How to use MET
Palpation skills 66
Ease and bind 66
Basic exercise in MET using postisometric relaxation in acute context 69
Basic exercise in MET using postisometric relaxation in chronic context 69
Reciprocal inhibition 70
Basic exercise in MET using reciprocal inhibition in
acute and chronic contexts 70
MET - some common errors and contraindications 70
Patient errors during MET 71
Practitioner errors in application of MET 71
Contraindications and side-effects of MET 71
Breathing and MET 72
Degree of effort with isometric contraction 73
MET variations 73
Strength testing - Mitcheirs view 73
Janda's view 74
Ruddy's methods -'pulsed MET‘ 75
Isotonic concentric strengthening MET methods 76
Isotonic eccentric alternatives 77
Strengthening a joint complex with isokinetic MET 77
Reduction of fibrotic changes with isolytic (isotonic eccentric) MET 78
Summary of choices for MET in treating muscle problems 78
Joints and MET 79
Self-treatment 79
When should MET be applied to a muscle? 81
Evaluation 81
Muscle energy technique - summary of variations 81
1. Isometric contraction - using reciprocal inhibition (acute setting, without
stretching 81
2. Isometric contraction-using postisometric relaxation (acute setting ithout
stretching) 82
3. Isometric contraction - using postisometric relaxation (chronic setting,
with stretching, also known as postfacilitation stretching) 82
4. Isometric contraction - using reciprocal inhibition (chronic setting, with
stretching) 83
5. Isotonic concentric contraction (for toning or rehabilitation) 83
6. Isotonic eccentric contraction (isolytic, forreduction of fibrotic change, to
introduce controlled microtrauma) 83
7. Isotonic eccentric contraction (isolytic, for strengthening weak postural
muscles) 84
8. Isokinetic (combined isotonic and isometric contractions) 84
References 84
How to use MET
Chapter 1 described a number of variations on the theme of MET (and stretching) as used by clinicians such as Karel Lewit, Vladimir Janda, Craig Liebenson, Aaron Mattes, Edward Stiles, Robert McAtee and others. Chapter 4 will describe a sequence for the evaluation/assessment of the major postural (or tnobiliser) muscles of the body 一 for relative shortness - along with details of suggested MET approaches for normalising, stretching and relaxing those muscles. Additionally there will be examples of the use of pulsed MET (repetitive mini-contractions based on the work of T. J. Ruddy (1962)) in facilitating proprioceptive re-education of weak and shortened structures.
In this chapter, suggestions are given as to how to begin to learn the application of MET methods, both for muscles and for joints (specific muscle by muscle and particular joint descriptions of MET treatment can be found in later chapters).
A primary requirement for the practitioner is the identification by means of assessment of a need for the use of MET. Is there an identifiable restriction
which requires releasing, modifying? TWs brings us to the need for sound palpation skills.
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In this text the practitioner is presented in descriptions of technique and exercises as being male (because the author is), whereas the patient/client is described variously as male or female. It is hoped that this gender bias regarding the practitioner does not offend the reader, since no offence is intended.
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PALPATION SKILLS
Ease and bind
The concept and reality of tissues providing the palpating hands or fingers with a sense of their relative tension or 'bind', as opposed to their state of relaxation or 'ease', is one which the beginner needs to grasp and the advanced practitioner probably takes for granted. There can never be enough focus on these two characteris�tics, which allow the tissues to speak as to their current degree of comfort or distress. In the pre�vious chapter (p. 36) the 'loose-tight’ concept was presented. Ward (1997) states that 'Tightness suggests tethering, while looseness suggests joint and/or soft tissue laxity, with or without neural inhibition !
Osteopathic pioneer H. V. Hoover (1969) describes ease as a state of equilibrium, or 'neutral', which the practitioner senses by having at least one completely passive 'listening' contact (either the whole hand or a single of several fingers or thumb) in touch with the tissues being assessed. Bind is, of course, the opposite of ease and can most easily be noted by lightly palpating the tissues surrounding, or associated with, a joint as this is taken towards the end of its range of movement - its resistance barrier (Box 3.1).
Greenman (1996) states:
The examiner must be able to identify and characterize normal and abnormal range of movement and normal and abnormal barrier to movement to make a diagnosis. Most joints have motion in multiple planes, but for descriptive purposes we describe barriers to movement within one plane of motion for one joint. The total range of motion from one extreme to the other is limited by the anatomical integrity of the joint and its supporting ligaments, muscles and fascia ...
somewhere within the total range of movement is found a midline neutral point.
This is the point of maximum ease which the exercise described below attempts to identify.
In order to 'read' hypertonicity (bind) and the opposite, a relaxed (ease) state, palpation skills need to be refined. As a first step, Goodridge sug�gests the following test, which examines medial hamstring and short adductor status. This exer�cise offers the opportunity for becoming comfort-able with the reality of ease and bind in a practi�cal manner (Goodridge 1981).2)
Box 3.1 Barriers
A variety of different terms can be used to describe what is perceived when a restriction barrier is reached or engaged. These terms relate to a large degree to the type of tissue providing the restriction, and to the nature of the restriction.
For example:
Normal end of range for soft tissues is felt as a progressive build-up of tension, leading to a gradually reached barrier, as all slack is removed.
If a fluid restriction (oedema, congestion, swelling) causes reduction in range of motion, the end-feel will have a ‘boggy’,yielding yet spongy feel.
If muscle physiology has changed (hypertonicity, spasm, contracture), the end-feel will produce a tight, tugging sensation.
If fibrotic tissue is responsible for a reduction in range, end-feel will be rapid and harsh but with a slight elasticity remaining.
In hypermobile individuals, or structures, the end-feel will be loose and the range greater than normal.
If bony tissue is responsible for reduction in range (arthritis for example), end-feel will be sudden and hard without any elasticity remaining.
Pain may also produce a restriction in range, and the end-feel resulting from sudden pain will be rapid and widespread, as surrounding tissues protect against further movement.
The barrier used in MET treatment is a 'first sign of resistance* barrier, in which the very first indication of the onset of 'bind* is noted. This is the place at which further movement would produce stretching of some fibres of the muscle(s) involved. This is where MET isometric contractions, whether these involve the agonists or antagonists, commence in acute (and joint) problems, and short of which contractions commence in chronic problems
Test for palpation of ease and bind during
assessment of adductors of the thigh
(Fig. 3.1A and 3.1B; see also Fig. 1.3)
Goodridge (1981) presents a basic method for beginning to become familiar with MET. Before starting this exercise, ensure that the patient/model lies supine, so that the non-tested leg is abducted slightly; heel over end of table. The leg to be tested should be close to the edge of the table. (Ensure that the tested leg is in the anatom�ically correct position, knee in full extension and with no external rotation of the leg, which would negate the test.)
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2) This test and its interpretation and suggested treatment, using MET (should shortness be noted), will be fully explained in Chapter 4, but in this setting it is being used as an exercise for the purposes of the practitioner becoming familiar with the sense of 'ease and bind', and not for actually testing the muscles involved for dysfunction.
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Good ridge's ease/bind palpation exercise, part 1 (Goodridge 1981)
1. The practitioner slowly eases the straight leg into abduction, 'After grasping the supine patient's foot and ankle, in order to abduct the lower limb, the practitioner closes his eyes during the abduction, and feels, in his own body, from his hand through his forearm, into his upper arm, the beginning of a sense of resistance!
2. 'He stops when he feels it, opens his eyes, and notes how many degrees in an arc the patients limb has travelled!
What Good ridge (1981) is trying to establish is that the practitioner senses the very beginning, the first sign of the end of the range of free move�ment, where easy, 'free-floating' motion ceases, and effort on the part of the practitioner moving the part begins. This barrier is not a pathological one, but represents the first sign of resistance, the place at which tissues require some degree of passive effort to move them. This is ako the place at which the first signs of bind should be palpated.
