Advanced Soft Tissue Techniques

Muscle Energy How can MET be used? Techniques These isometric and isotonic techniques are used to: What are muscle energy techniques? • Strengthen or tone weak muscles Muscle energy techniques (MET) describe those • Release hypertonicity manipulative treatments in which a patient, on request, • Stretch tight muscles and fascia actively uses his or her muscles from a controlled • Improve musculoskeletal function position and in a specific direction against a distinct • Mobilise joints in which movement is restricted counterforce. These techniques are now widely • Improve local circulation recognised as an effective approach to the treatment of musculoskeletal dysfunction. They bring together About the book treatment methods used in physical therapy, osteopathy and manual medicine. In Muscle Energy Techniques Leon Chaitow and contributing authors set out clear, practical, clinical guidance for students and practitioners wishing to use MET techniques as part of their patient management.

Musc e Energy Techniques

For Churchill Livingstone: Senior Commissioning Editor: Sarena Wolfaard Associate Editor: Claire Wilson Project Manager: David Fleming Design: Stewart Larking Illustration Manager: Bruce Hogarth Treatment table in the CD-Rom videoclips supplied by Russell Medical Worcestershire UK.

Musc e Energy Techniques With accompanying DVD Leon Chaitow NDDO Registered Osteopathic Practitioner a n d Senior Lecturer, University o f Westminster, London, UK With contributions by Ken Crenshaw BS ATC CSCS Sandy Fritz BS MS Gary Fryer BSe ND DO Craig Liebenson DC Ron J Porterfield BS ATC Nathan Shaw ATC CSCS Erie Wilson PT DSe OCS SCS CSCS Foreword by Donald R Murphy DC DACAN IIIustrations by Graeme Chambers BA(Hons) Medical Artist THIRD EDITION CHURCHILL LIVINGSTONE ELSEVIER EDINBURGH LONDON NEW YORK OXFORD PHILADELPHIA ST LOUIS SYDNEY TORONTO 2006

CHURCHILL LIVINGSTONE ELSEVIER An imprint of Elsevier Limited © Pearson Professional Limited 1996 © Elsevier Limited 1999 © 2006, Elsevier Limited. All rights reserved. The right of Leon Chaitow to be identified as author of this work has been asserted by him in accordance with the Copyright, Designs and Patents Act 1988 No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherw- ise, without either the prior permission of the publishers or a licence permitting restricted copying in the United Kingdom issued by the Copyright licensing Agency, 90 Tottenham Court Road, London WIT 4LP. Permissions may be sought directly from Elsevier's Health Sciences Rights Department in Philadelph.ia, USA: phone: (+1) 215 238 7869, fax: (+1) 215 238 2239, e-mail: [email protected]. You may also complete your request on-line via the Elsevier homepage (http://www.elsevier.com). by selecting 'Customer Support' and then 'Obtaining Permissions'. First edition 1996 Second edition 1999 Third edition 2006 ISBN 10: 0443 101140 ISBN 13: 978 0443 101144 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data A catalog record for this book is available from the Library of Congress Notice Neither the Publisher nor the Author assume any responsibility for any loss or injury and/or damage to persons or property arising out of or related to any use of the material contained in this book. It is the responsibility of the treating practitioner, relying on independent expertise and knowledge of the patient, to determine the best treatment and method of application for the patient. The Publisher your source for books, The journals and multimedia publishers in the health sciences policy is to use www.elsevierhealth.com paper manufactured from sustainable forests Working together to grow libraries in developing countries I www.elsevier.com I www.bookaid.org I www.sabre.org Printed in China

Contents - -- -- The CD-ROM accompanying this text includes video sequences of all the techniques indicated in the text by the icon. To look at the video for a given technique, click on the relevant icon in the contents list on the CD-ROM. The CD-ROM is designed to be used in conjunction with the text and not as a stand-alone product. Contributors vii Foreword ix Preface xi Acknowledgements xiii 1. An introduction to muscle energy techniques 23 77 2. Patterns of function and dysfunction 107 3. How to use MET 131 4. MET: efficacy and research 199 247 Gary Fryer 257 5. Sequential assessment and MET treatment of main postural muscles 27 3 6. MET and the treatment of joints 299 7. Integrated neuromuscular inhibition technique (I NIT) 311 8. Manual resistance techniques in rehabilitation 341 Craig Liebenson 9. MET in the physical therapy setting Eric Wilson 10. MET in a massage therapy setting Sandy Fritz 11. MET in treatment of athletic injuries Ken Crenshaw, Nathan Shaw, Ron J Porterfield Index

THIS PAGE INTENTIONALLY LEFT BLANK

Contributors Ken Crenshaw BS ATC CSCS Ron J Porterfield BS ATC Head Athletic Trainer, Arizona Diamondbacks Head Athletic Trainer, Tampa Bay Devil Rays Baseball Team, Phoenix, AZ, USA Baseball Team, St Petersburg, FL, USA Sandy Fritz BS MS Nathan Shaw ATC CSCS Director, Health Enrichment Center, School of Strength and Conditioning Coordinator, Therapeutic Massage, Lapeer, MI, USA Arizona Diamondbacks Baseball Team, Phoenix, AZ, USA Gary Fryer BSc NO DO Senior Lecturer, School of Health Science, Eric Wilson PT DSc OCS SCS CSCS Victoria University, Melbourne, Australia; Chief, Physical Therapy Element, 7th MDG, Centre for Aging, Rehabilitation, Exercise and Dyess Air Force Base, TX, USA Sport, Victoria University, Melbourne, Australia Craig Liebenson DC L.A. Sports and Spine, Los Angeles, CA, USA

THIS PAGE INTENTIONALLY LEFT BLANK

Foreword As the art and science of neuromusculoskeletal specific treatment approaches that are most likely care evolve, it is becoming increasingly clear that to correct the identified dysfunctions. Muscle energy manual techniques are essential in the proper techniques (METs) are among the most valuable management of patients with problems in this area. tools that any manual clinician can have in his or What is less easily measured, however, is the impact her tool box. There are many reasons for this. of the degree of skill with which these techniques are applied on the outcome of management. Most First, METs have a wide application. This is clinicians who use manual techniques in the treat­ exemplified by the presence in this edition of chapters ment of dysfunction in the locomotor system would specific to massage therapy, physical therapy and agree, however, that the level of skill with which a athletic training. METs can be applied to muscle practitioner applies a certain technique is of the hypertonicity and muscle tightness, but can be utmost importance in the success of any management equally effectively applied to joint dysfunction and strategy. Intuition would tell us that a clinician joint capsule adhesions. They can be applied to with limited skill and a limited variety of methods little old ladies or high level athletes, and anyone in his or her armamentarium would be less effective, in between. Important modifications must be made especially for a difficult case, than one who for each application and each individual, as is possesses wide-ranging knowledge and ability. demonstrated in this book. But because the method is as flexible as it is, the clinician is provided with It has been said that \"you can't learn manual a tool that he or she can modify for a variety of types skills from a book\". However, you can build upon of dysfunction, and a variety of types of patients. an existing body of knowledge, skill and expe­ rience with a written source that introduces new Second, METs can be applied in a gentle manner. methodology and instructs in the scientific basis In manual therapy, we always want to be as gentle and proper application of one's current methodology. as possible, in a way that still provides effective In addition, a written source of high-quality, correction of dysfunction. MET, particularly when clinically applicable information can be an excellent applied to muscle hypertonicity and to joint source of support material when one is taking an dysfunction, is both gentle and effective. For those undergraduate or postgraduate course in manual of us who use thrust techniques, METs also represent therapy. Dr. Chaitow has produced such a book. a different method of applying joint manipulation that is well tolerated by the apprehensive patient, One of the unique aspects of manual therapy or the acute situation. And, MET has been shown that one discovers early on in practice is that no to be equally effective as thrust techniques. two patients are alike and no two locomotor systems are alike. As a result, each patient requires a Third, METs actively involve the patient in the highly individualized approach that addresses his process. One of the essential ingredients in a or her unique circumstances. This means that one successful management strategy involves empower­ must be meticulous about identifying those specific ing the patient to take charge of his or her own dysfunctions, be they joint, muscle or otherwise, recovery. This means that the patient must not be that are most important in producing the disorder a passive recipient of treatment, but rather and from which the patient suffers, and choosing those active participant. Unlike many manual procedures, with METs the patient must be involved in every

step, contracting at the appropriate time, relaxing techniques can be incorporated into the overall at the appropriate time, engaging in eye move­ rehabilitation strategy. I can say for myself that I ments, breathing, etc. METs allow the clinician to could not imagine how I would attempt to manage apply corrective measures while at the same time the majority of patients that I see without METs at beginning the process of transferring responsibility my disposal. to the patient. But, for all these benefits of METs to be realized, Finally, METs are effective. As Dr. Fryer demon­ one must apply them with skill and precision. And strates in his chapter, the research into the clinical they must be applied in the context of a manage­ efficacy of METs is in it's infancy. And he also ment strategy that takes into consideration the points out the interesting challenges to effective entire person. This book represents an important research in this area. However, Dr. Fryer also step in this direction. reveals that those studies that have begun to assess whether METs have an impact on clinical outcome Donald R. Murphy, DC, DACAN have suggested that, when an overall management strategy includes the use of skilled METs, patients Clinical Director, Rhode Island Spine Center benefit to a greater degree than when these methods are not included. In this book, not only is this Clinical Assistant Professor, research presented, but also, in Dr. Liebenson's chapter, the reader is instructed as to how these Brown University School of Medicine Adjunct Associate Professor of Research, New York Chiropractic College Providence, RI USA

