Muscle energy techniques

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Front cover Muscle Energy Techniques with DVD-ROM Copyright page Table of Contents Contributors Foreword References Preface Acknowledgements The Website 1 Muscle Energy Techniques Chapter Contents What is MET? Variables MET – an evolving approach Adaptation leading to somatic dysfunction Repetitive lumbar injury – an example of failed adaptation Grieve’s decompensation model A therapeutic formula: reduce adaptive load and enhance function Functional independence STAR and TART assessments STAR (Dowling 1998) TART (Chase 2009) Differences? Are these features of somatic dysfunction real? Definitions of PNF and MET Muscle Energy Technique (MET) & Proprioceptive Neuromuscular Facilitation (PNF): similarities and differences MET-PNF similarities MET-PNF differences Different MET approaches A note on terminology The addition of respiratory and visual synkinesis Muscle types and MET Change of muscle type Stress implications for different muscle types Which muscles belong in which groupings? Postural and phasic muscle lists Joints, muscles and MET – identifying sources of pain (Kaltenborn 1985; Kuchera and Kuchera 1992) Muscles and joints: causes and effects – Janda’s view Mitchell’s ‘short muscle paradigm’ view Greenman’s view Mense’s view More on joints and MET Viscoelasticity in relation to MET/PNF contractions and stretching Possible neurological effects of MET Distraction as a means of increasing stretch tolerance Analgesia following sustained isometric contractions Possible mechanisms Possible features of hypoalgesia following isometric contractions Stretching increases stretch tolerance MET in tissue remodelling and mechanotransduction An example of mechanotransduction Summary References 2 The history of Muscle Energy Technique Chapter Contents Fred L. Mitchell Sr.’s approach to osteopathy The origin of the development of MET Ruddy’s influence Further development of MET PNF and MET Kimberly and Mitchell Sr. The meaning and recognition of MET First tutorial MET after the death of Fred Mitchell Sr. Lewit and MET Janda and Mitchell The model of MET and research findings in recent years References 3 MET: efficacy and research Chapter Contents Efficacy and effectiveness Muscle energy for pain and restricted motion of the spine Effect on range of motion Effect on spinal pain Muscle energy for myofascial extensibility Immediate effects of isometric contraction stretching techniques Applications of isometric contraction stretching techniques over longer periods Studies on muscles other than hamstrings Chronic shoulder dysfunction Eccentric isotonic MET (see also Chapter 8b) Direction of contraction Duration of contraction Force of contraction Number of contraction phases Duration of post-contraction stretch Frequency of application Post-exercise Heat and cold Muscle pain Conclusion Research into the mechanisms of therapeutic effect Mechanisms for increasing myofascial extensibility Reflex muscle relaxation Viscoelastic or muscle property change Stretch tolerance Mechanisms for improving spinal function Increase in range of motion Reduction in pain Tissue fluid drainage Improvement of proprioception and motor control Diagnostic issues References 4 How to use MET Chapter Contents Palpation skills Ease and bind/loose and tight Three-dimensional patterns Clinical possibilities Palpating balance Test for palpation of ease and bind during assessment of adductors of the thigh (see Fig. 4.1A, B) Goodridge’s ease–bind palpation exercise, part 1 (Goodridge 1981) Goodridge’s ease–bind palpation exercise, part 2 MET exercise Basic MET exercise using post-isometric relaxation (PIR) in an acute context Basic MET exercise using postisometric relaxation (PIR) followed by stretch, in a chronic context Modification of Janda’s approach The differences between Janda’s and Lewit’s use of PIR Reciprocal inhibition Basic exercise in MET using reciprocal inhibition in acute and chronic contexts MET – some common errors and contraindications Possible patient errors during MET Practitioner errors in application of MET Contraindications and side-effects of MET Side-effects will be limited if MET is used in ways that: Breathing and MET Degree of effort with isometric contraction More on MET variations Strength testing – Mitchell’s (1979) view Janda’s contrary view on the accuracy of muscle testing Strain-transmission and stretching Conclusion Mitchell and Janda and ‘the weakness factor’ Should you stretch short/tight muscles before facilitating tone in inhibited antagonists? Strength testing methodology