It is suggested that the process described by Goodridge be attempted several (indeed many) times, so that the practitioner gets a sense of where resistance begins. The exercise is then performed again as described below.
Goodridge's ease/bindpalpation exercise, part 2
The patient lies close to the edge of the table on the side of the leg being tested. The practitioner stands between the patient's partially abducted leg and the table, facing the head of the table, so that all control of the tested leg is achieved by using the lateral (non table-side) hand which holds and supports the leg at the ankle. The other (table-side) hand rests passively on the inner thigh, palpating the muscles which are being tested (adductors and medial hamstrings).
This palpating hand (often called a 'listening' hand in osteopathy) must be in touch with the skin, moulded to the contours of the tissues being assessed, but should exert no pressure, and should be completely relaxed.
As in part 1 of this exercise, abduction of the tested leg is introduced by the non table-side hand/arm, until the first sign of resistance is noted by the hand which is providing the motive force (i.e. the one holding the leg). As this point of resistance is approached, a tighten�ing of the tissues ('a sense of bind') in the mid�inner thigh should be noted under the palpating hand.
If this sensation is not clear, then the leg should be taken back towards the table, and slowly abducted again, but this time it should be taken past the point where easy movement is lost, and effort begins, and towards its end of range. Here 'bind' will certainly be sensed.
As the leg is once more taken back towards the table, a softening, a relaxation, an 'ease', will be noted in these same tissues.
The same sequence should then be performed with the other leg, so that the practitioner becomes increasingly familiar with the sense of these two extremes (ease and bind).
It is important to try to note the very moment at which the transition from ease to bind (and bind to ease) occurs, not to an extreme degree, but where it begins, whether movement is from ease to bind or vice versa.
Normal excursion of the straight leg into abduction is around 45°, and by testing both legs in the manner described it is possible to evaluate whether they are both tight and short, or whether one is and the other is not. Even if both are tight and short, one may be more restricted than the other. This is the one to treat first using MET.
MET exercise
It is suggested that before using MET clinically you should perform palpation exercises relating to ease and bind (as described above) on many other muscles as they are being both actively and passively moved, until skill in reading this change in tone has been acquired. Once you feel that the beginnings of bind in the adductors can be ascertained by palpation, and having decided which leg to treat, you can attempt simple use of MET.
The point at which the very first sign of bind was noted (or where the hand carrying the leg felt the first sign that effort was required during abduction) is the resistance barrier (see also Box 3.1, above). In subsequent chapters this barrier will be referred to over and over again. It is the place where an MET isometric contraction can begin in some applications of the methods (notably PIR 一 see below). It is also the place which is mentally/visually marked if the practitioner wishes to start a contraction from an easier mid-range position, but which it is necessary to note as the place at which resistance was a feature before the isometric contraction.
Identification and appropriate use of the first sign of the barrier of resistance (i.e. where bind is first noted) is a fundamental and absolutely critical part of the successful use of MET, along with other key features which include the degree of effort used by the patient, and whether subsequently (after the contraction) the tissues are taken to a new barrier, or through the old one to introduce passive stretching. The following exercises in MET variations include the key features emphasised by some o: the leading clinicians who have contributed to MET modern methodology:
Basic exercise in MET using postisometric relaxation (PIR)
in acute context
The patient's limb is positioned where resist�ance is first perceived during abduction, and at this point the practitioner employs MET to lessen the sense of resistance and increase the range o£ movement.
The patient/model is asked to use no more than 20% of available strength to try to take the leg gently back towards the table (i.e. to adduct the leg) against firm, unyielding resistance offered by the practitioner.
In this example the patient is trying to take the limb away from the barrier, while the practitioner holds the limb firmly at the barrier.
The patient/model should be contracting the agonists, the muscles which require release (and which, once released, would allow greater and less restricted abduction).
As the patient/model induces and holds the contraction she is commonly asked to hold an inhaled breath.
The isometric contraction should be intro�duced slowly, and resisted without any jerking, wobbling, or bouncing.
Maintaining the resistance to the contraction should produce no strain in the practitioner.
The contraction should be held for between 7 and 10 seconds - the time it is thought necessary for the 'load' on the Golgi tendon organs to become active and to neurologically influence the intrafusal fibres of the muscle spindles, which inhibits muscle tone, so providing the opportunity for the area (muscle, joint) to be taken to a new resting length/resistance barrier with far less effort, or to stretch it through the barrier of resistance, if this is appropriate (see below) (Scariati 1991).
An instruction is given to the patient,'Now let your breath go, and release your effort, slowly and completely', while the practitioner maintains the limb at the same resistance barrier.
The patient/model is asked to breathe in and out once more, and to completely relax, and as she exhales the limb is gently guided to the new resistance barrier, where bind is once more sensed (the range should almost always be able to be increased by a significant degree).
After use of the isometric contraction (which induces postisometric relaxation (PIR) in the previously contracted tissues) there exists a latency period of anything from 15 to 30 seconds during which the muscle can be taken to its new resting length, or stretched more easily than would have been the case before the contraction (Guissard et al 1988).
The exercise can be repeated, precisely as described above, to see whether even more release is possible, working from the new resistance barrier to whatever new range is gained following the each successive contraction. This approach represents an example of Lewit's PIR method, as described in Chapter 1 (Lewit 1999), and is ideal for releasing tone, for relaxing spasm, particularly in acute conditions.
Basic exercise in MET using postisometric relaxation (PIR) in
chronic context
Where fibrosis is a feature, or for chronic condi�tions, a more vigorous approach can be used in order to actually stretch the muscle(s) rather than simply taking them to a new barrier This would be closer to Janda's (1993) approach ('postfacil�itation stretch' as described in Ch. 1, p. 10), which calls for the starting of the contraction from a more 'slack’, mid-range position, rather than at the actual barrier.
Janda suggests stretching the tissues immediately following cessation of the contraction, and holding the stretch for at least 10 seconds, before allowing a rest period of up to half a minute. He also suggests the procedure be repeated if necessary.
Modification of Janda's approach
The recommendation for use of MET for chronic fibrotic tissues, based on the author's expe�rience, is that following a contraction of between 10 and 12 seconds, commencing from a mid-range position rather than at a barrier; using more than 20% but not more than 50% of the patient's avail�able strength (Janda asks for full strength), a short (2-3 seconds) rest period is allowed for complete postisometric relaxation (PIR), before stretch is introduced which takes the tissues to a point just beyond the previous barrier of resistance.
It is useful to have the patient gently assist in taking the (now) relaxed area towards and through the barrier. Patient participation in movement towards stretch activates the antago�nists, and therefore reduces the danger of a stretch reflex (Mattes 1990).
The procedure of contraction, relaxation, fol�lowed by patient assisted stretch is repeated (with or without a rest period between contrac�tions) until no more gain in length of restricted tissues is being achieved.
The differences between Janda's and Lewit's use of PIR
Lewit starts at, and Janda short of, the restric�tion barrier
Janda utilises a longer and stronger contraction
Janda takes the tissues beyond, rather than just to, the new barrier of resistance (with or without patient assistance).
Janda's approach is undoubtedly successful but carries with it a possibility of very mildly traumatising the tissues (albeit that this is an approach only recommended for chronic and not acute situations). The stronger contraction which he asks for, and the rapid introduction of stretch�ing following the contraction, are the areas which it is suggested should be modified (as described above) with little loss of successful outcome, and with a greater degree of safety.
Reciprocal inhibition (Rl)
An alternative physiological mechanism, recipro�cal inhibition (RI), produces a very similar latency ('refractory’) period to that produced by PIR.
RI is advocated for acute problems, especially where the muscle(s) requiring release are trau�matised or painful, and cannot easily or safely be used in sustained contractions such as those described in the notes on PIR above.
