MET Beyond the Nordic Hamstring Curl


Are Appropriately Designed and Dosed Eccentrics part of your Early Treatment Plan?

Not even 25 minutes into the opening game of the 2018 World Cup, Russian midfielder Alan Dzagoev pulled his hamstring.

The prevalence of hamstring injuries during soccer match play remains high. It has been reported that sprinting-type hamstring injuries might be related to insufficient eccentric hamstring strength. Recurrent injury rates remain equally high and might be related to inadequate rehabilitation and too early return to play.

Inclusion of the Nordic hamstring exercise has showed promise in reducing occurrence rates in professional soccer players. However, due to the high torque/force requirements to perform the Nordic exercise, it is mainly used in prevention and in the later phases of rehabilitation.

With appropriate design and dosing we can introduce eccentrics early on in the rehabilitation treatment plan and therefore be more effective in preparing the tissue for its task. Appropriate design considerations include:

  • Where to place maximum external peak torque?
  • Eliminating the concentric phase
  • Open and closed chain, depending on the injury mechanism


WRITTEN BY: Jeremy Lewis, Peter O’Sullivan
A repost from:


The majority of persistent non-traumatic musculoskeletal pain disorders do not have a pathoanatomical diagnosis that adequately explains the individual’s pain experience and disability. We contend this has resulted in two concerning developments in the management of people with such disorders. First, structural changes observed on imaging that are highly prevalent in pain free populations, such as rotator cuff tears, intervertebral disc degeneration, labral tears and cartilage changes, are ascribed to individuals as a diagnosis for their condition. In this context, this information may result in the individual believing that their body is damaged, fragile and in need of protection, resulting in a cascade of movement and activity avoidance behaviours and seeking interventions to correct the structural deficits.1 This trend has led to exponential increases in elective surgery rates and associated costs, while the efficacy of repairing (eg, rotator cuff and medical meniscal tears), reshaping (eg, subacromial decompression) or replacing (eg, lumbar intervertebral discs) the structures considered to be at fault has been substantially challenged.2–10Second, it is arguable that musculoskeletal clinicians have invented treatments for conditions that may not exist or be readily detected (such as trigger points, sacral torsions), and they have developed and perpetuated treatment paradigms (such as ‘correcting’ upper body posture and muscle imbalances) that do not conform to current research evidence.11–14 These two trends have created an expectation that interventions (frequently ‘passive’) will provide a ’cure’, and typically quickly, with minimal self-contribution. This expectation may have been derived from a conversation with a friend or family member, from the Internet or from an advertising campaign, but almost certainly originated from health professionals.


Contemporary evidence demonstrates that many musculoskeletal pain conditions are associated with long term disability that are often resistant to current treatments. They are influenced by multiple interacting factors, including genetics, psychological, social and biophysical factors, comorbidities and lifestyle.15 We propose that when these conditions become persistent and disabling they should be viewed in a similar way to other chronic health conditions. For example, when an individual presents with non-insulin dependent diabetes, best practice would involve an interview and examination where a diagnosis is reached and the relevant biopsychosocial contributing factors to the disorder are identified. Based on this, education, advice and shared decision making, a management plan, underpinned with empathy and support, would be agreed. This plan would typically involve highlighting the importance of good sleep hygiene, the role of nutrition and diet, stress management and, if relevant, cessation or reduction of smoking. The profound benefits of participating in appropriate graduated physical activity would be emphasised and, if necessary, medication, such as metformin, may also be prescribed. It also involves the management of comorbid health complaints. While, if required, the prescribed medicine would differ, the management of other chronic disorders, such as asthma and high blood pressure, would follow a similar process.

In the management of these conditions, the focus is not on providing a ‘cure’ but rather the discussion is about providing a ‘management’ plan to control the disorder and limit its impact on the person’s well-being. While the signs and symptoms of many of these chronic problems may reduce to the level that the individual no longer feels disabled or symptomatic, ongoing self-management is essential.


We believe there is a need to reframe the way we care for non-traumatic persistent and disabling musculoskeletal pain conditions, by aligning the management of such conditions with the principles underpinning the management of other chronic conditions: strong clinical alliance, education, exercise and lifestyle (sleep hygiene, smoking cessation, stress management, etc) in order to build the individual’s self-efficacy to take control and ultimately be responsible for their health. Although the arguments for such an approach are compelling,16 and evidence is emerging for a number of musculoskeletal disorders, it is acknowledged that definitive evidence for all musculoskeletal conditions is currently lacking. Such an approach would be supported by other and emerging evidence, translated from the available research for the condition being managed.

Reframed in this manner, patients would no longer be led to expect a ‘magic’ manipulation or other passive approach to ‘cure’ their condition, and this in turn may reduce stress and burnout experienced by many clinicians who are unable to deliver on such unsubstantiated promises. Interventions such as manual therapy, pharmacology and injections, when provided, should be seen as an adjunct, and their risks and benefits must be considered and honestly communicated.


We need to reframe what is currently doable and achievable in the management of many non-traumatic musculoskeletal presentations, and honest and open conversations regarding the outcome evidence for these disorders needs to be sensitively communicated. There would be many obstacles to overcome and respect when considering such an approach. For clinicians, these might be pain beliefs, professional identify, time, financial pressures and lack of adequate training. Patient beliefs and expectations may also pose a significant challenge for clinicians, especially when they desire a structural diagnosis and a ‘fix’ for their pain. For patients, creating an understanding and expectation that, as with other chronic health conditions, there is no magic cure for many persistent and disabling musculoskeletal pain conditions, and that ultimately ongoing evidence informed self-management is the key. To achieve this, the efforts of many institutions, including educational, healthcare, political and professional organisations, health funding bodies and the media, need to be involved.

We believe in the need to frame past beliefs against new evidence, and when in conflict we need to evolve with that evidence. We contend this requires those of us working in the musculoskeletal field to acknowledge the limitations of current surgical and non-surgical interventions for persistent and disabling non-traumatic presentations, as well as upskill and reframing of our practice, language and expectations to consider aligning our current practice with that supporting most chronic healthcare conditions. By doing this we can better support those members of our societies who seek care, and be more honest with the level and type of care we can and should currently offer, and the outcomes that may be achieved.

WRITTEN BY: Jeremy Lewis, Peter O’Sullivan



MET strives to deliver optimal improvements for our patients and clients. Optimal improvement is defined as:

  1. Achieving improvements in 4 outcome domains which,
  2. Are meaningful (such as an improvement equal or greater than the MDC and/or MID), and
  3. Result in reduced risk for recurrence; improved community independence; and overall healthier individuals.

This third criteria is illustrated in a recent article of Van Onsem and colleagues who identified two outcome measures, range of motion (from the impairment outcome domain) and 6-min walk test (from the objective performance domain) which can predict patient satisfaction with TKA. A cluster of patients whose Improvements were beyond the pre-surgical level are 6–8 times more likely of being satisfied after TKA.

This illustrates the need for clinician not only to strive for normalization but also for optimization.

Van Onsem S et al. Improved walking distance and range of motion predict patient satisfaction after TKA. Knee Surg Sports Traumatol Arthrosc. 2018 Feb 8.


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.


  • 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.