricted to the spine and it is expensive.
  3. Patients take no active steps to retain the newly acquired strength. In time, they may lose their new strength and the symptoms return.

Option 1 is preferable as it encourages patients to take personal responsibility. The process is external to the world of therapy and patients can do strength training like “healthy individuals” albeit with some limitations. It also helps to prevent osteoporosis, age-related weaknesses and ailments caused by degenerative changes.

Ideal MST patient

The ideal MST patient adopts an active approach to his/her back problem, is able to escape from years of therapy dominated by symptoms and can prevent a further chronification of symptoms. The patient is sufficiently motivated to undergo an effective treatment that produces a positive outcome – both objective and subjective. There is no claim for a disability pension or other factor associated with the secondary gain derived by the patient from his or her symptoms. The patient is interested in maintaining the therapy gain over many years and is prepared to do strength training on completion of therapy. The ideal MST patient improves his/her quality of life and in the long run makes fewer demands on the national health budget.

7 Equipment, staff and quality assurance

These Guidelines have already identified several important aspects of quality assurance for MST, e.g. defined access criteria and standard methodology/documentation. In the following paragraphs, we describe structural quality, e.g. equipment and technical requirements, staff skills and training and maintaining the quality of therapy gains.

Equipment and technical requirements

  • at least 1 machine for testing and treating the lumbar region in accordance with the criteria in Section 2
  • training machines suitable for strengthening the major trunk and support muscles:
  • latissimus dorsi
  • greater pectoral muscle
  • trapezium muscle
  • straight muscle of the abdomen
  • oblique muscle of the abdomen
  • gluteus maximus and gluteus medius muscles
  • flexor muscles of the thigh
  • extensor muscles of the thigh
  • deltoid muscle

  • separate examination room for doctor
  • adequate washing and toilet facilities with changing rooms and showers
  • machines that allow training over the entire range of motion in line with the physiological strength curve
  • opportunity for independent and occasionally non-independent training on suitable machines as an active way of maintaining therapy gains

Staff, skills and training

  • MST section is under the direction of a doctor.
  • The senior therapist is a physiotherapist or qualified sports teacher with additional qualification in sports therapy or rehabilitation.
  • Doctor and senior therapist are members of GMKT.
  • Doctor and therapists have completed the standard training in accordance with the requirements laid down by the University of Florida in respect of all therapy machines in the facility.
  • Therapists have completed a one-week practical in a MST facility that has been operational for at least one year.
  • Doctor and therapists have the required knowledge of MST and the machines used in the supplementary programme and can provide documentary evidence of this.
  • A representative from the facility attends the annual GMKT user conference, if possible every year but at least every two years.
  • Doctor and therapists complete a minimum of 2 days of specific training every two years in the field of Medical Strengthening Therapy (GMKT Congress or similar).

Quality circle

  • internal quality circle: meeting of all staff involved in MST every two weeks
  • regional quality circle: twice a year
  • MST users meeting: once a year
  • GMKT Board Meetings: four times a year
  • GMKT Congress: once every 2 years

As well as providing an opportunity for the exchange of information and experience, these meetings are also an opportunity to evaluate the results of MST for individual facilities and for users as a whole. A written record is kept of these quality-circle meetings.

Quality of therapy results

The GMKT Board is responsible for the quality assurance of MST. It has a committee that acts as a contact point for members. The Board reports regularly (at least once a year) to GMKT members on its activities.

The following tools ensure the quality of results:

Internal:

  • ongoing standard evaluation of therapy results
  • quarterly MST statistics submitted to GMKT Board
  • analysis of therapies not completed or undesirable side effects
  • follow-ups 6 and 12 months after completion of therapy (F 6/F 12)
  • standard documentation and methodology in line with these Guidelines
  • “overuse” of MST is avoided through application of defined access criteria and monitoring of their implementation
  • internal quality circles

External 
  • all MST practitioners must provide an information sheet
  • external quality circle
  • regular user meetings
  • supervision in facilities where therapy results give cause for concern
  • ongoing evaluation of scientific publications and annual review of the validity of these Guidelines
  • intensive national and international communication and cooperation with scientific bodies, professional bodies representing doctors and  other health professionals and ethical bodies

8 Payment of costs

The majority of MST costs come from staff, equipment and accommodation.  The base unit for charging purposes is time: the more machines included in the therapy, the longer therapy takes and the higher the unit cost per session. In addition, the fee charged for MST must include administrative costs, quality assurance, staff training (initial and continuing professional development) and planning costs. A patient with chronic back pain will normally need therapy on a medical machine designed specifically for the lumbar extensors (LE) together with a supplementary programme for secondary trunk stabilisers. A patient with chronic neck pain will normally require therapy on a medical machine designed specifically for cervical extensors together with a supplementary programme for upper-body muscles. If a patient has both back and neck problems, MST is on one LE machine and one CE machine. In addition, patient will do a supplementary programme. If patients have a localised problem in either the lumbar or cervical spine but otherwise their muscles are well trained, a supplementary programme may not be required or patients can do supplementary exercises independently as part of preventive strength training.

The use of more than two medical machines per therapy session is unnecessary and should be avoided. Similarly, only one diagnostic test may be done at any one therapy session. Staff, accommodation and administrative costs may vary from region to region.

Diagnostic session with assessment by a doctor:

The patient’s condition should be assessed by a doctor before starting therapy. This allows the doctor to determine whether MST is indicated or contraindicated. In addition, the doctor should document therapy results and also see patient after every 6 therapy sessions for monitoring purposes.

Alternatively, specialist medical reports can be compiled outside the framework of therapy.

In both cases diagnostic sessions must include:

  • detailed medical consultation with assessment of X rays provided by patient
  • thorough physical examination of musculoskeletal system, in particular the spine in order to exclude contraindicators for tests
  • machine settings (LE or CE medical machine) for particular patient
  • completion of an isometric maximum strength test of the isolated autochthonous muscles of the lumbar/cervical spine
  • dynamic load on a medical machine until local fatigue

9 Documentation

All facilities working in accordance with these Guidelines use standard documentation. This ensures the quality of MST, allows a comparison of therapy outcomes and provides anonymous patient data for evaluating results and use in scientific research. If necessary, therapy started in one facility can be continued in another with no loss of data. This can only occur if there is adequate documentation providing transparent and understandable data. The documentation is also used for accounting purposes, internal quality assurance and external supervision in the event of unexpected side effects during therapy. All patient files have the same structure and so doctors and therapists have speedy access to the required data. Documents are up-to-date at all times and kept for a minimum of 10 years after completion of therapy. Until the development of dedicated practice management software, documents are predominantly paper-based and consist of:

  1. cover sheet with main patient data
  2. record of examination by doctor for MST purposes and if necessary a separate sheet for “additional findings”
  3. declaration form countersigned by the patient
  4. pain questionnaire
  5. therapy flow chart including record of individual measures
  6. MST training protocol showing all machine settings and training gains
  7. therapy protocol on which is entered subjective and objective findings and anything of particular note; this must be signed off by doctor at regular intervals
  8. training programme for the supplementary programme
  9. computer printouts for the isometric maximum strength test and overview of dynamic training
  10. report on completion of therapy
  11. follow-up questionnaire and results of isometric maximum strength tests 6 or 12 months after completion of therapy (F 6 / F 12)
  12. correspondence relating to patient with paying authority and reports from other doctors