To use RI, the tissues requiring treatment should be placed just short of their resistance barrier (as identified by palpation) (Liebenson 1989). This requirement relates to two factors:
1. The greater ease of initiating a contraction from a mid-range position as opposed to the relative difficulty of doing so when at an end of range position
2. Reduced risk of inducing cramp from a mid-range position, particularly in lower extremity structures such as the hamstrings, and especially if longer or stronger
contractions than the norm (20% strength, 10-12 seconds) are being used.
Basic exercise in MET using 1 reciprocal inhibition (Rl) in
acute and chronic contexts
The example involves abduction of the limb, as outlined above:
The first sense of restriction/bind is evaluated as the limb is abducted, at which point the limb is returned a fraction towards a mid-range position (by a few degrees onlyh
From this position the patient/model is asked to attempt to abduct the leg themselves, using no more than 20% of strength, taking it towards the restriction barrier, while the practitioner resists this effort.
Following the end of the contraction (which may be accompanied by breath holding as described earlier), the patient/model is asked to "release and relax’, followed by a further exhaled breath and further relaxation, at which time the limb is guided by the practitioner to (acute problem) or through (chronic problem) the new barrier with (chronic) or without (acute) the patient's/moders assistance.
MET - SOME COMMON ERRORS AND CONTRAINDICATIONS
Greenman (1989) summarises several of the im�portant component elements of MET as follows:
There is a patient-active muscle contraction
— from a controlled position
— in a specific direction
— met by practitioner applied distinct counterforce
— involving a controlled intensity of
contraction.
The common errors which he notes, and which are as important to memorise as are the directions for use of MET, include those listed below:
Patient errors during MET
(Usually based on inadequate instruction from the practitioner!)
1. Contraction is too hard (remedy: give specific guidelines, e.g. 'use only 20% of strength', or whatever is most appropriate).
2. Contraction is in the wrong direction (remedy: give simple but accurate instructions).
3. Contraction is not sustained for long enough (remedy: instruct the patient/model to hold the contraction until told to ease off, and give an idea ahead of time as to how long this will be).
4. The individual does not relax completely after the contraction (remedy: have them release and relax and then inhale and exhale once or twice, with the suggestion "now relax completely').
To this list the author would add;
5. Starting and/or finishing the contraction too hastily. There should be a slow build-up of force and a slow letting go; this is easily achieved if a rehearsal is carried out first to educate the patient into the methodology.
Practitioner errors in application of MET
These include:
1. Inaccurate control of position of joint or muscle in relation to the resistance barrier (remedy: have a clear image of what is required and apply it).
2. Inadequate counterforce to the contraction (remedy: meet and match the force in an isometric contraction; allow movement in an isotonic concentric contraction; and overcome the con�traction in an isolytic manoeuvre).
3. Counterforce is applied in an inappropriate direction (remedy: ensure precise direction needed for best effect).
4. Moving to a new position too hastily after the contraction (there is usually more than 20 seconds of refractory muscle tone release during which time a new position can easily be adopted 一 haste is unnecessary and counterproductive).
5. Inadequate patient instruction is given (remedy: get the words right so that the patient can cooperate). Whenever force is applied by the patient in a particular direction, and when it is time to release that effort, the instruction must be to do so gradually. Any quick effort is self�defeating.
6. The coinciding of the forces at the outset (patient and practitioner) as well as at release is important. The practitioner must be careful to
use enough, but not too much, effort, and to ease off at the same time as the patient.
7. The practitioner fails to maintain the stretch position for a period of time which allows connective tissue to begin to lengthen (ideally .20-30 seconds, but certainly not just a few seconds).
Contraindications and side-effects cf. MET
If pathology is suspected, no MET should be used until an accurate diagnosis has been established. Pathology (osteoporosis, arthritis, ect.) does not rule out the use of MET, but its presence needs to be established so that dosage of application can be modified accordingly (amount of effort used, number of repetitions, stretching introduced or not, etc.).
As to side-effects, Greenman (1989) explains:
All muscle contractions influence surrounding fascia, connective tissue ground substance and interstitial fluids, and alter muscle physiology by reflex mechanisms. Fascial length and tone is altered by muscle contraction. Alteration in fascia influence^not only its biomechanical function, but also its biochemical and immunological functions. The patient’s muscle effort requires energy and the metabolic process of muscle contraction results in carbon dioxide, lactic acid and other metabolic waste prcxducts which must be transported and metabolised. It is for this reason that the patient will frequently experience some increase in muscle soreness within the first 12 to 36 hours following MET treatment. Muscle energy procedures provide safety for the patient since the activating force is intrinsic and the dosage can be easily controlled by the patient, but it must be remembered that this comes at a price. It is easy for the inexperienced practitioner to overdo these procedures and in essence to overdose the patient.
DiGiovanna (1991) states that side-effects are
minimal with MET:
MET is quite safe. Occasionally some muscle stiffness and soreness after treatment. If the area being treated is not localised well or if too much contractive force is used pain may be increased. Sometimes the patient is in too much pain to contract a muscle or may be unable to cooperate with instructions or positioning. In such instances MET may be difficult to apply.
If beginners to MET:
Stay within the very simple guideline which states categorically cause no
pain when using MET
Stick to light (20% of strength) contractions
Do not stretch over-enthusiastically; but only take muscles a short way past
their restriction barrier when stretching
• Have the patient assist in this stretch.
No side-effects are likely apart from the soreness mentioned above, and this is a normal part of all manual methods of treatment.
While the author advocates that the above recommendations be kept as a guideline for all therapists and practitioners exploring the MET approach, not all texts advocate a completely painless use of stretching and the contrary view needs to be recorded.
Sucher (1990), for example, suggests that dis�comfort is inevitable with stretching techniques, especially when self-applied at home: "There should be some discomfort, often somewhat intense locally ... however, symptoms should
subside within seconds or minutes following the stretch/ Kottke (1982) says, Stretching should be past the point of pain, but there should be no residual pain when stretching is discontinued.'
Clearly what is noted as pain for one individ�ual will be described as discomfort by another, making this a subjective exercise. Hopefully, sufficient emphasis has been given to the need to keep stretching associated with MET light, just past the restriction barrier, and any discomfort tolerable to the patient.
Breathing and MET
Many of the guidelines for application of isometric contraction call for patient participation over and above their 'muscle energy' activity, most notably involving the holding of a breath during the contraction/effort and the release of the breath as the new position or stretch is passively or actively adopted. Is there any valid evidence to support this apparently clinically useful element of MET methodology?
There is certainly "common practice' evidence, for example in weight training, where the held breath is a feature of the harnessing and focusing of effort, and in yoga practice, where the released breath is the time for adoption of new positions. Fascinating as such anecdotal material might be, it is necessary to explore the literature for evidence which carries more weight, and fortunately this is available in abundance.
Cummings & Howell (1990) have looked at the influence of respiration on myofascial tension and have dearly demonstrated that there is a mechanical effect of respiration on resting myofascial tissue (using the elbow flexors as the tissue being evaluated). They also quote the work of Kisselkova & Georgiev, who reported that resting EMG activity of the biceps brachii, quadriceps femoris and gastrocnemius muscles 'cycled with respiration following bicycle ergo�nometei、exercise, thus demonstrating that non respiratory muscles receive input from the respir�atory centres' (Kisselkova & Georgiev 1976). The conclusion was that 'these studies document both a mechanically and a neurologically medi�ated influence on the tension produced by myo�fascial tissues, which gives objective verification of the clinically observed influence of respiration on the musculoskeletal system, and validation of its potential role in manipulative therapy!
So there is an influence, but what variables does it display? Lewit helps to create subdivisions in the simplistic picture of 'breathing in enhances effort' and 'breathing out enhances movement', and a detailed reading of his book Manipulative Therapy in Rehabilitation of the Motor System (Lewit 1999) is highly recommended for those who wish to understand the complexities of the mechanisms involved.