Preface What has surprised and excited me most about Captain Eric Wilson PT Dsc, author of that chapter, the content of this third edition is the speed with gained his MET knowledge from impeccable which research and new methods of using MET sources at Michigan State University's School of have made the previous edition relatively out of Osteopathic Medicine. date. It's not that the methods described in previous editions are inaccurate, but rather that the theo­ There are fascinating descriptions in Chapter 11 retical explanations as to how MET 'works' may of MET as used by athletic trainers Ken Crenshaw, have been over-simplistic. The diligent research, Nate Shaw and Ron Porterfield in the context of much of it from Australia, that is outlined by Gary a professional baseball team's (Tampa Bay Devil Fryer DO in Chapter 4, reveals mechanisms Rays) need to help their athletes to remain func­ previously unsuspected, and this may well change tional, despite overuse patterns that would not be the way muscle energy methods are used clinically. easily tolerated by normal mortals. In addition, increasingly refined and focused Chapter 10 provides a respite from extremes ways of using the variety of MET methods are of pain and overuse and illustrates the efficiency emerging, and excitingly many of these are from with which MET can be incorporated into normal professions other than the usual osteopathic therapeutic massage settings. Here Sandy Fritz backgrounds. MS describes incorporation of these safe and effec­ tive approaches in ways that avoid breaking the MET emerged initially from osteopathic tradi­ natural flow of a traditional bodywork setting. tion, but what has become clear is just how well it has travelled into other disciplines, with chapters From my own perspective I am increasingly in this book variously describing MET usage in exploring the dual benefits gained by use of slow chiropractic rehabilitation, physical therapy, athletic eccentric isotonic contraction/stretches (see Chapters training and massage contexts. For example: 3 and 5), and of the remarkably efficient 'pulsed' MET methods devised by Ruddy (1962) over half In Chapter 8 a chiropractic perspective is offered a century ago and described in Chapters 3 and 6. by Craig Liebenson DC, in which MET is seen to offer major benefits in rehabilitation. The evolution In short, the expanded content of this third of the methods outlined in that chapter also cross­ edition highlights the growing potential of MET in fertilize with the pioneering manual medicine multidisciplinary and integrated settings and, by approaches as taught by Vladimir Janda MD and offering an updated evidence base, takes us closer Karel Lewit MD, with both of whom Liebenson to understanding the mechanisms involved in its trained. These East European giants collaborated multiple variations. and worked with some of the osteopathic developers of MET. Leon Chaitow NO DO Corfu, Greece 2005 The clinical use of MET in treating acute low­ back pain in physical therapy settings, as described REFERENCES in detail in Chapter 9, has identified very precise Ruddy T J 1962 Ost�opathic rhythmic resistive MET applications in which acutely distressed spinal technic. Academy of Applied Osteopathy Yearbook joints have been successfully treated and rehabilitated. 1962, pp 23-31

THIS PAGE INTENTIONALLY LEFT BLANK

Acknowledgements As in previous editions, my respect and appre­ commonly has to be carved out of non-existent ciation go to the osteopathic and manual medicine spare time. I truly cannot thank any of you pioneers who developed MET, and to those who enough! continue its expanding use in different professional settings. I wish to thank the editorial staff at Elsevier in Edinburgh, in particular Sarena Wolfaard and My profound thanks also go to the remarkable Claire Wilson, who continue to help me to solve group of health care professionals who have con­ the inevitable problems associated with compila­ tributed their time and efforts to the chapters they tion of a new edition, not least those linked to the have authored in this new edition: Ken Crenshaw, filming of new material for the CD-ROM. Sandy Fritz, Gary Fryer, Craig Liebenson, Ron Porterfield, Nate Shaw and Eric Wilson. And, for creating and maintaining the tranquil and supportive environment in Corfu that allowed Only those who have undertaken the writing me to work on this text, my unqualified thanks of a chapter for someone else's book will know the and love go to my wife Alkmini. effort it requires, and the space to accomplish this

THIS PAGE INTENTIONALLY LEFT BLANK

An 1 introduction to muscle energy techniques ---- - --- CHAPTER CONTENTS Muscle energy techniques (MET) Muscle energy techniques (MET) Muscle energy techniques are a class of soft tissue osteopathic (originally) manipulation methods The route of dysfunction that incorporate precisely directed and controlled, patient initiated, isometric and/or isotonic con­ Revolution or evolution 3 tractions, designed to improve musculoskeletal function and reduce pain. MET by any other name 3 As will be seen in later chapters, MET methods History 3 have transferred to almost all other manual thera­ peutic settings. Liebenson (chiropractic, Ch. 8), Early sources of MET 7 Wilson (physical therapy, Ch. 9), Fritz (massage therapy, Ch. 10) and Crenshaw and colleagues Postisometric relaxation and reciprocal inhibition: (athletic training, Ch. 1 1 ) have all described the usefulness, in their professional work, of incor­ two forms of MET 8 porating MET methodology, while in Ch. 4 Fryer evaluates the evidence base for MET. Key points about modern MET 9 The route to dysfunction Variations on the METtheme 12 _.._. -- Lewit's postisometric relaxation method Why and how we lose functional balance, flexi­ (Lewit 1999a) 13 bility, stability and strength differs from person to person, although the basic formula leading to What may be happening? 14 altered functionality inevitably contains similar ingredients. Why fibrosis occurs naturally 16 Ignoring for the moment psychosocial (anxiety, Putting it together 17 fear, depression, etc.) and biochemical (nutritional status, hormonal balance, etc.) issues, we might Why METmight be ineffective at times 18 consider the decline into dysfunction from a largely biomechanical perspective. It should be To stretch or to strengthen 18 possible to agree that the nature and degree of the demands of our active, or inactive, daily life, work Tendons 18 and leisure activities, as well as our individual relationships with the close environment (shoes, Joints and M ET 20 References ' 21