Ruddy’s methods – ‘pulsed MET’ Isotonic concentric strengthening MET methods Isotonic eccentric alternatives Example of a slow eccentric isotonic stretch (SEIS) Strengthening a joint complex with isokinetic MET Reduction of fibrotic changes with isolytic (rapid isotonic eccentric) MET Summary of choices for MET in treating muscle problems Joints and MET Self-treatment How often should self-treatment be prescribed? When should MET be applied to a muscle? Evaluation Muscle maps References 5 Sequential assessment and MET treatment of main postural muscles Chapter Contents Clinical research evidence MET and myofascial pain MET and muscles in clinical settings Shoulder range of motion, impingement and dysfunction Low-back and sacroiliac pain MET – with other modalities – for example in treatment of fibromyalgia Objectives of manual treatment Evaluating muscle shortness and strength Important notes on assessments and use of MET What’s short? What’s tight? Postural muscle assessment sequence checklist Sequential assessment and MET treatment of postural muscles 1. Assessment of gastrocnemius (01) and soleus (02) (Fig. 5.1A, B) Assessment of tight soleus (02) Squat screening test MET treatment of shortened gastrocnemius and soleus (see Fig. 5.1A, B) 2. Assessing for shortness in medial hamstrings (03) (semi-membranosus, semi-tendinosus as well as gracilis) and short adductors (04) (pectineus, adductors brevis, magnus and longus) (Figs 5.3 and 5.4) Screening short adductors (04) from medial hamstrings (03) MET treatment of shortness in short and long adductors of the thigh Caution and alternative treatment position (Fig. 5.5) 3. Assessment and treatment of hip flexors – rectus femoris (05), iliopsoas (06) (see also Box 5.4 and Fig. 5.6A) Mitchell’s Strength Test What if one psoas is inhibited, and the other tight? Alternative psoas strength test and toning exercise (Norris 1999) (Fig. 5.7B) MET treatment for shortness of rectus femoris Alternative rectus femoris MET treatment, using slow eccentric isotonic stretching (SEIS) of the hamstrings (in chronic, not acute, settings) MET treatment of psoas Method A Prone (Fig. 5.9A, B) Method B (Fig. 5.10A) MET treatment of psoas Method C (Fig. 5.11A, B) Self-treatment of psoas Method A Method B (Fig. 5.12) 4. Assessment and treatment of hamstrings (07) (Fig. 5.13A, B) Methodology Hamstring test A Hamstring test B (Fig. 5.13C) Janda’s hip extension test (see Fig. 5.14) Commentary on hip extension test Alternative observational test Method A. MET for shortness of lower hamstrings using agonists Method B. MET treatment of lower hamstrings using antagonists (Fig. 5.13C) Method C. Co-contraction MET method of hamstring treatment Method D. Simultaneous toning of hamstring antagonists (quadriceps) and preparation for stretch of shortened hamstrings using SEIS MET for shortness of the upper hamstrings 5. Assessment and treatment of tensor fascia lata (TFL) (08) (see also Box 5.5) Lewit’s (1999) TFL palpation Janda’s (1996) Observation assessment – hip abduction test (Fig. 5.16) Method A. Supine MET treatment of shortened TFL (Fig. 5.17) Method B. Greenman alternative supine MET treatment of shortened TFL (Fig. 5.18) Method C. Isolytic variation Method D. Side-lying MET treatment of TFL Additional methods Self-treatment and maintenance 6. Assessment and treatment of piriformis (09) (see also Boxes 5.6 and 5.7) Test A1. Piriformis stretch test Test A2. Alternative: FAIR test = flexion, adduction, internal rotation Test B. Piriformis palpation test (Fig. 5.20) Piriformis strength test MET treatment of piriformis Method A: Supine Method B: Supine, with full hip flexion and external rotation Method C: Prone (see Fig. 5.21B) Method D: Side-lying – ischaemic compression together with MET 7. Assessment and treatment of quadratus lumborum (10) (see also Box 5.8) Quadratus lumborum test A (Fig. 5.23, see also Fig. 5.16) Quadratus lumborum test B Treatment of shortened QL Method A. MET for shortness in quadratus lumborum (‘banana’) (Fig. 5.24) Method B. Quadratus lumborum side-lying MET (Fig. 5.25) Method C. Quadratus lumborum gravity-induced MET – self-treatment Method D. Quadratus lumborum MET 8. Assessment and treatment of pectoralis major (11) and latissimus dorsi (12) Latissimus and pectoral test A Latissimus and pectoral test B Assessment of shortness in pectoralis major (Fig. 5.28) Assessment for strength of pectoralis major Method A. MET treatment of short pectoralis major (Fig. 5.29A, B) Method B. Pectoralis major MET (Fig. 5.30) Method C. Slow eccentric isometric contraction (SEIS) MET treatment of pectoralis major MET treatment