Among the simpler connections which he dis�cusses, and for which evidence is provided, are the following facts;
The abdominal muscles are assisted in their action during exhalation, especially against resistance
Movement into flexion of the lumbar and cervical spine is assisted by exhalation
Movement into extension (i.e. straightening up from forward bending; bending backwards) of the lumbar and cervical spine is assisted by inhalation
Movement into extension of the thoracic spine is assisted by exhalation (try it and see how much more easily the thoracic spine extends as you exhale than when you inhale)
Thoracic flexion is enhanced by inhalation
Rotation of the trunk in the seated position is enhanced by inhalation and inhibited by exhalation
Neck traction (stretching) is easier during exha�lation but lumbar traction (stretching) is eased by inhalation and retarded by exhalation.
The author suggests that breathing assistance to isometric contractions only be employed if they prove helpful to the patient, and in specific situa�tions, for example involving the scalenes where they are directly involved in producing a con�traction of the muscles.
Degree of effort with isometric contraction
Most MET contractions are light and only rarely, when large muscle groups are involved, might contractions involving up to 50% of a patierit's strength be called for.
There is evidence that recruitment of phasic muscle fibres occurs when an effort much in excess of 30% of strength is used (Liebenson 1996). Since in most instances it is the postural fibres which require stretching, little advantage would be gained by inducing reduced tone in phasic fibres. To increase the recruitment of postural fibres there is more benefit in sustaining a mild contraction for a longer period rather than increasing the force of a contraction. (For more on this topic see the discussion of MVC in Ch. 1).
In the case of the scalene muscles, a held inhalation automatically produces an isometric contraction. Therefore in treating these muscles with
MET a held breath would seem to be essential.
MET VARIATIONS
Strength testing 一 MitchelPs view
Before applying MET to an apparently short muscle, Mitchell suggests (Mitchell et al 1979) that it and its pair should be assessed for relative strength. If the muscle which requires lengthen�ing tests as weaker than its pair, he calls for the reasons for this relative weakness to be evaluated and treated. For example an antagonist might be inhibiting it, and this factor should be dealt with so that the muscle which is due to receive MET attention is strengthened. At this time, according to Mitchell and colleagues (1979), MET as described can most suitably be used.
Good ridge (1981) concurs with this view, and states that:
When a left-right asymmetry in range of motion exists, in the extremities that asymmetry may be due to either a hypertonic or hypotonic condition.
Differentiation is made by testing for strength, comparing left and right muscle groups. If findings suggest weakness is the cause of asymmetry in range of motion, the appropriate muscle group is treated to bring it to equal strength with its opposite number before range of motion is retested to determine whether shortness in a muscle group may also contribute to the restriction.
One common reason for a muscle testing as 'weak' (compared with norms or with its pair) involves increased tone in its antagonist, which would automatically inhibit the weaker muscle.
One approach at restoring relative balance might therefore involve the antagonists to any muscle which tests as weak first receiving attention - possibly using MET - to reduce excessive tone and/or to initiate stretching. Following MET treatment of those muscles found to be short and/or hypertonic, subsequent assessment may show that previously weak or hypotonic antago�nists have strengthened but still require toning.
This can be achieved using isotonic contractions, or Ruddy's methods (see below), or some other form of rehabilitation. Reference to strength testing will be made periodically in descriptions of MET application to particular muscles in Chapter 4 whenever this factor seems important clinically, especially in regard to its mention by Mitchell (Mitchell et al 1979).
Janda’s view
Janda (1993) provides evidence of the relative lack of accuracy involved in strength testing, preferring instead an assessment of balanced or unbal�anced function and relative shortness in particular structures, considered in the context of overall musculoskeletal function, as a means of deciding what needs attention. This seems to be close to the ^oose-tight* concept discussed in Chapter 2 (Ward 1997). Janda effectively dismisses the idea of using strength tests to any degree in evaluating func�tional imbalances (Janda 1993, Kraus 1970), when he states:
Individual muscle strength testing is unsuitable because it is insufficiently sensitive and does not take into account evaluation of cwrdinated activity between different muscle groups. In addition in patients with musculoskeletal syndromes, weakness in individual muscles may be indistinct, thus rendering classical muscle testing systems unsatisfactory. This is probably one of the reasons why conflicting results have been reported in studies of patients with back pain.
Janda is also clear in his opinion that weak, short muscles will regain tone if stretched appropriately.
Mitchell and Janda and ‘the weakness factor9
Mitchell's (1979) recommendation regarding strength testing prior to use of MET complicates the approach advocated by the author, which is to use indications of overactivity or stress, or, even more importantly, signs of malcoordination and imbalance, as clues to a postural (mobiliser) muscle being short. 'Functional' tests, such as those devised by Janda and described by Liebenson in Chapter 5, or objective evidence of dysfunction (using one of the many such tests described in Ch. 4) can be used to provide such evidence. Put simply:
If a postural (mobiliser, see Ch. 2) muscle is overused, misused, abused or disused; it will modify by shortening. Evidence of overactivity; inappropriate firing sequences and/or excessive tone all suggest that a muscle is dysfunctional.
If such a muscle falls within one of the groups described in Chapter 2 as postural or mobiliser, then it may be considered to have shortened.
The degree of such shortening may then be assessed using palpation and basic tests as described in Chapter 4.
Additional evidence of a need to use MET induced stretching can be derived from basic palpation which indicates the presence of fibrosis and/or myofascial trigger point activity, or of inappropriate electromyographic (EMG) activity (should such technology be available).
Ideally therefore some observable and/or palpable evidence of functional imbalance will be available which can guide the therapist/practitioner as to the need for MET or other interven�tions in particular muscles.3 For example, in testing for overactivity, and by implication short�ness, in quadratus lumborum (QL)Z an attempt may be made to assess the muscle firing sequence involved in raising the leg laterally in a side-lying posture. There is a 'correct’ and an 'incorrect’ (or balanced and unbalanced) sequence; if the latter is noted, stress is proved and, since this is a postural muscle (or at least the lateral aspect of it is, see dis�cussion of QL in Ch. 2), shortness can be assumed.
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3) This topic is discussed further in Chapter 5 which is devoted to Dr Liebenson's views on rehabilitation and which further discusses aspects of Vladimir Janda's functional tests. Some of Janda's, as well as Lewit’s, functional assessments are also included in the specific muscle evaluations given in Chapter 4.
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The reader must decide whether to introduce MitchelKs (Mitchell et al 1979) element of strength testing into any assessment protocol which they adopt. The recommendation by Mitchell and colleagues (1979) that muscle strength be taken into account before MET is used will not be detailed in each paired muscle discussed in the text, and is highlighted here (and in a few specific muscles where these noted authors and clinicians place great emphasis on its importance) in order to remind the reader of the possibility of its incorporation into the methodology of MET use.
The author has not found that application of weakness testing (as part of the work-up before deciding on the suitability or otherwise of MET use for particular muscles) significantly improves results. He does, however, recognise that in individual cases it might be a useful approach, but considers that systematic weak�ness testing may be left until later in a treatment programme, after dealing with muscles which show evidence of shortness.
Strength testing methodology
In order to test a muscle for strength a standard procedure is carried out as follows:
The area should be relaxed and not influenced by gravity.
The area/muscle/joint should be positioned so that whatever movement is to be used can be easily performed
The patient should be asked to perform a concentric contraction which is evaluated against a scale, as outlined in Box 3.2.
The degree of resistance required to prevent movement is a subjective judgement unless mechanical resistance and/or electronic measurement is available. For more detailed knowledge of muscle strength testing, texts such as Janda's Muscle Function Testing (Janda 1983) are recommended.