CHAPTER ONE 2 An introduction to muscle energy techniques L chairs, cars, etc.), define the adaptive changes that In truth, however, structure and function are are superimposed on our unique inherited and so intertwined that one cannot be considered acquired characteristics. Leaving aside the effects without the other. The structure of a unit, or area, of trauma, how our structures respond to the determines what function it is capable of. Seen in repetitive demands of living, and habits of use reverse, it is function that imposes demands on (posture, gait, breathing patterns, etc.), determines the very structures that allow them to operate, and the dysfunctional configurations that emerge. which, over time, can modify that structure - just think of the gross structural changes that Liebenson (2000) has observed that to prevent occur in response to the functions involved in musculoskeletal injury and dysfunction the indi­ lifting weights or running marathons! Quite vidual needs to avoid undue mechanical stress different changes emerge compared with those (excessive adaptive demands), while at the same that would result from playing cards or chess. time improving flexibility and stability in order to acquire greater tolerance to strain. The lead author On 'a cellular level this has been expressed of this book has expressed Liebenson's observation succinctly by Hall & Brody (1 999), who stated: differently, as follows (Chaitow & DeLany 2005): The number of sarcomeres in theory deter­ Benefit will usually emerge if any treatment mines the distance through which a muscle can shorten and the length at which it reduces the overall stress load to which the person produces maximum force. Sarcomere num­ ber is not fixed and in adult muscle the is adapting (whether this be chemical, psycho­ number can increase or decrease. The stimulus logical, physical, or a combination of these), or if for sarcomere length changes may be the amount the person's mind-body can be helped to copel of tension along the myofibril or the myotendon adapt more efficiently to that load. (musculotendenous) junction, with high tension Liebenson (2000) suggests that there is evidence that too little (or infrequent) tissue stress can be leading to an addition of sarcomeres and low just as damaging as too much (or too frequent, or too prolonged) exposure to biomechanical stress. tension causing a decrease [italics added]. In other words, deconditioning through inactivity provokes dysfunction just as efficiently as does So, at its simplest, the load on tissue, which excessive, repetitive and inappropriate bio­ makes functional demands, leads to structural mechanical stress. change. It is therefore essential, when considering dysfunction, to identify, as far as possible through If, over time, as a result of too little or too much observation, assessment, palpation, testing, imag­ in the way of adaptive demand, pathological ing, and questioning, just what structural modifi­ changes occur in soft tissues and joints, the conse­ cations coexist with the reported functional quences are likely to include altered (commonly changes and /or pain, in order to construct a reduced) functional efficiency, often with painful rational plan of therapeutic action. Conversely, in consequences. attempting to restore normal function, or to reduce the degree of dysfunction and/or pain, at It was Karr ( 1 976) who described the musculo­ least some of the focus needs to be towards skeletal system as 'the primary machinery of modifying the identified structural changes that life.' It is, after all, largely through that system have evolved. that we express our uniqueness, by means of which we walk, and move, dance, run, paint, lift Fortunately a variety of methods exist that can and play, and generally interact with the world. encourage more normal function, modify structure, But it was Lewit (1999a) who used the term and r.educe ar eliminate pain, depending on the 'locomotor system', and it is this descriptor that nature and chronicity of the problem. Among the seems closer to reality than the phrase 'musculo­ most effective of such clinical tools - capable of skeletal system'. The word 'locomotor' embraces assisting in both structural and functional change a sense of activity and movement, whereas - are the range of methods that have been labelled musculoskeletal sounds passive and structural, muscle energy techniques (MET) (Mitchell 1967, rather than functional. Lewit & Simons 1 984, Janda 1 990, Lewit 1999a).

Revolution or evolution 3 Revolution or evolution Fryer (see Ch. 4) notes that, As will become clear, as the content of this revised 'The most common forms of isometric stretching and expanded text unfolds, muscle energy tech­ referred to in the literature are contract-relax niques, originating as they did in osteopathic (CR), where the muscle being stretched is con­ medicine, are now increasingly likely to be found tracted and then relaxed, agonist contract-relax in chiropractic (see Ch. 8), physiotherapy (see (ACR), where contraction of the agonist (rather Ch. 9) and massage therapy (Ch. 1 0) and athletic than the muscle being stretched) actively moves training settings (Ch. 11). the joint into increased ROM, and contract-relax agonist contract (CRAC), a combination of these A slow but steady (r)evolution i s taking place two methods. These techniques are commonly in manual and manipulative therapy, involving a referred to as PNF [proprioceptive neuromuscular movement away from high-velocityflow-amplitude facilitation] stretching, but the similarity to MET thrust methods (HVLT - now commonly known methods for lengthening muscles is obvious' as 'mobilisation with impulse' - a characteristic of most chiropractic and, until recently, much (see Box 1 .1 , and further discussion of these osteopathic manipulation) towards gentler methods methods later in this chapter). that take far more account of the soft tissue com­ ponent (DiGiovanna 1 991, Lewit 1 999a, Travell & While Fryer 's description of variations on the Simons 1992) and/ or which focus on joint mobili­ theme of isometric contraction and stretching is sation methods, rather than high-velocity thrust helpful, it highlights a semantic problem relating manipulation (Maitland 1 998) . to the words 'agonist' and 'antagonist'. Once it has been determined that a muscle requires releasing, Greenman (1996) states that: relaxing or and/or stretching, the general usage in this book will describe that muscle as the 'agonist', 'Early [osteopathic] techniques did speak of muscle irrespective of which muscle(s) are contracted in relaxation with soft tissue procedures, but specific the procedure. Evaluation of the descriptions of manipulative approaches to muscle appear to be ACR and CRAC, as outlined above by Fryer, will 20th century phenomena.' make clear that attribution of the word 'agonist' is not always applied in the same way in different It is important to make clear that while muscle therapeutic settings. (Fryer addresses this semantic energy techniques (MET) target the soft tissues confusion in Ch. 4.) primarily, they can also make major contributions towards joint mobilisation. As an example see To be clear - from the perspective of the termi­ discussion of MET as a significant addition to nology that will be used in this book, whenever a Spencer mobilisation methods for the shoulder, in muscle, or muscle group, is being treated, it will be Ch. 6 (Patriquin 1 992, Kneb12002) . referred to as 'the agonist'. MET can also usefully b e employed t o 'prepare' History joints for subsequent HVLA thrust application. MET by any other name MET evolved out of osteopathic procedures developed by pioneer practitioners such as T. J. There are a variety of other terms used to describe Ruddy (1961), who termed his approach 'resistive the MET approach. Some years ago chiropractor duction', and Fred Mitchell Snr ( 1 967). Craig Liebenson (1 989, 1 990) described 'muscle energy' techniques as 'active muscular relaxation As will become clear in this chapter, there also techniques' . As will be seen in Ch. 8, Liebenson exists a commonality between MET and various now uses the more generalised descriptor, manual procedures used in orthopaedic and physiotherapy resistance techniques. methodology, such as proprioceptive neuromus­ cular facilitation (PNF). Largely due to the work of

CHAPTER ONE Proprioceptive neuromuscular facilitation (PNF) variations (including hold-relax and contract-relax) 4 An introduction to muscle energy techniques (Voss et al 1985, Surburg 1981) L Most PNF variations involve stretching that is either passive or passive-assisted, following a strong (frequently Box 1.1 Stretch ing variations a l l available strength) contraction. Some variations attempt incremental degrees of strength with FaciIitated stretching subseq uent contractions. (Sch mitt et al 1999). The same This active stretching approach represents a refinement reservations l isted above (in the facil itated stretching of PNF (see below), and is largely the work of Robert discussion) a pply to these methods. There are excellent McAtee (McAtee Et Charland 1999). This a pproach uses aspect� to the use of PNF; however, the a uthor considers strong isometric contractions of the muscle to be M ET, as detailed in this text, to have distinct advantages, treated, fol lowed by active stretching by the patient. with no drawbacks. An acronym, CRAC, is used to describe what is done (contract-relax, antagonist contract). The main difference Active isolated stretching (AIS) (Mattes 1995) between this and MET l ies in the strength of the Flexibility is encouraged in AIS, which uses active contraction and the use of spira l , diagona l patterns, stretching by the patient and reciprocal inhibition (RI) a lthough these concepts (spira l activities) have a l so been mechanisms. AIS, unlike M ET (which combines RI and used in M ET in recent yea rs (consider scalene M ET PIR, as well as active patient participation), does not treatment in Ch. 5 for exa m ple). utilise the assu med benefits of postisometric relaxation (PIR). The reader is reminded to regard use of the words 'agonist' and 'antagonist' in decriptors such as CRAC as In AIS: commonly being at odds with the general use of 'agonist' 1. The muscle that needs stretching is identified. and 'antagonist' in the descripton of M ET methods. 2. Precise loca lisation is used to ensure that the muscle Reminders will be made throughout the text to help avoid confusion. receives specific stretching. 3. Use is made of a contractile effort to prodlJce The debate as to how much strength shou ld be used in PNF-like methods is unresolved and is discussed in relaxation of the muscles involved. relation to research in Ch. 4. 4. Repetitive, fairly short duration, isotonic muscle In general the M ET usage advocated in this text contractions are used to increase loca l blood flow and prefers lighter contractions than both facilitated oxygenation. stretching and PNF because: 5. A synch ronised breathing rhythm is established, using • It is considered that once a greater degree of strength inha lation as the part returns to the starting position (the 'rest' phase) and exha lation as the muscle is than 25-35% of available force is used, recruitment taken to, and through, its resistance barrier (the is occurring of phasic m uscl e fibres, rather than the 'work' phase). postural fibres that will have shortened and require 6. The muscle to be lengthened/released is taken into stretching (Liebenson 1996). (The im portance of stretch just beyond a point of light irritation - with va riations in response between phasic and postural the patient's assistance - and held for 1-2 -seconds muscles is discussed in more detail in Ch. 2.) before being returned to the starting position. • I t is fa r easier for the practitioner to control light 7. Repetitions continue (sometimes for minutes) until contractions than it is strong ones, ma king M ET a less adequate gain has been achieved. arduous experience for practitioner and patient. Mattes uses patient participation in moving the part • There is far less likelihood of provoking cra mp, tissue through the barrier of resistance in order to prevent damage or pain, when light contractions rather than activqtion of the myotatic stretch reflex, and this strong ones a re used, ma king M ET safer and gentler. component of his specialised stretching approach has been • Physicians and researchers such as Karel Lewit (1999) incorporated into M ET methodology by many have demonstrated that extremely light isometric practitioners. contractions, utilising breathing and eye movements a l one, are often sufficient to produce a degree of tissue relaxation that a l lows g reater movement, as wel l as facilitating subsequent stretching. What little research there has been into the relative benefits of different degrees of contraction effort is discussed in Ch. 4.