of short pectoralis minor (Fig. 5.31) Latissimus dorsi (12) test for shortness Method A. MET treatment of shortened latissimus dorsi Method B. MET of shortened latissimus dorsi (Fig. 5.32) 9. Assessment and treatment of upper trapezius (13) Upper trapezius shortness test A (Fig. 5.33) Upper trapezius shortness test B Upper trapezius shortness test C Method A. MET treatment of chronically shortened upper trapezius (Fig. 5.35 A–C) Method B. MET treatment of acutely shortened upper trapezius, with visual synkinesis Cervical mobility and MET 10. Assessment and treatment of scalenes (14) (see also Box 5.9) Assessment A: Scalene observation – the paradoxical breathing assessment Assessment B: Scalene functional observation and palpation MET treatment of short scalenes (Fig. 5.37A–C) 11. Assessment for shortness of sternocleidomastoid (15) (see also Box 5.10) Functional SCM test MET treatment of shortened SCM (Fig. 5.38) 12. Assessment and treatment of levator scapulae (16) Test A (spring test) for levator scapula shortness Test B for levator scapula shortness (observation) Test C for levator dysfunction MET treatment of levator scapula (Fig. 5.39) Facilitation of tone in lower shoulder fixators using pulsed MET (Ruddy 1962) Method A Method B Pulsed MET treatment for eye muscles (Ruddy 1962) 13. Assessment and treatment of shortness in infraspinatus (17) Infraspinatus shortness test A Infraspinatus shortness test B (Fig. 5.40) Assessment for infraspinatus weakness MET treatment of infraspinatus (Fig. 5.41) 14. Assessment and treatment of subscapularis (18) Subscapularis shortness test A Subscapularis shortness test B (Fig. 5.42A) Assessment of weakness in subscapularis MET treatment of subscapularis 15. Assessment for shortness of supraspinatus (19) Supraspinatus shortness test Assessment for supraspinatus weakness MET treatment of supraspinatus (Fig. 5.43) 16. Assessment and treatment of flexors of the arm (20) Biceps tendon shortness test A Biceps tendon shortness test B Biceps tendon shortness test C MET treatment for shortness in biceps tendon Flexors of the forearm – MET treatment Biceps brachii – assessment and MET treatment 17. Assessment and treatment of paravertebral muscles (21) Paravertebral muscle shortness test A Paravertebral muscle shortness test B Interpretation of paravertebral muscle shortness tests A and B Paravertebral muscle shortness test C – the ‘breathing wave’ (Fig. 5.47) MET treatment of erector spinae muscle – seated MET transverse stretching of paraspinal musculature ‘C’ bend & ‘S’ bend techniques (Figs. 5.48 & 5.49) Thoracolumbar dysfunction MET treatment of thoracolumbar dysfunction Assessment for shortness in erector spinae muscles of the neck (22) Assessment of weakness of deep neck flexors Toning the deep neck flexors using slow eccentric isotonic stretching (SEIS; see Ch. 4) MET treatment of short neck extensor muscles MET treatment methods for joint problems References 6 MET and the treatment of joints Chapter Contents Joints and MET Opinion or evidence? What makes joints stiff? Age, disease and MET End-of-range, end-feel, restrictions to normal motion Kaltenborn’s (1985) description of normal end-feel variations Kaltenborn’s definition of abnormal end-feel variations Lewit’s anaesthetised patients Muscles or joints? MET mechanisms in treatment of joints Evidence for MET Examples of joint ROM increases following MET Ideal length of contraction for increasing joint ROM Burns and Wells (2006): Cervical ROM study Selkow et al (2009): MET and lumbopelvic pain Wilson et al (2003): Acute low-back pain and MET (see Ch. 7) MET versus HVLA thrust Brodin (1987): MET treatment of chronic low-back pain MET approaches used in the Brodin study MET treatment of joints damaged by haemophilia Preparing joints for HVLA manipulation using MET Avoid wrestling Basic criteria for treating joint restriction with MET (Fig. 6.1A–F) Precise focus of forces – example of lumbar dysfunction Focus rather than force Harakal’s cooperative isometric technique (Harakal 1975) (see Fig. 6.2A–D) Grieve (1984) and MET for the low back Grieve’s low-back approach (Fig. 6.3) Discussion of Grieve’s method Additional choices Method (Fig. 6.3) What if it hurts? MET for thoracic spinal dysfunction T3 restriction: MET protocol summary Reminders Cervical application of MET General procedure using MET for cervical restriction Localised cervical restriction assessment and MET treatment Greenman’s exercise in cervical palpation and use of MET Exercise in cervical palpation (Fig. 6.4A, B) MET treatment of the cervical area to treat translation restriction MET in joint