Ruddy's methods - 'pulsed MET’
In the 1940s and 50s, osteopathic physician T. J. Ruddy developed a method which utilised a series of rapid pulsating contractions against resistance, which he termed 'rapid resistive duction’. As described in Chapter 1, it was in pare this work which Fred Mitchell Snr used as his base for the development of MET, along with
Box 3.2 Scale for evaluation of concentric contractions
Grade 0 = no contraction/paralysis
Grade 1 = no motion noted but contraction felt by palpating hand
Grade 2 = some movement possible on contraction, if gravity influence
eliminated ('poor')
Grade 3 = Motion possible against gravity's influence ('fair')
Grade 4 = Movement possible during contraction against resistance ("good')
PNF methodology. Ruddy's method (Ruddy 1962) called for a series of muscle contractions against resistance, at a rhythm a little faster than the pulse rate. This approach can be applied in all areas where isometric contractions are suitable, and is particularly useful for self-treatment following instruction from a skilled practitioner.
According to Greenman (1996), who studied with him, ‘He [Ruddy] used these techniques in the cervical spine and around the orbit in his prac�tice as an ophthalmologist-otorhinolaryngologist.‘
Ruddy’s work is now known as 'pulsed MET’.
Its simplest use involves the dysfunctional tissue/joint being held at its resistance barrier, at which time the patient, ideally (or the practitioner if the patient cannot adequately cooperate with the instructions), against the resistance of the practitioner, introduces a series of rapid (2 per second), minute efforts towards (or sometimes away from) the barrier. The barest initiation of effort is called for with, to use Ruddy’s words, 'no wobble and no bounce’. The use of this 'conditioning7 approach involves contractions which are 'short, rapid and rhythmic, gradually increasing the amplitude and degree of resistance, thus conditioning the proprioceptive system by rapid movements'.
In describing application of this method to the neck (in a case of vertigo) Ruddy gives instruction as to the directions in which the series of resisted efforts should be made. These must include
'movements ... in a line of each major direction, forwards, backwards, right forward and right backwards or along an antero-posterior line in four directions along the multiplication "X" sign, also a half circle, or rotation right and left.’
If reducing joint restriction or elongation of a soft tissue is the objective then, following each series of 20 mini-contractions, the slack should be taken out of the tissues and another series of contractions should be commenced from the new barrier, possibly in a different direction - which can and should be varied according to Ruddy's guidelines, to take account of all the different elements in any restriction. Despite Ruddy’s suggestion that the amplitude of the contractions be increased over time, the effort itself must never exceed the barest beginning of an isometric contraction.
The effects are likely, Ruddy suggests, to include improved oxygenation and improved venous and lymphatic circulation through the area being treated. Furthermore, he believes that the method influences both static and kinetic posture because of the effects on proprioceptive and interoceptive afferent pathways, and that this helps maintain 'dynamic equilibrium’, which involves ’a balance in chemical, physical, thermal, electrical and tissue fluid homeostasis'.
In a setting in which tense, hypertonic, poss�ibly shortened musculature has been treated by stretching, it may prove useful to begin facilitating and strengthening the inhibited, weakened antagonists by means of Ruddy’s methods. This is true whether the hypertonic muscles have been treated for reasons of shortness/hypertonicity alone, or because they accommodate active
trigger points within their fibres. The introduction of a pulsating muscle energy procedure such as Ruddy’s, involving these weak antagonists, therefore offers the opportunity for:
Proprioceptive re-education
Strengthening facilitation of the weak antagonists
Further inhibition of tense agonists
Enhanced local circulation and drainage
In Liebenson’s words, 'reeducation of movement patterns on a reflex, subcortical basis
,
(Liebenson 1996).
Ruddy's work was a part of the base on which
Mitchell Snr and others constructed MET and his
work is worthy of study and application since it
offers, at the very least, a useful means of modi�fying the employment of sustained isometric
contraction and has particular relevance to acute
problems and safe self-treatment settings.
Examples of Ruddy’s method will be described
in later chapters.
Isotonic concentric strengthening
MET methods
Contractions which occur against, and overcome, resistance allow tensions to develop within a muscle which vary as the joint angle alters. The effect is to tone and strengthen the muscle(s) involved in the contraction. For example:
The practitioner positions the limb, or area, so that the muscle group will be at resting length, and thus will develop a strong contraction.
The practitioner explains the direction of movement required, as well as the intensity and duration of that effort. The patient strongly contracts the muscle with the objective of moving the muscle through a complete range, quickly (about 2 seconds).
The practitioner offers counterforce which is less than that of the patient's contraction, and maintains this throughout the contraction. This is repeated several times, with a progressive increase in practitioner's counterforce (the patient's effort in the strengthening mode is always maximal).
Where weak muscles are being toned via such isotonic methods, the practitioner allows the concentric contraction of the muscles (i.e. offers only partial resistance to the contractile effort).
Such exercises always involve practitioner effort which is less than that applied by the patient. The subsequent isotonic concentric contraction of the weakened muscles should allow approximation of the origins and insertions to be achieved under some degree of control by the practitioner.
Isotonic efforts are usually suggested as being of short duration, ultimately employing maximal effort on the part of the patient. The use of concentric isotonic contractions to tone a muscle or muscle group can be expanded to become an iso�kinetic, whole joint movement (see below).
Isotonic eccentric alternatives
Norris (1999) suggests that there is evidence that when rapid movement is used in isotonic concentric activities it is largely phasic, type II, fibres which are being recruited. In order to tone pos�tural (type 1) muscles which may have lost their endurance potential, eccentric isotonic exercises, performed slowly, are more effective. Norris states: 'Low resistance, slow movements should be used ... eccentric actions have been shown to be better suited for reversal of serial sarcomere adaptation/Rapidly applied isometric eccentric manoeuvres('isolytic') are described later in this chapter.
Strengthening a joint complex with
isokinetic MET
A variation on the use of simple isotonic concentric contractions, as described above, is to use iso�kinetic contraction (also known as progressive
resisted exercise). In this the patient, starting with a weak effort but rapidly progressing to a maximal contraction of the affected muscle(s), introduces a degree of resistance to the practitioner's effort to put a joint, or area, through a full range of motion. An alternative or subsequent exercise involves the practitioner partially resisting the patient's active movement of a joint through a rapid series of as full a range of movements as possible.
Mitchell (Mitchell et al 1979) describes an isokinetic exercise as follows: The counter force is increased during the contraction to meet changing contractile force as the muscle shortens and its force increases/ These are, he says, especially valuable in improving efficient and coordinated use of muscles, and in enhancing the tonus of the resting muscle. 'In dealing with paretic muscles, isotonics (in the form of progressive resistance exercise) and isokinetics, are the quickest and most efficient road to rehabilitation.'
The use of isokinetic contraction is reported to be a most effective method of building strength, and to be superior to high repetition, lower resistance exercises (Blood 1980). It is also felt that a limited range of motion, with good muscle tone, is preferable (to the patient) to normal range with limited power. Thus the strengthening of weak musculature in areas of limitation of mobility is seen as an important contribution in which isokinetic contractions may assist.
Isokinetic contractions not only strengthen the (largely phasic, type II) fibres which are involved, but have a training effect which enables them to operate in a more coordinated manner. There is often a very rapid increase in strength. Because of neuromuscular recruitment, there is a progressively stronger muscular effort as this method is repeated. Contractions and accompanying mobilisation of the region should take no more than 4 seconds at each contraction in order to achieve maximum benefit with as little fatiguing as poss�ible of either the patient or the practitioner. Prolonged contractions should be avoided.