History 5 Box 1.1 Continued Supplementary magnesium can correct a tendency to hyperventilation (Pereira 1988). As noted, a key feature of AIS is the rapid rate of stretching, and the del iberately ind uced irritation of the Another result, identified by Hodges et al (2001), stretched tissues. The undoubted ability of AIS to shows that after a mere 60 seconds of over-breathing, lengthen muscles rapidly is therefore achieved at the the normal stabil ising functions of both transversus expense of some degree of microtrauma, which is not abdominis, and the diaph rag m , are reduced or absent. always an acceptable exchange - particularly in elderly and/or already pain-ridden patients. AIS may be more It is therefore suggested that AIS, effective though it suited to ath letic settings than to use on more is in achieving lengthening and increased range, should vulnerable individuals. be employed cautiously. There is an additional concern associated with AIS Yoga stretching (and static stretching) that provokes a degree of anxiety. Hodges Et Gandavia Adopting specific postures based on traditional yoga and (2000) studied coordination between respi ratory and maintaining these for some minutes at a time (combined, postural functions of the diaphrag m: 'The results indicate as a rule, with deep relaxation breathing) allows a slow that activity of h u man phrenic motoneu rones is release of contracted and tense tissues to take place. organised such that it contributes to both posture and A form of self-induced viscoelastic myofascial release respiration du ring a task which repetitively chal lenges seems to be taking place as tissues are held, unforced, at trunk posture: their resistance barrier (see discussion of 'creep' in Ch. 2). Yoga stretching, applied carefu lly, after appropriate Put simply, active limb movement creates an entrainment instruction, represents an excellent means of home care pattern with respiration. Additionally the A IS protocol (Galantino et al 2004). There are superficial similarities actually cal ls for active control of the breathing rate between yoga stretching and static stretching as during the d;fferent phases of movement leading to a described by Anderson (1984). Anderson, however, rate of one limb movement approximately every 3 seconds maintains the stretch, at the barrier, for short periods leading to a distinct possibility of frank hyperventilation, (usual ly no more than 30 seconds) before moving to a together with a host of symptoms. new barrier. In some settings the stretching aspect of this method is assisted by the practitioner. This rate of breathing would be acceptable d u ring running, for exam ple, as the al kal isation caused by rapid Ballistic stretching (Beaulieu 1981) breathing (due to CO2 loss) would balance the acidification A series of rapid, 'bouncing', stretching movements are caused by activity (lactic acid, etc.) (Pryor Et Prasad the key featu re of bal listic stretching. Despite claims that 2002). However, in a relatively static setting, respiratory it is an effective means of lengthening short m uscu lature alkalosis would probably emerge, at which time muscles rapidly, in the view of the author the risk of irritation, become prone to fatigue, dysfunction (e.g. cramp), and or frank inj ury, makes this method undesirable. trigger point evolution (Nixon Et Andrews 1996). Loss of intracel l u lar magnesium occurs as part of the renal compensation mechanism for correcting al kalosis. experts in physical medicine such as Karel Lewit more recent refinements deriving from the work (1 999a), MET has evolved and been refined, and of researchers and clinicians such as Karel Lewit now crosses all interdisciplinary boundaries. (1986, 1 999) and the late Vladimir Janda ( 1 989) of the former Czech Republic, both of whose work MET has as one of its objectives the induced will be referred to many times in this text. Some of relaxation of hypertonic musculature and, where the pioneers of MET (and other methods) are appropriate (see below), the subsequent stretching briefly introduced below. of the muscle. This objective is shared with a num­ ber of 'stretching' systems, and it is necessary to T. J. Ruddy examine and to compare the potential benefits and drawbacks of these various methods (see Box 1 . 1 ) . In the 1 940s and 1 950s, osteopathic physician T. J. Ruddy (1961) developed a treatment method MET, as presented i n this book, owes most of its involving patient-induced, rapid, pulsating contrac- development to osteopathic clinicians such as T. J. Ruddy (196 1 ) and Fred Mitchell Snr ( 1 967), with

CHAPTER ONE 6 An introduction to muscle energy techniques L tions against resistance, which he termed 'rapid The function of any articuLation of the body, resistive duction'. It was in part this work which Fred which can be moved by voLuntary muscle action, Mitchell Snr used as the basis for the evolution of either directly or indirectly, can be influenced by MET (along with PNF methodology, see Box 1 .1 ) . muscle energy procedures ... . Muscle energy techniques can be used to Lengthen a shortened, Ruddy's method called for a series o f rapid, contractured or spastic muscle; to strengthen a low-amplitude muscle contractions against resist­ physiologically weakened muscle or group of ance, usually at a rate of 20 pulsations in 1 0 muscles; to reduce Localized edema, to reLieve seconds. This approach i s now known a s pulsed passive congestion, and to mobiLize an articu­ MET, rather than the tongue-twisting 'Ruddy's Lation with restricted mobility. rapid resistive duction'. Sandra Yale As a rule, at least initially, these patient-directed pulsating contractions involve an effort towards Osteopathic physician Sandra Yale (in DiGiovanna the barrier, using antagonists to shortened struc­ 1 99 1 ) extols MET's potential in even fragile and tures. This approach can be applied in all areas severely ill patients: where sustained contraction MET procedures are appropriate, and is particularly useful for self­ Muscle energy techniques are particuLarLy treatment, following instruction from a skilled effective in patients who have severe pain from practitioner. Ruddy (1961) suggested that the effects acute somatic dysfunction, such as those with a include improved local oxygenation, enhanced whipLash injury from a car accident, or a patient venous and lymphatic circulation, as well as with severe muscle spasm from a faLL. MET having a positive influence on both static and methods are aLso an excellent treatment modality kinetic posture, because of the effects on proprio­ for hospitalized or bedridden patients. They can ceptive and interoceptive afferent pathways. be used in oLder patients who may have severeLy restricted motion from arthritis, or who have Ruddy's work formed part of the base on which brittle osteoporotic bones. Mitchell Snr and others constructed MET, and aspects of its clinical application are described in Edward Stiles Ch. 3. Among the key MET clinicians who have helped Ruddy's original work using pulsing isometric develop MET is Edward Stiles, who elaborates on efforts involved treatment of the intrinsic eye the theme of the wide range of its application muscles. See Ch. 5 (Box 5. 1 1 ) for examples of this (Stiles 1 984a, 1 984b). He states (Stiles 1 984a) that: approach. Basic science data suggests the muscuLoskeLetal Fred M itchell Snr system pLays an important roLe in the function of other systems. Research indicates that segmen­ No single individual was alone responsible for tally reLated somatic and visceraL structures may MET, but its inception into osteopathic work must affect one another directLy, via viscerosomatic and be credited to F. L. Mitchell Snr, in 1 958. Since then somaticovisceraL reflex pathways. Somatic dys­ his son F. Mitchell Jnr (Mitchell et al 1 979) and function may increase energy demands, and it many others have evolved a highly sophisticated can affect a wide variety of bodiLy processes; system of manipulative methods (Mitchell Jnr vasomotor control, nerve impulse patterns (in 1 976) in which the patient 'uses his/her muscles, faoiLitation), axionic flow of neurotrophic proteins, on request, from a precisely controlled position in venous and Lymphatic circulation and ventiLation. a specific direction, against a distinctly executed The impact of somatic dysfunction on various counterforce', the accepted definition of MET. combinations of these functions may be associated with myriad symptoms and signs. A possibility Philip Greenm an which couLd account for some of the observed clinicaL effects of manipulation. Professor of biomechanics Philip Greenman ( 1 996) accurately and succinctly summarises most of the potential benefits of correctly applied MET:

History 7 As to the methods of manipulation Stiles now PNF methodology tended to stress the impor­ uses clinically, he states that he employs MET tance of rotational components in the function methods when treating about 80% of his patients, of joints and muscles, and employed these using and functional techniques (such as strain/ resisted (isometric) forces, usually involving counterstrain) on 1 5-20%. He uses high-velocity extremely strong contractions. Initially, the focus thrusts in very few cases. The most useful manipu­ of PNF related to the strengthening of neuro­ lative tool available is, Stiles maintains, muscle logically weakened muscles, with attention to the energy technique. release of muscle spasticity following on from this, as well as to improving range of motion at J. Goodridge and W. Kuchera intervertebral levels (Kabat 1 959, Levine et al 1 954) (see Box 1 . 1 ) . Modern osteopathic refinements of MET - for example the emphasis on very light contractions, B o x 1.2 Defining t h e terms used in MET which has strongly influenced this text - owe much to osteopathic physicians such as John The terms used in M ET requ i re clear defi n ition and Goodridge and William Kuchera, who consider emphasis: that (Goodridge & Kuchera 1 997): 1. An isometric contraction is one in wh ich a muscle, o r Localisation of force is more important than inten­ g roup o f muscles, or a joi nt, or reg ion of the body, i s sity. Localisation depends on palpatory proprio­ ca l l ed u pon t o contract, o r move i n a specified ceptive perception of movement (or resistance to direction, and in wh ich that effort is matched by the movement) at or about a specific articulation ... . practitioner/thera pist's effort, so that no movement is Monitoring and confining forces to the muscle a l lowed to take place. group or level of somatic dysfunction involved are 2. An isotonic contraction is one in which movement important for achieving desirable changes. Poor does take place, i n that the counterforce offered by results are most often due to improperly localized the practitioner/thera pist is either less than that of forces, often with excessive patient effort [italics the patient. or is g reater. In the first isotonic exa m p l e addedl. there would b e a n a pproxi mation of t h e ori g i n and i nsertion of the muscle(s) i nvolved, as the effort Ea rly sources of M ET exerted by the patient more than matches that of the practitioner/therapist. This has a ton ic effect on the MET emerged squarely out of osteopathic tradi­ muscle(s) and is ca l led a concentric isotonic tion, although a synchronous evolution of treat­ contraction. This method is useful in toning weakened ment methods, involving isometric contraction musculature. and stretching, was taking place independently in 3. The other form of isotonic contraction involves a n physical therapy, called proprioceptive neuro­ eccentric movement i n which t h e m uscle, while muscular facilitation (PNF) (see Box 1 .1 ). • contracting, is stretched. The effect of the practitioner/therapist offering g reater cou nterforce Fred Mitchell Snr ( 1 958) quoted the words of than the patient's m uscu l a r effort is to l engthen a the developer of osteopathy, Andrew Taylor Still: muscle w hich is tryi ng to shorten. This is ca lled a n 'The attempt to restore joint integrity before sooth­ isolytic contraction when performed ra pid ly. This ingly restoring muscle and ligamentous normality manoeuvre is useful in cases where there exists a was putting the cart before the horse.' ma rked degree of fibrotic change. The effect is to stretch a n d a lter these tissues - i nd ucing control led As stated earlier, Mitchell's work drew on the microtra u ma - thus a l lowing an i m provement i n methods developed by Ruddy; however, it is elasticity and circu lation. W h e n t h e eccentric isotonic unclear whether Mitchell Snr, when he was stretch is performed slowly the effect is to tone the refining MET methodology in the early 1 950s, m uscle being stretched, while simu ltaneously inhibiting had any awareness of PNF, a method which the antagonists, which can subsequently be stretched had been developed a few years earlier, in the (Norris 1999, Lewit 1999b). late 1940s, in a physical therapy context (Knott & Voss 1 968). L

CHAPTER ONE Two aspects to MRT [i.e. MET by another name] are their ability to relax an overactive muscle ... 8 An introduction to muscle energy techniques and their ability to enhance stretch of a shortened muscle or its associated fascia when connective L tissue or viscoelastic changes have occurred. Postisometric relaxation and reciprocal As referred to above, two fundamental neuro­ physiological principles have long been thought inh ibition: two forms of M ET (Box 1.2) to account for the neuromuscular inhibition that occurs during application of MET. These concepts A term much used in more recent developments are explored by Fryer in Ch. 4, where he describes of muscle energy techniques is postisometric current research that throws doubt on the validity reLaxation (PIR), especially in relation to the work of these previously widely held concepts. of Karel Lewit ( 1 999) . PIR refers to the assumed effect of reduced tone experienced by a muscle, or One basic premise has been that post-contrac­ group of muscles, after brief periods following an tion inhibition (also known as PIR) is operating. isometric contraction. As will be seen in Ch. 4, the This states that after a muscle is contracted, it is degree to which this neurological effect is indeed automatically in a relaxed state for a brief, latent, part of the MET process is under review, and has period. The second premise relates to reciprocal been disputed. inhibition (RI), which states that when one muscle is contracted, its antagonist is automatically A further MET variation involves the physio­ inhibited. While neither of these hypotheses has logical response of the antagonists of a muscle been discredited, there do now exist doubts as to which has been isometrically contracted - recip­ whether they are the primary, or even major, rocal inhibition (RI). When a muscle is isomet­ physiological reasons for the benefits noted when rically contracted, its antagonist will be inhibited, MET is used. In Ch. 4 Fryer shows the reasoning and will demonstrate reduced tone immediately that leads current opinion to believe that the effect following this. Thus, as part of an MET procedure, of MET is simply to increase tolerance to stretch. the antagonist of a shortened muscle, or group of muscles, may be isometrically contracted in Ib Dorsal root order to achieve a degree of ease and additional ganglion movement potential in the shortened tissues. Response from The relative importance of this process, based Golgi tendon Dorsal root on research evidence, is also discussed further organ in Ch. 4. Strong . neurone Sandra Yale (in DiGiovanna 1 99 1 ) acknowledges contraction of that, apart from the well-understood processes of skeletal muscle reciprocal inhibition, the precise reasons for the effectiveness of MET remain unclear, despite the Motor end plate Ventral root commonly (but not universally) held view that an isometric contraction seems to set the muscle to Figure' 1.1 Schematic representation of the neurological a new length by inhibiting it via the influence of effects of the load i n g of the Golgi tendon organs of a the golgi tendon organ (Moritan 1 987). Other skeleta l m uscle by means of an isometric contraction, which methods that appear to utilise this concept include produces a postisometric relaxation effect in that m uscle. 'hold-relax' and 'contract-relax' techniques (see This effect occurs (Carter et al 2000), but may not be the Box 1 .1 and Ch. 4). pri mary reason for the benefits of M ET (see Ch. 4). Lewit & Simons (1 984) agree that while reciprocal inhibition is a factor in some forms of therapy related to postisometric relaxation techniques, it is not a factor in PIR itself, which they believed to involve a phenomenon resulting from a neurological loop associated with the Golgi tendon organs (see Figs 1 .1 and 1 .2). Liebenson (1996) discusses both the benefits of, and the mechanisms involved in, the use of MET, which he terms 'manual resistance tech­ niques' (MRT):