treatment Spencer shoulder sequence incorporating MET Treating muscles, for shoulder restrictions A. Assessment and MET treatment of shoulder extension restriction (Fig. 6.5A) B. Assessment and MET treatment of shoulder flexion restriction (Fig. 6.5B) C. Articulation and assessment of circumduction with mild compression (Fig. 6.5C) D. Articulation and assessment of circumduction with traction (Fig. 6.5D) E. Assessment and MET treatment of shoulder abduction restriction (Fig. 6.5E) F. Assessment and MET treatment of shoulder adduction restriction (Fig. 6.5E) G. Assessment and MET treatment of internal rotation restriction (Fig. 6.5F) Variable directions of effort Modified PNF ‘spiral stretch’ techniques Spiral MET method 1. Shoulder ‘spiral’ stretch into extension to increase the range of motion in flexion, adduction and external rotation (Fig. 6.6A) Spiral MET method 2. Shoulder ‘spiral’ stretch into flexion to increase the range of motion in extension, abduction and internal rotation (Fig. 6.6B) MET treatment of acromioclavicular and sternoclavicular dysfunction Acromioclavicular dysfunction (Fig. 6.7A, B) Assessment and MET treatment of restricted abduction in the sternoclavicular joint (‘Shrug’ test) MET treatment of restricted abduction in the sternoclavicular joint (Fig. 6.8B) Assessment (‘prayer’ test) and MET treatment of restricted horizontal flexion of the upper arm (sternoclavicular restriction) MET treatment of restricted horizontal flexion of the upper arm (sternoclavicular restriction) MET for rib dysfunction (Greenman 1996, Goodridge & Kuchera 1997) Preferred approach Terminology Rib treatment guidelines Rib palpation test: rib 1 (Fig. 6.10) Rib palpation test: ribs 2–10: patient seated (Fig. 6.11) Rib palpation test: ribs 11 and 12 (Fig. 6.12) General principles of MET for rib dysfunction MET treatment for elevated 1st rib, patient seated (Fig. 6.13A) MET treatment for elevated 1st rib, patient supine (Fig. 6.13B) MET treatment for elevated 2nd to 10th ribs (Fig. 6.14) MET treatment for depressed 1st to 5th ribs, patient supine (Fig. 6.15) MET treatment for elevated 11th–12th ribs (Fig. 6.16) MET treatment for depressed 11–12th ribs (Fig. 6.17) General mobilisation Lower thorax and diaphragm attachment release using MET (Fig. 6.18) General thoracic release using MET (Lenehan et al 2003) (see Fig. 1.3) Assessment and MET treatment of sacroiliac (SI) and iliosacral (IS) restrictions Which spinal and SIJ tests do American practitioners use? The most commonly reported findings for assessment of spinal somatic dysfunction were: The most commonly used spinal treatment methods were: Assessment of pelvic landmark asymmetry employed during palpation were the following: For assessment of sacroiliac joint motion the following methods were most frequently employed: In treatment of pelvic and sacroiliac dysfunction, the following methods were most frequently employed: Validity of such tests? Form and force assessment Active straight leg raise (ASLR) test ASLR test supine: functional SI assessments (form/force closure) (Vleeming et al 1995, 1996, 1997, Barker et al 2004, Lee 1997, 2000, 2010) (Fig. 6.20A, B) A variation on the ASLR Test ASLR test prone: functional SIJ assessment (form/force closure) (Vleeming et al 1995, 1996, 1997, Barker et al 2004, Lee 1997, 2000, 2010) (Fig. 6.21A, B) Modified Trendelenburg Test Tests and MET treatment for pelvic and sacroiliac joint dysfunction Standing flexion (iliosacral) test Seated flexion (sacroiliac) test Paravertebral ‘fullness’ assessment Confirmation of iliosacral dysfunction: standing hip flexion test What type of iliosacral dysfunction exists? Landmark test Rotations Flares MET treatment of iliac inflare (Fig. 6.24A, B) MET treatment of iliac outflare (Fig. 6.25) MET treatment of anterior iliac rotation: Method 1 patient prone (Fig. 6.26A) MET treatment of anterior iliac rotation: Method 2 patient supine (Fig. 6.26B) MET for treatment of posterior iliac rotation (Fig. 6.27) ‘Shotgun’ method of pelvic stabilisation and pubic dysfunction ‘Shotgun’ method 1 (see Fig. 6.28A) ‘Shotgun’ method 2 (see Fig. 6.28B) ‘Shotgun’ method 3 ‘Shotgun’ method 4 MET treatment for sacroiliac dysfunction: keeping it simple Clinical questions when confronted with SI dysfunction and pain MET for sacroiliac dysfunction Method A (see Fig. 6.29A) Method B (see Fig. 6.29B) Method C (see Fig. 6.29C) Method D (see Fig. 6.29D) Method E (see Fig. 6.29E) MET treatment for temporomandibular joint (TMJ) dysfunction MET TMJ method 1 (Fig. 6.30A) MET TMJ method 2 (Fig. 6.30B) MET TMJ method 3 (Fig. 6.30C) TMJ self-treatment isometric