The simple and safest applications of isokinetic methods involve small joints such as those in the extremities, largely because they are more easily controlled by the practitioner's hands. Spinal joints are more difficult to mobilise and to control when muscular resistance is being utilised at full strength. The options in achieving increased tone and strength via these methods therefore involves a choice between a partially resisted isotonic contraction, or the overcoming of such a contraction, at the same time as the full range of movement is being introduced. Both of these options can involve maximum contraction of the muscles by the patient. Home treatment of such conditions is possible via self-treatment, as in other MET methods.4 DiGiovanna (1991) suggests that isokinetic exercise increases the work which a muscle can subsequently perform more efficiently and rapidly than either isometric or isotonic exercises.
To summarise:
To tone weak phasic (stabiliser, sec Ch. 2) muscles, perform concentric isotonic exercises using full strength, rapidly (4 seconds maximum).
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4 Both isotonic concentric and eccentric contractions will take place during the isokinetic movement of a joint.
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To tone weak postural (mobiliser, see Ch. 2) muscles, slowly perform eccentric isotonic (i.e. isolytic, see below) exercises using increasing degrees of effort. In order to tone postural fibres, slow speed, eccentric resistance is most effective (Norris 1999).
Reduction of fibrotic changes with
isolytic (isotonic eccentric) MET
As discussed above, when a patient initiates a contraction and it is overcome by the practitioner, this is termed an 'isotonic eccentric contraction' (e.g. when a patient tries to flex the arm and the practi�tioner overrides this effort and straightens it during the contraction of the flexor muscles). In such a contraction the origins and insertions of the muscles (and therefore the joint angles) are separated, despite the patient's effort to approximate them. This is termed an isolytic contraction, in that it involves the stretching and to an extent the breaking down (sometimes called 'controlled microtrauma') of fibrotic tissue present in the affected muscles.
Microtrauma is inevitable, and this form of 'controlled' injury is seen to be useful especially in relation to altering the interface between elastic and non-elastic tissues - between fibrous and non-fibrous tissues. Mitchell (Mitchell et al 1979) states that 'Advanced myofascial fibrosis sometimes requires this "drastic" measure, for it is a powerful stretching technique.' 'Adhesions’ of this type are broken down by the application of force by the practitioner which is just a little greater than that of the patient. This procedure can be uncomfortable, and patients should be advised of this, as well as of the fact that they need only apply sufficient effort to ensure that they remain comfortable. Limited degrees of effort are therefore called for at the outset of isolytic contractions.
However, in order to achieve the greatest degree of stretch (in the condition of myofascial fibrosis for example), it is necessary for the largest number of fibres possible to be involved in the isotonic contraction. Thus there is a contradiction in that in order to achieve this large involvement, the degree of contraction should be a maximal one, which could produce pain which, while undesirable in most manual treatment, may be deemed necessary in this instance.
Additionally, in many instances the procedure might be impossible to achieve if a large muscle group (e.g. hamstrings) is involved were a maximal contraction to be used, especially if the patient is strong and the practitioner slight or at least inad�equate to the task of overcoming the force of the contracting muscle(s). Less than optimal contraction is therefore called for, repeated several times perhaps, but confined to specific muscles where fibrotic change is greatest (e.g. tensor fascia lata (TFL)) and to patients who are not frail, pain-sensitive or in other ways unsuitable for what is the most vigorous MET method.
Unlike isotonic eccentric contractions, which have the aim of strengthening weak postural (mobiliser) muscles and which are performed slowly (as discussed earlier in this chapter), isolytic contractions aimed at stretching fibrotic tissues are performed rapidly.
Summary of choices for MET in
treating muscle problems
To return to Goodridge's introduction to MET (see earlier in this chapter) - using the adductors as our target tissues we can now see that a number of choices are open to the practitioner once the objective has been established, for example to lengthen shortened adductor muscles.
If the objective is to lengthen shortened adductors, on the right, several methods could be used:
The patient could contract the right abductors, against equal practitioner counterforce, in order to relax the adductors by reciprocal inhibition.
The patient could contract the right adductors, against equal practitioner counterforce, in order to achieve post isometric relaxation.
The patient could contract the right adductors while the practitioner offered greater counter�force, thus rapidly overcoming the isotonic contraction (producing an eccentric isotonic, or isolytic, contraction), introducing microtrauma to fibrotic tissues.
• The limb could be abducted to the restriction barrier where Ruddy’s 'pulsed MET could be introduced. The practitioner offers counterforce as the patient 'pulses' towards the barrier 20 times in 10 seconds.
In all of these methods the shortened muscles would have been taken to their appropriate barrier before commencing the contraction - either at the first sign of resistance if PIR and movement to a new barrier was the objective, or in a mid-range (just short of the first sense of 'bind’) position if RI or a degree of postfacilitation stretching was considered more appropriate.
For an isolytic stretch the contraction commences from the resistance barrier, as do all iso�kinetic and 'Ruddy’ activities.
If the objective were to strengthen weakened adductors, on the right:
Since these are defined as postural (mobiliser) muscles, the patient could be asked to slowly adduct the limb from its barrier, as the operator allowed the patient's effort to overcome resistance, so toning the muscle while it was contracting.
The essence of muscle energy methods then is the harnessing of the patient’s own muscle power.
The next prerequisite is the application of coun�terforce, in an appropriate and predetermined manner.
In isometric methods this court ter force must be unyielding. No test of strength must ever be attempted. Thus the patient should never be asked to 'try as hard as he can' to move in this or that direction. It is important before commencing that this instruction, and the rest of the procedure, be carefully explained, so that the patient has a clear idea of his role. The direction, limited degree of effort and duration must all be clear, as must the associated instructions regarding breathing patterns and eye movements (if these are being used).
Joints and MET
MET uses muscles and soft tissues for its effects; nevertheless, the impact of these methods on joints is clearly profound since it is impossible to consider joints independently of the muscles which support and move them. For practical pur�poses, however, an artificial division is made in the text of this book, and in Chapter 6 there will be specific focus given to topics such as MET in treatment of joint restriction and dysfunction; preparing joints for manipulation with MET; as well as the vexed question of the primacy of muscles or joints in dysfunctional settings. The opinions of experts such as Hartman, Stiles, Evjenth, Lewit, Janda, Good ridge and Harakal will be outlined in relation to these and other joint-related topics.
A chiropractic view is provided in Chapter 5, which looks at rehabilitation implications of MET as its prime interest, but which also touches on the treatment protocol which chiropractic expert Craig Liebenson suggests in relation tn dysfunctional imbalances which involve joint restriction/blockage.
Self-treatment
Lewit (1991) is keen to involve patients in home treatment, using MET. He describes this aspect thus:
Receptive patients are taught how to apply this treatment to themselves, as aulolherapy, in a home programme. They passively stretched the tight muscle with their own hand. This hand next provided counter pressure to voluntary contraction of the tight muscle (during inhalation) and then held the muscle from shortening, during the relaxation phase. Finally, it supplied the increment in range of motion (during exhalation) by taking up any slack that had developed.
How often should self-treatment be prescribed?
Gunnari & Evjenth (1983) recommend frequent applications of mild stretching or, if this is not possible, more intense but less frequent self-stretching at home. They state that Therapy is more effective if it is supplemented by more frequent self-stretching. In general, the more frequent the stretching, the more moderate the intensity; less frequent stretching, such as that done every other day, may be of greater intensity.'
Self-treatment methods are not suitable to all regions (or for all patients) but there are a large number of areas which lend themselves to such methods. Use of gravity as a counter pressure source is often possible in self-treatment. For example, in order to stretch quadratus lumborum (see Fig. 3.2A-C), the patient stands, legs apart and sidebending, in order to impose a degree of stretch to the shortened muscle. By inhaling and slightly easing the trunk towards an upright posi�tion, against the weight of the body, which gravity is pulling towards the floor, and then releasing the breath at the same time as trying to sidebend further towards the a lengthening of quadratus will have been achieved.