Key points about modern MET 9 Dorsal root Figure 1.2 Schematic representation of the reciproca l ganglion effect of an isometric contraction of a skeleta l m uscle, resulting in an inhibitory influence on its a ntagonist. Interneurone This effect occurs but may n ot be the primary reason for releasing the ben efits of M ET (see Ch. 4). inhibitory Muscle mediator spindle Motor neurone Agonist of agonist muscle muscle Motor neurone of antagonist muscle Antagonist muscle A number of researchers, including Karel Lewit response (via the Golgi tendon organs) of Prague (Lewit 1 999a), have reported on the involving a combination of: usefulness of aspects of MET in the treatment of trigger points, and MET is indeed seen by many to reciprocal inhibition of the antagonist(s) of be an excelJent method of treating these myofascial the muscle(s) being contracted, as well as phenomena, and of achieving the restoration of a postisometric relaxation of the muscle(s) situation where the muscle in which the trigger which are being contracted. lies is once more capable of achieving its full Other mechanisms are almost certainly involved resting length, with no evidence of shortening. in the subsequent ability to stretch the tissues more comfortably and efficiently, including a possible Travell & Simons (1983) mistakenly credited viscoelastic change in the connective tissues, and Lewit with developing MET, stating that The more probably an increased tolerance to stretch­ concept of applying postisometric relaxation in ing. These issues, and supporting research, are the treatment of myofascial pain was presented explored fully in Ch. 4. for the first time in a North American journal in 1 984 [by Lewitl'. In fact Mitchell Snr had 2 The practitioner/therapist's force may described the method some 25 years previously, overcome the effort of the patient, thus a fact acknowledged by Lewit (Lewit & Simons moving the area or joint in the direction 1 984). opposite to that in which the patient is attempting to move it (this is an isotonic Key points about modern MET eccentric contraction, known, when performed rapidly, as an isolytic contraction). A slowly MET methods all employ the use of the patient's performed isotonic eccentric stretch has the own muscular efforts in one of a number of ways, effect of toning the muscle being stretched usually in association with the restraining or in this way, while inhibiting its antagonist(s), assisting efforts of the therapist: allowing it/them to be more easily stretched subsequently (Kolar 1 999, Norris 1 999). 1 The practitioner/therapist's force may exactly See Ch. 5 for examples of this method. match the effort of the patient (so producing an isometric contraction) allowing no 3 The practitioner/therapist may partially movement to occur - and possibly producing match the effort of the patient, thus allowing, as a result a physiological neurological whilst slightly retarding, the patient's effort (and so producing a toning effect by means of the isotonic concentric, isokinetic, contraction).

CHAPTER ONE lO An introduction to muscle energy techniques L Other variables may be also introduced, for based on the precise needs of the tissues - to example involving: achieve relaxation, reduction in fibrosis or tonifying/re-education • Whether the contraction should commence with the muscle or joint held at the resistance • Whether to take the muscle or joint to its new barrier or short of it - a factor decided largely barrier following the contraction, or whether on the basis of the degree of chronicity or or not to stretch the area/muscle(s) beyond the acuteness of the tissues involved barrier - this decision is based on the nature of the problem being addressed (does it involve • How much effort the patient uses - say, 20% shortening? fibrosis?) and its degree of of strength, or more, or less. Research evidence acuteness or chronicity is inconclusive on this topic, and is detailed in Ch. 4. • Whether any subsequent (to a contraction) stretch is totally passive, or whether the • The length of time the effort is held - patient should participate in the movement, 7-10 seconds, or more, or less (Lewit ( 1 999) the latter being thought by many to be favours 7-1 0 seconds; Greenman ( 1 989) and desirable in order to reduce danger of stretch Goodridge & Kuchera (1 997) favour reflex activation (Mattes 1 995) 3-5 seconds). See Ch. 4. • Whether to utilise MET alone, or in a sequence • Whether, instead of a single maintained with other modalities such as the positional contraction, to use a series of rapid, low­ release methods of strain/counterstrain, or the amplitude contractions (Ruddy's rhythmic ischaemic compression/inhibitory pressure resisted duction method, also known as pulsed techniques of neuromuscular technique (NMT) muscle energy technique) - such decisions will depend upon the type of problem being addressed, with myofascial • The number of times the isometric contraction trigger point treatment frequently benefiting (or its variant) is repeated - three repetitions from such combinations (see description of are thought to be optimal (Goodridge & integrated neuromuscular inhibition (INIT), Kuchera 1 997). See Ch. 4. in Ch. 7 (Chaitow 1 993» • The direction in which the effort is made - • Greenman summarises the requirements for towards the resistance barrier or away from it, the successful use of MET in osteopathic thus involving either the antagonists to the situations as 'control, balance and localisation'. muscles or the actual muscles (agonists) which His suggested basic elements of MET include require 'release' and subsequent stretching the following: (these variations are also known as 'direct' and 'indirect' approaches. See Box 1 .3) • A patient/active muscle contraction, which - commences from a controlled position • Whether to incorporate a held breath and/or is in a specific direction (towards or away specific eye movements (respiratory or visual from a restriction barrier) synkinesis) to enhance the effects of the contraction. These tactics are desirable if • The practitioner/therapist applies distinct possible, it is suggested - see Ch. 5 (Goodridge counterforce (to meet, not meet, or to & Kuchera 1 997, Lewit 1 999a) overcome the patient's force) • What sort of resistance is offered to the • The' degree of effort is controlled (sufficient to patient's effort (for example by the obtain an effect but not great enough to induce practitioner/therapist, by gravity, by the trauma or difficulty in controlling the effort) patient, or by an immovable object) • What is done subsequent to the contraction • Whether the patient's effort is matched, may involve any of a number of variables, overcome or not quite matched - a decision as will be outlined in later chapters

Key points about modern M ET 11 • New chapters in this revised text outline the marises as follows: 'Good results [with MET] depend use of MET in a variety of settings ranging on accurate d iagnosis, appropriate levels of force, from chiropractic to physical (physio) therapy, and sufficient localisation. Poor results are most athletic training and massage therapy. often caused by inaccurate diagnosis, improperly localized forces, or forces that are too strong' The essence of MET then is that it uses the energy (Goodridge & Kuchera 1 997) (see also Box 1 .4). of the patient, and that it may be employed in one or other of the manners described above with any Using agonist or antagonist? (see also Box 1.3) combination of variables, depending upon the par­ ticular needs of the case. Goodridge (one of the first As mentioned, a critical consideration in MET, osteopaths to train with Mitchell Snr in 1 970) sum- apart from degree of effort, duration and frequency Box 1.3 Di rect and i n d i rect action i n which the patient attempts to produce motion away from the motion barrier, i.e. the movement lim itation is It is sometimes easier to describe the variations used in attacked i nd i rectly: MET i n terms of whether the practitioner/thera pist's force is the same as, less than, or g reater than that of On the other hand, Goodridge (1981), having previously the patient. In any g iven case there is going to exist a i l l ustrated a n d described a tech n iq u e where the patient's degree of lim itation i n movement towards end of ra nge, effort was directed away from the barrier of restriction, i n one d i rection or another, which may involve purely states: The aforementioned i l l ustration used the d i rect soft tissue romponents of the a rea, or actual joint method. With the indirect method the component is restriction (and even in such cases there is bou nd to be moved by the practitioner/therapist away from the some involvement of soft tissues). restrictive barrier: The practitioner/thera pist establishes, by palpation Thus: and by mobil ity assessments (such as motion pal pation, • If the practitioner/therapist is moving away from the idea lly i nvolving 'end-feel' ), the d i rection of maximum 'bind', or restriction. This is felt as a defi n ite point of barrier, then the patient is moving towards it, a nd in limitation in one or more directions. In many i nstances Goodridge's terminology (i.e. osteopathic) this is an the m uscle(s) w i l l be shortened and cu rrently inca pable indirect approach. of stretching and relaxi ng. • I n Grieve's terminology (physiothera py) this i s a d i rect approach. Should the isometric, or isoton ic, contraction w hich Plainly these views a re contra d ictory. the patient is asked to perform, be one in which the Si n ce M ET a lways i nvolves two opposing forces (the contraction of the muscles or movement of the joint is patient's and the practitioner/therapist's/or g ravity/or a away from the barrier or poi nt of bind, while the fixed object), it is more logical to indicate which force practitioner/therapist is using force i n the direction is bei n g used in order to characterise a given tec h n ique. which goes towards, or through that barrier, then this Thus a practitioner/therapist-direct method ca n a l so form of treatment i nvolves what is called a direc(action. equa l ly accurately be described as a patient-in d i rect method. Shou ld the opposite apply, with the patient attempting Practitioner/thera pist-direct methods (in w h ich the to take the a rea/joint/muscle towards the barrier, w h i l e patient is utilising muscles - the agon ists - a l ready in a the practitioner/therapist is resisting, then this is an shortened state) may be more a ppropriate to managing indirect manoeuvre. chronic conditions, rather than acute ones, for exa mple d u ri n g rehabilitation , where muscle shorten i ng has Experts differ occurred. When acute, shortened m uscles could involve As with so much in manipulative term inology, there is existing sustai ned fibre damage, or may be oedematous, d isagreement even in this a pparently simple matter of a nd could be painfu l, and/or go i n to spasm, were they which method should be termed 'direct' and which asked to contract. I t would therefore seem both more 'indirect'. Grieve (1985) describes the variations th us: logical, and safer, to contract their a ntagonists - using 'Direct action techniques [are those] in which the patient patient-direct methods. attempts to produce movement towa rds, i nto or across a motion barrier; and i n d i rect techniq ues, [are those]