concentric exercise References 7 Muscle Energy Techniques in cases of spinal injury or pathology Chapter Contents Introduction Patient preference Patients with acute radiculopathy Patients with neurologic deficit Post-surgical patients Patients with osteopenia or osteoporosis Patients with central pain hypersensitivity Conclusion References 8a Manual resistance techniques in rehabilitation Chapter Contents Clinical progression of care Postisometric relaxation (PIR) techniques Method Proprioceptive neuromuscular facilitation (see also Ch. 1) The environmental basis for muscle imbalance Experiment in postural correction (Figs 8a.4, 8a.5) Brügger’s relief position Developmental influences The key role of coactivation of antagonists in producing and maintaining upright posture Functional screening tests Experiment in facilitation of an inhibited muscle chain Investigation Brügger’s facilitation method for inhibited muscle chains in the extremities Conclusion References 8b MET in post-surgical rehabilitation Chapter Contents Introduction Clinical post-surgical situations Muscle physiology relevant to the post-surgical environment Need for functional muscle re-education after surgery in the immediate and late post-surgical period Why MET in the post-surgical condition/rehabilitation? Slow Eccentric Isotonic Stretching (SEIS)/Isolytic Contraction (ILC) as a form of Active Stretching technique in the post-operative phase Clinical evidence and clinical case settings Methodology Clinical application Clinical examples Scenario 1 Distal end radius Scenario 2 Supracondylar Humerus Scenario 3 Upper end tibia Further scope Conclusion References 9 MET in the physical therapy setting Chapter Contents Classification models Staging classification and indexing Further refinement of classification MET studies Positive reliability study Misconceptions in the literature Clinical utilisation of Muscle Energy Technique Staging Clinical correlation: LBP and ankle sprains Stage 1: Pain modulation Example Stage 2: Pain modulation and addressing impairments Addressing impairments: segmental-specific strengthening Positioning for segmental-specific strengthening Isolation of effort: three-finger stacking Progressing the process The importance of rest Parameters Summary and Conclusion Appendix A: Reviews of studies Faas et al (1993) Cherkin et al (1998) Appendix B: Segmental strengthening programme Part 1: Neuromuscular re-education Part 2: Hypertrophy Part 3: Endurance phase References 10 MET in a massage therapy setting Chapter Contents Marrying assessment and treatment Soft tissues Joints Laxity Summary Integrating muscle energy methods into the massage session ‘Wellness’ and therapeutic (clinical) modes of massage Example: Massage including MET to stretch the hip flexor tissues MET in a typical massage setting MET as part of a general massage application Case study Patient prone Patient side-lying Patient supine Summary References 11 MET in treatment of athletic injuries Chapter Contents Adaptation of athletes Dysfunction in sports Screening for dysfunction Pre-season screen Spine measurements Hip region measurements Abdominal strength and coordination Diaphragmatic control Function Strengthening Endurance training Lower extremity measurements Upper extremities Manual assessment of connective tissues Corrective/preventative strategies Dynamic flexibility versus static stretching Warm-up Recovery techniques Muscle Energy Techniques (MET) and integrated neuromuscular inhibition techniques (INIT) in sports injuries Prevention of injury using MET, INIT and other techniques Indications Acute injury care with MET and other therapies INIT/MET in acute settings Indications Chronic injury and long-term rehabilitation using MET Indications MET using isotonic, isometric and isokinetic contractions for strengthening weak postural muscles Case A: Sub-acute low-back strain Treatment Case B: Shoulder tendonitis (subacromial long head of biceps) Treatment Summary References Further reading 12 Integrated neuromuscular inhibition technique (INIT) and myofascial pain Chapter Contents Local facilitation Locating trigger points STAR palpation Drag palpation Trigger point treatment methods The stretching effect of isometric contractions Hypothesis Selye’s concepts Ischaemic compression validation Ischaemic compression in trigger point deactivation Effects of sustained or intermittent compression? An alternative methodology Associated methods Strain/counterstrain (SCS) briefly explained INIT method Discussion Validation of INIT Summary References Index A B C D E F G H I J K L M N O P Q R S T U V W