Lewit (1999) suggests, in such a movement, that the movement against gravity be accompanied by movement of the eyes in the direction away from which bending is taking place, while the attempt to bend further - after the contraction - should be enhanced by looking in the direction towards which bending is occurring. Use of eye movements in this way facilitates the effects.
Several attempts by the patient to induce greater freedom of movement in any restricted direction by means of such simple measures should achieve good results.
The use of eye movements relates to the increase in tone which occurs in muscles as they prepare for movement when the eyes move in a given direction. Thus, if the eyes look down there will be a general increase in tone (slight, but' measurable) in the flexors of the neck and trunk. In order to appreciate the influence of eye movement on muscle tone the reader might experiment by fixing their gaze to the left as they attempt to turn their head to the right. This should be followed by gazing right and simultaneously turning the head to the right.
The principles of MET are now hopefully clearer and the methods seen to be applicable to a large range of problems.
Rehabilitation, as well as first-aid and some degree of normalisation of both acute and chronic soft tissue and joint problems are all possible, given correct application. Combined with NMT, this offers the practitioner the chance of achieving safe and effective therapeutic intervention.
When should MET be applied to a
muscle?
When should MET (PIR, RI or postfacilitation stretch) be applied to a muscle to relax and/orstretch it?
1. When it is demonstrably shortened - unlessthe shortening is attributable to associated joint restriction, in which case this should receive primary attention, possibly also involving MET(see Ch. 6).
2. When it contains areas of shortening, such as are associated with myofascial trigger points or palpable fibrosis. It is important to note that trigger points evolve within stressed (hypertonic) areas of phasic, as well as postural muscles, and that these tissues will require stretching, based on evidence which shows that trigger points reactivate unless shortened fibres in which they are housed are stretched to a normal resting length as part of a therapeutic intervention (Simons et al 1998).
3. When periosteal pain points are palpable, indicating stress at the associated muscle’s origin and/or insertion (Lewit 1999).
4. In cases of muscular imbalance, in order to reduce hypertonicity when weakness in a muscle is attributable, in part or totally, to inhibition deriving from a hypertonic antagonist muscle (group).
Evaluation
It is seldom possible to totally isolate one muscle in an assessment, and reasons other than muscle shortness can account for apparent restriction (intrinsic joint dysfunction for example). Other methods of evaluation as to relative muscle short�ness are also called for, including direct palpation.
The 'normal' range of movements of particular muscles should be taken as guidelines only, since individual factors will often determine that what is 'normal' for one is not so for another.
Wherever possible, an understanding is called for of functional patterns which are observable, for example in the case of the upper fixators of the shoulder/accessory breathing muscles. If a pattern of breathing is observed which indicates a predominance of upper chest involvement, as opposed to diaphragmatic, this in itself would indicate that this muscle group was being ’stressed’ by overuse. Since stressed postural (mobiliser) muscles will shorten, an automatic assumption of shortness can be made in such a case regarding the scalenes, levator scapulae, etc. (see Ch. 2 for a fuller discussion of Janda’s evidence for this and for Garland’s description of structural changes relating to this pattern of breathing).
Once again let it be clear that the various tests and assessment methods suggested in Chapter 4, even when utilising evidence of an abnormally short range of motion, are meant as indicates of, and not certainties, as to shortness (Gunnari & Evjenth 1983). As Evjenth observes: 'If the preliminary analysis identifies shortened muscles, then provisional trial treatment is performed. If the provisional treatment reduces pain and improves the affected movement pattern, the preliminary analysis is confirmed, and treatment may proceed.'
MUSCLE ENERGY TECHNIQUE i
SUMMARY OF VARIATIONS
1. Isometric contraction - using
reciprocal inhibition (acute setting, without stretching)
Indications .;
Relaxing acute muscular spasm or contraction
Mobilising restricted joints .
Preparing joint for manipulation.
Contraction starting point For acute muscle or any joint problem, commence at 'easy' restriction barrier (first sign of resistance).
Modus operand! Antagonist(s) to affected muscle(s) is used in isometric contraction, so obliging shortened muscles to relax via reciprocal inhibition. Patient is attempting to push towards the barrier of restriction against practitioner/therapist's precisely matched counterforce.
Forces Practitioner/therapists and patient’s forces are matched. Initial effort involves approx�imately 20% of patienfs strength (or less); an increase to no more than 50% on subsequent contractions if appropriate. Increasing the dura�tion of the contraction (up to 20 seconds) may be more effective than any increase in force.
Duration of contraction Initially 7-10 seconds, increasing to up to 20 seconds in subsequent con�tractions if greater effect required, and if no pain
is induced by the effort.
Action following contraction Area (muscle/joint) is taken to its new restriction barrier without stretch after ensuring complete relaxation. Perform move�ment to new barrier on an exhalation.
Repetitions Repeat three to five times or until no further gain in range of motion is possible.
2.Isometric contraction - using
postisometric relaxation (acute setting, without stretching)
Indications
Relaxing acute muscular spasm or contraction
Mobilising restricted joints
Preparing joint for manipulation.
Contraction starting point At resistance barrier.
Modus operand! The affected muscles (agonists) are used in the isometric contraction, there�fore the shortened muscles subsequently relax via postisometric relaxation. If there is pain on contraction this method is contraindicated and the previous method (use of antagonist) is employed. Practitioner/thcrapist is attempting to push towards the barrier of restriction against the patienfs precisely matched counter-effort.
Forces Practitioner/therapist's and patient's forces are matched. Initial effort involves approximately 20% of patienfs strength; an increase to no more than 50% on subsequent contractions is appropriate. Increase of the duration of the con�traction (up to 20 seconds) may be more effective than any increase in force.
Duration of contraction Initially 7-10 seconds, increasing to up to 20 seconds in subsequent con�tractions if greater effect required.
Action following contraction Area (muscle/joint) is taken to its new restriction barrier without stretch after ensuring patient has completely relaxed. Perform movement to new barrier on an exhalation.
Repetitions Repeat three to five times or until no further gain in range of motion is possible.
3. Isometric contraction - using
postisometric relaxation (chronic setting, with stretching, also known as postfacilitation stretching)
Indications
Stretching chronic or subacute restricted, fibrotic, contracted soft tissues (fascia, muscle) or tissues housing active myofascial trigger points.
Contraction starting point Short of resistance barrier.
Modus operandi Affected muscles (agonists) are used in the isometric contraction, therefore the shortened muscles subsequently relax via postisometric relaxation, allowing an easier stretch to be performed. Practitioner/therapist is attempt�ing to push through barrier of restriction against the patient's precisely matched counter-effort.
Forces Practitioner/therapists and patient's forces are matched. Initial effort involves approximately 30% of patienfs strength; an increase to no more than 50% on subsequent contractions is appropriate. Increase of the duration of the con�traction (up to 20 seconds) may be more effective than any increase in force.
Duration of contraction Initially 7-10 seconds, increasing to up to 20 seconds in subsequent con�tractions if greater effect required.
Action following contraction Rest period of 5 seconds or so, to ensure complete relaxation before commencing the stretch, is useful. On an exhalation the area (muscle) is taken to its new restriction barrier and a small degree beyond, painlessly, and held in this position for at least 10 and up to 60 seconds. The patient should, if possible, participate in helping move the area to and through the barrier, effectively further inhibit�ing the structure being stretched and retarding the likelihood of a myotatic stretch reflex.
Repetitions Repeat three to five times or until no further gain in range of motion is possible, with each isometric contraction commencing from a position short of the barrier.
4.Isometric contraction - using
reciprocal inhibition (chronic setting, with stretching)
Indications
Stretching chronic or subacute restricted, fibrotic, contracted soft tissues (fascia, muscle) or tissues housing active myofascial trigger points
This approach is chosen if contraction of the agonist is contraindicated because of pain.
Contraction starting point A little short of resist�ance barrier.