C H APTER ONE 12 An introduction to muscle energy techniques Box 1 .4 M uscle energy sources (Jacobs Et: than would be the case were the relaxation effect being achieved via use of the antagonist (i.e. using Wa l l s 1 9 9 7 . Lederman 1 9 9 8 . Liebenson reciprocal inhibition). 1 9 9 6 . Schafer 1 987) Following on from an isometric contraction - whether agonist or antagonist is being used - • M u scles a re the body's force generators. I n order to there appears to be a refractory, or latency, period ach ieve this function, they req u i re a sou rce of power, of approximately 15 seconds during which there which they derive from their abi l i ty to produce can be an easier (due to reduced tone, or to mech a n ical energy from chemica l ly bound energy increased tolerance to stretch) movement towards (i n the form of adenosi n e triphosphate - ATP). the new position (new resistance barrier) of a joint or muscle. In Ch. 4 this latency period is discussed • Some of the e nergy so produced is stored i n further in relation to research evidence. A study contractile tissues for subseq uent use w h e n activity by Moore & Kukulka ( 1 991), for example, suggests occurs. The force w hich skeleta l m uscles generate is only about 1 0 seconds of reduced EMG activity used to either produce or prevent movement, to following an isometric contraction. However, i nd uce motion or to ensure stability. whether this relates to the increased ease of stretching is queried by other research findings • Muscu l a r contractions can be described i n relation to (Magnusson et aI 1 996). what has been termed a strength continuum, varying from a small degree of force, capable of lengthy Variations on the M ET theme m a i nten a n ce, to a f u l l -strength contraction, which can be susta ined for very short periods on ly. As with most manual therapy approaches, the MET methods employed will vary with the • When a contraction involves more than 70% of objectives. available strength, blood flow is reduced and oxygen availability diminishes. • Relaxation of soft tissues has the objective of inducing a reduction of tension in contractile of use, involves the direction in which the effort structures such as muscle. Relaxation may be is made. This may be varied, so that the all that can usefully be done using MET (or practitioner/therapist's force is d irected towards other methods) during the acute and overcoming the restrictive barrier (created by a remodelling phases of soft tissue distress. shortened muscle, restricted joint, etc.); or indeed An 'acute' model of MET usage will be opposite forces may be used, in which the outlined in Ch. 5. practitioner/therapist's counter-effort is directed away from the barrier. • 'Release' of soft tissue shortening is directed towards the non-dynamic connective tissue There is general consensus among the various component of soft tissues. Because such tissue osteopathic experts already quoted that the use is slow to shorten, it generally requires a of postisometric relaxation (i.e. a contraction lengthy period of applied load (minutes rather involving the muscle that requires releasing or than seconds), such as is used in myofascial lengthening) is more useful than reciprocal release. The benefit of initially using MET inhibition in attempting to normalise hypertonic components (isometric contractions) will be musculature. This, however, is not generally held explained. There is an undoubted increase in to be the case by experts such as Lewit (1999) and stretch tolerance following use of MET, which Janda ( 1 990), who see specific roles for the enhances 'release' techniques (Magnusson et al reciprocal inhibition variation. 1 996). Release, in this context, differs from 'stretch' (see below) in that tissues tend to Osteopathic clinicians such as Stiles (1 984b) be held against their end of range barrier(s), and Greenman (1 996) believe that the muscle rather than being forced through those barriers which requires stretching (the agonist) should be as they are when being stretched. the main source of 'energy' for the isometric contraction, and suggest that this achieves a more significant degree of relaxation, and so a more useful ability to subsequently stretch the muscle,

Key points about modern M ET 13 • Stretch commonly requires a relatively greater 2. The patient gently contracts the affected load to the tissue than relaxation or release hypertonic muscle away from the barrier (i.e. method, as - following one or other version of the agonist is contracted) for between 5 and MET contraction - tissues are taken to, and 10 seconds, while the effort is resisted with an beyond, their end of range barriers in an exactly equal counterforce. Lewit usually has attempt to increase length. Stretch methods the patient inhale during this effort. target the non-contractile portion of muscle, the ground substance, although it also affects 3. This resistance involves the practitioner/ contractile tissues by overcoming any therapist holding the contracting muscle in resistance. Stretching carries an increased risk a direction which would stretch it, were of pain and injury that seldom applies when resistance not being offered . relaxation or release objectives are sought. 4. The degree of effort, in Lewit's method, is • Liebenson (1 989, 1 990) has described three minimal. The patient may be instructed to basic variations of MET, as used by Lewit and think in terms of using only 10 or 20% of his Janda, as well as by himself in a chiropractic available strength, so that the manoeuvre is rehabilitation setting to achieve one or a never allowed to develop into a contest of combination of these objectives. strength between the practitioner/therapist and the patient. • Lewit's (1 999a) modification of MET, which he called postisometric relaxation, is directed 5. After the effort, the patient is asked to exhale towards relaxation of hypertonic muscle, and to 'let go' completely, and only when this especially if this relates to reflex contraction, is achieved is the muscle taken to a new or the involvement of myofascial trigger barrier with all slack removed - but no stretch points. Liebenson (1 996) notes that 'this is also - to the extent that the relaxation of the a suitable method for joint mobilisation when hypertonic muscles will now allow. a thrust is not desirable'. 6. Starting from this new barrier, the procedure Lewit's postisometric relaxation method is repeated two or three times. ( Lewit 1 9 9 9a) 7. In order to facilitate the process, especially 1. The hypertonic muscle is taken, without force where trunk and spinal muscles are involved, or 'bounce', to a length just short of pain, or Lewit usually asks the patient to assist by to the point where resistance to movement is looking in the direction of the contraction first noted (Fig. 1 .3). during the contracting phase, and in the direction of stretch during the stretching phase of the procedure. Pathological or Figure 1.3 A schematic representation of the restriction directions i n which a muscle or joint can move - barrier towards a restriction barrier (at which point M ET cou ld be usefu lly applied) or towards a position of relative ease. z o 3 � Neutral

14 An introduction to muscle energy techniques The key elements in this approach, as in most this factor does not always seem to be essential. In MET methods, involve precise positioning, as some areas, self-treatment, using gravity as the well as taking out slack and using the barrier resistance factor, is effective, and such cases as the starting and ending points of each sometimes involve no actual stretch of the contraction. muscles. What may be happening? Stretching of muscles during MET, according to Lewit (1 999), is only required when contracture Karel Lewit, discussing MET methods (Lewit due to fibrotic change has occurred, and is not 1 999a), states that medullary inhibition is not necessary if there is simply a disturbance in capable of explaining their effectiveness. He function. He quotes results in one series of considers that the predictable results obtained patients (Lewit 1 985, p 257), in which 351 painful may relate to the following: muscle groups, or muscle attachments, were treated oy MET (using postisometric relaxation as • During resistance using minimal force described above) in 244 patients. Analgesia was (isometric contraction) only a very few fibres immediately achieved in 330 cases, and there was are active, the others being inhibited no effect in only 21 cases. These are remarkable results by any standards. • During relaxation (in which the shortened musculature is taken gently to its new limit Lewit suggests that trigger points and 'fibrositic' without stretching) the stretch reflex is changes in muscle will often disappear after MET avoided - a reflex which may be brought contraction methods. He further suggests that about even by passive and non-painful stretch. referred local pain points, resulting from problems elsewhere, will also disappear more effectively • He concludes that this method demonstrates than where local anaesthesia or needling (acupunc­ the close connection between tension and pain, ture) methods are employed. and between relaxation and analgesia. Janda's postfacil itation stretch method • The use of eye movements (visual synkinesis) as part of the methodology is based on Janda's variation on this approach (Janda 1 993), research by Caymans ( 1 980) which indicates, known as 'postfacilitation stretch', uses a different for example, that flexion is enhanced by the starting position for the contraction, and also a far patient looking downwards, and extension by stronger isometric contraction than that suggested the patient looking upwards. Similarly, side­ by Lewit, and by most osteopathic users of MET: bending and rotation are facilitated by looking towards the side involved. 1. The shortened muscle is placed in a mid­ range position about halfway between a fully • The potential value of this method is easily stretched and a fully relaxed state. proved by self-experiment: an attempt to flex the spine while maintaining the eyes in an 2. The patient contracts the muscle isometrically, upwards (towards the forehead) looking using a maximum degree of effort for 5-1 0 d irection, will be found to be less successful seconds while the effort is resisted completely. than an attempt made to flex while looking downwards. These eye-direction aids are also 3. On release of the effort, a rapid stretch is useful in manipulation of the joints and will be made to a new barrier, without any 'bounce', mentioned in various technique descriptions and this is held for at least 10 seconds. in later chapters. 4. The patient relaxes for approximately Effects of M ET 20 seconds and the procedure is repeated between three and five times more. Lewit ( 1 999) in discussion of the element of passive muscular stretch in MET maintains that Some sensations of warmth and weakness may be anticipated for a short while following this more vigorous approach.