Modus operand! Antagonist(s) to affected muscles are used in the isometric contraction, therefore the shortened muscles subsequently relax via reciprocal inhibition, allowing an easierstretch to be performed. Patient is attempting to push through barrier of restriction against the practitioner/therapisfs precisely matched counter-effort.
Forces Practitioner/therapist's and patient’s forces are matched. Initial effort involves approx�imately 30% of patient's strength; an increase to no more than 50% on subsequent contractions is appropriate. Increase of the duration of the con�traction (up to 20 seconds) may be more effective than any increase in force.
Duration of contraction Initially 7-10 seconds, increasing to up to 20 seconds in subsequent con�tractions if greater effect required.
Action following contraction Rest period of 5 seconds or so, to ensure complete relaxation before commencing the stretch, is useful. On an exhalation the area (muscle) is taken to its new restriction barrier and a small degree beyond, painlessly, and held in this position for at least 10 and up to 60 seconds. The patient should, if possible, participate in helping move the area to and through the barrier, effectively further inhibiting the structure being stretched and retarding the likelihood of a myotatic stretch reflex.
Repetitions Repeat three to five times or until no further gain in range of motion is possible, with each isometric contraction commencing from a position short of the barrier.
5. Isotonic concentric contraction
(for toning or rehabilitation)
Indications
Toning weakened musculature.
Contraction starting point In a mid-range easy position.
Modus operand! The contracting muscle is allowed to do so, with some (constant) resistance from the practitioner/therapist.
Forces The patienfs effort overcomes that of the practitioner/therapist since patient's force is greater than practitioner/therapist resistance. Patient uses maximal effort available, but force is built slowly not via sudden effort. Practitioner/therapist maintains a constant degree of resistance.
Duration 3-4 seconds.
Repetitions Repeat five to seven times, or more if appropriate.
6. Isotonic eccentric contraction
(isolytic, for reduction of fibrotic change, to introduce controlled
microtrauma)
Indications
Stretching tight fibrotic musculature.
Contraction starting point At restriction barrier.
Modus operandi The muscle to be stretched is contracted and is rapidly prevented from doing so by the practitioner/ therapist, via superior practitioner/ therapist effort, and the contraction is overcome and reversed so that a contracting muscle is stretched. The process should take no more than 4 seconds. Origin and insertion do not approximate. Muscle is stretched to, or as close as possible to, full physiological resting length.
Forces Practitioner/therapist's force is greater than patient's. Less than maximal patient's force is employed at first. Subsequent contractions towards this, if discomfort is not excessive.
Duration of contraction 2-4 seconds.
Repetitions Repeat three to five times if discomfort is not excessive.
/\ CAUTION : Avoid using isolytic contractions on head/neck muscles or at all if patient is frail, very pain-sensitive, or osteoporotic.
7. Isotonic eccentric contraction
(isolytic, for strengthening weak postural muscles)
Indications
Strengthening weakened postural muscle.
Contraction starting point At restriction barrier.
Modus operandi The muscle is contracted and is prevented from doing so by the practitioner/therapist, via superior practitioner/therapist effort, and the contraction is slowly overcome and reversed, so that a contracting muscle is stretched. Origin and insertion do not approximate. Muscle is stretched to, or as close as possible to, full physiological resting length.
Forces Practitioner/therapisfs force is greater than patient’s. Less than maximal patient's force is employed at first. Subsequent contractions build towards this, if discomfort is not excessive.
Duration of contraction 5-7 seconds.
Repetitions Repeat three to five times if discomfort is not excessive.
卜\ CAUTION: Avoid using isotonic eccentric
contractions on head/neck muscles or at all if
patient is frail, very pain-sensitive, or osteoporotic.
8. Isokinetic (combined isotonic and
isometric contractions)
Indications
Toning weakened musculature
Building strength in all muscles involved in particular joint function
Training and balancing effect on muscle fibres.
Starting point of contraction Easy mid-range position.
Modus operandi Patient resists with moderate and variable effort at first, progressing to maximal effort subsequently; as practitioner/ therapist puts joint rapidly through as full a range of movements as possible. This approach differs from a simple isotonic exercise by virtue of whole ranges of motion, rather than single motions being involved, and because resistance varies, progressively increasing as the procedure progresses.
Forces Practitioner/therapisfs force overcomes patient's effort to prevent movement. First move�ments (taking an ankle, say; into all its directions of motion) involve moderate force, progressing to full force subsequently. An alternative is to have the practitioner/therapist (or machine) resist the patient's effort to make all the movements.
Duration of contraction Up to 4 seconds.
Repetitions Repeat two to four times. .
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REFERENCES
------------------------------------------------------------------
Blood S 1980 Treatment of the sprained ankle. Journal of the
American Osteopathic Asswiation 79(11): 689
Cummings ], Howell J 1990 The n>le of respiration in the
tension production of myofascial tissues. Journal of the
American Osteopathic AssDiGiovanna E 1991 Treatment of the spine. In: DiGiovanna E
ed) An osteopathic approach to diagnosis and treatment.
Lippincott, Philadelphia
Goodridge J 1981 MET - definition, explanation, methexis of
procedure. Journal of the American Osteopathic
Association 81(4): 249
Greenman P 1989 Principles of manual medicine. Williams
and Wilkins, Baltimore
Greenman I* 1996 Principles of manual medicine, 2nd edn.
Williams and Wilkins, Baltimore
Guissard N et al 1988 Muscle stretching and motorneurone
excitability. European Journal of Applied Physiology 58: 47-52
Gunnari H, Evjenth O 1983 Sequence exercise. (NorwegianJ
Dreyers Verlag, Oslo
Hoover H 1969 A method for teaching functional technique.
Yearbook of Academy of Applied Osteopathy 1969, Newark, Ohio
Janda V 1993 Assessment and treatment of impaired
movement patterns and motor recruitment. Presentation
to Physical Medicine Research Foundation, Montreal, October 9-11, 1993
Kisselkova, Georgiev J 1976 Journal of Applied Physiology 46: 1093-1095
Kottke F 1982 Therapeutic exercise to maintain mobility. In:
Krusen's handbook of physical medicine and
rehabilitation, 3rd edn. W B Saunders, Philadelphia
Kraus H 1970 Clinical treatment of back and neck pain.
McGraw Hill, New York
Lewit K 1991 Manipulative therapy in rehabilitation of the
motor system. Butterworths, London
Lewit K 1999 Manipulative therapy in rehabilitation of the
motor system, 3rd edn. Butterworths, London
Liebenson C 1989 Active muscular relaxation methods. ...
Journal of Manipulative and Physiological Therapeutics 12(6): 446-451
Liebenson C 1996 Rehabilitation of the spine. Williams and
Wilkins, Baltimore
Mattes A 1990 Active and assisted stretching. Mattes, Sarasota
Mitchell Fz Moran R Pruzzo N 1979 An evaluation and
treatment manual of osteopathic muscle energy
technique. Valley Park, Missouri
Norris C 1999 Functional load abdominal training (part 1).
Journal of Bodywork and Movement Therapies 3(3): 150-158
Ruddy T J 1962 Osteopathic rhythmic resistive technic.
Academy of Applied Osteopathy Yearbook 1962z pp 23-31
Sea ria ti P 1991 Neurophysiology relevant to osteopathic
manipulation. In: DiGiovanna E (ed) An osteopathic
approach to diagnosis and treatment. Lippincott, Philadelphia
Simons D, Travell ], Simmons L 1998 Myofascial pain and
dysfunction: the trigger point manual (vol 1》, 2nd edn.
Williams and Wilkins, Baltimore
Sucher B 1990 Thoracic outlet syndrome - a myofascial
variant (part 2). Journal of the American Osteopathic
Association 90(9): 810-823
Ward R 1997 Foundations of osteopathic medicine. Williams
and Wilkins, Baltimore