Key points about modern MET 1 5 Recip rocal inhibition variation of weak musculature in areas of permanent limita­ tion of mobility is seen as an important contribu­ This method, which forms a component of PNF tion in which isokinetic contractions may assist. methodology (see Box 1 . 1 ) and MET, is mainly used in acute settings, where tissue damage or Isokinetic contractions not only strengthen the pain precludes the use of the more usual agonist fibres involved, but also have a training effect which contraction, and also commonly as an addition to enables them to operate in a more coordinated such methods, often to conclude a series of manner. There is often a very rapid increase in stretches whatever other forms of MET have been strength. Because of neuromuscular recruitment, used (Evjenth & Hamberg 1 984): there is a progressively stronger muscular effort as this method is repeated. Isokinetic contractions, 1. The affected muscle is placed in a mid-range and accompanying mobilisation of the region, position. commonly take no more than 4 seconds at each contraction, in order to achieve maximum benefit 2. The patient is asked to push firmly towards with as little fatiguing as possible, either of the the restriction barrier and the practitioner/ patient or the practitioner/therapist. The simplest, therapist either completely resists this effort safest, and easiest-to-handle use of isokinetic (isometric) or allows a movement towards methods involves small joints, such as those in the it (isotonic). Some degree of rotational or extremities. Spinal joints may be more difficult to diagonal movement may be incorporated into mobilise while muscular resistance is being fully the procedure. applied. 3. On ceasing the effort, the patient inhales and The options available in achieving increased exhalef fully, at which time the muscle is strength via these methods therefore involve a passively lengthened. choice between either a partially resisted isotonic contraction, or the overcoming of such a contrac­ Liebenson notes that 'a resisted isotonic effort tion, at the same time as the full range of move­ towards the barrier is an excellent way in ment is being introduced (note that both isotonic which to facilitate afferent pathways at the concentric and eccentric contractions will take conclusion of treatment with active muscular place during the isokinetic movement of a joint). relaxation techniques or an adjustment (joint). Both of these options should involve maximum This can help reprogram muscle and joint contraction of the muscles by the patient. Home proprioceptors and thus re-educate treatment of such conditions is possible, via self­ movement patterns.' (See Box 1 .2.) treatment, as in other MET methods. Strengthening variation Isotonic eccentric M ET Another major MET variation is to use what has Another application of the use of isotonic contrac­ been called isokinetic contraction (also blown as tion occurs when a direct contraction is resisted progressive resisted exercise). and overcome by the practitioner/therapist (see Fig. 1 .4). When performed rapidly this has been In this the patient starts with a weak effort but termed isolytic contraction, in that it involves the rapidly progresses to a maximal contraction of the stretching, and sometimes the breaking down, of affected muscle(s), introducing a degree of resist­ fibrotic tissue present in the affected muscles. ance to the practitioner/therapist's effort to put Adhesions of this type are reduced by the appli­ the joint, or area, through a full range of motion. cation of force by the practitioner/therapist which is just greater than that being exerted by the The use of isokinetic contraction is reported to patient. This procedure can be uncomfortable, and be a most effective method of building strength, the patient should be advised of this. Limited and to be superior to high repetition, lower degrees of effort are therefore called for at the resistance exercises (Blood 1 980). It is also felt that outset of isolytic contractions. a limited range of motion, with good muscle tone, is preferable (to the patient) to having a normal range with limited power. Thus the strengthening

CHAPTER ONE 16 An introduction to muscle energy techniques An isotonic eccentric contraction involves the In some muscles, of course, this may require a origins and insertions of the muscles involved heroic degree of effort on the part of the becoming further separated as they contract, practitioner/therapist, and alternative methods despite the patient's effort to approximate them. are therefore desirable. Deep tissue techniques, such as neuromuscular technique, would seem to In order to achieve the greatest degree of stretch offer such an alternative. The isolytic manoeuvre (in the condition of myofascial fibrosis, for exam­ should have as its ultimate aim a fully relaxed ple), it is necessary for the largest number of fibres muscle, although this will not always be possible. possible to be involved in the isotonic contraction. Thus there is a contradiction in that, in order to Issues relating to the optimal degree of patient achieve this large involvement, the degree of con­ effort, and the ideal number of repetitions of such traction should be a maximal one, and yet this is effort, based on current research evidence, will be likely to produce pain, which is contraindicated. The discussed fully in Ch. 4. muscle force may also, in many instances, be impos­ sible for the practitioner/therapist to overcome. When performed slowly an istonic eccentric stretch has the effect of toning the muscles To achieve an isolytic contraction the patient involved, and of inhibiting the antagonist(s) to should be instructed to use about 20% of possible those muscles, with minimal or no tissue damage strength on the first contraction, which is resisted such as would occur if performed rapidly. The and overcome by the practitioner/therapist, in a clinical use of slow eccentric isotonic stretching contraction lasting 3-4 seconds. This is then (SEIS) is described further in Chs 3 and 5. repeated, but with an increased degree of effort on the part of the patient (assuming the first effort Why fibrosis occurs naturally was relatively painless). This continuing increase in the amount of force employed in the contract­ An article in the Journal of the Royal Society of ing musculature may be continued until, hope­ Medicine (Royal Society of Medicine 1 983) discusses fully, a maximum contraction effort is possible, connective tissue changes: again to be overcome by the practitioner/therapist. Aging affects the function of connective tissue Figure 1.4 Example of an isolytic contraction in which more obviously than almost any organ system. the patient is attem pting to move the rig h t leg into Collagen fibrils thicken, and the amounts of abduction tow a rds the right at exactly the same time as the solubLe poLymer decrease. The connective tissue practitioner/therapist is overriding this effort. This stretches cells tend to decline in number, and die off. the m uscles w hich a re contracting (TFL shown in exam ple) CartiLages become less elastic, and their comple­ thereby inducing a degree of control led microtra u ma , with ment of proteoglycans changes both quantitatively the aim of increasing the elastic potential of shortened or and quaLitatively. The interesting question is how fibrosed tissues. many of these processes are normal, that con­ tribute blindly and automatically, beyond the point at which they are useful? Does prevention of aging, in connective tissues, simply imply inhibition of crosslinking in collagen fibrils, and a slight stimulation of the production of chon­ droitin sulphate proteoglycan? The effects of various soft tissue approaches such as NMT and MET will impact directly on these tissues, as well as on the circulation and drainage of the affected structures, which suggests that at least some of the effects of the ageing process can be influenced. Research has identified a feature of stiffness that may relate directly to the water content of connective tissue (see Box 1 .5).

Putting it together 1 7 Destruction of collagen fibrils, however, is a Putting it together serious matter (for example when using isolytic stretches, as described above), and although the The recommendation of this text is that the MET fibrous tissue may be replaced in the process of methods outlined above should be 'mixed and healing, scar-tissue formation is possible, and this matched', so that elements of all of them may be makes repair inferior to the original tissues, both used in any given setting, as appropriate. Lewit's in functional and structural terms. An isolytic (1 999) approach seems ideal for more acute and contraction has the ability to break down tight, less chronic conditions, while janda's (1 989) more shortened tissues and the replacement of these vigorous methods seem ideal for hardy patients with superior material will depend, to a large with chronic muscle shortening. There is a time to extent, on the subsequent use of the area (exercise, relax, to release and to stretch tissues, and some­ etc.), as well as the nutritive status of the indi­ times to do all three. vidual. Collagen formation is dependent on ade­ quate vitamin C, and a plentiful supply of amino MET offers a spectrum of approaches which acids such as proline, hydroxyproline and arginine. range from those involving hardly any active con­ Manipulation, aimed at the restoration of a traction at all, relying on the extreme gentleness of degree of normality in connective tissues, should mild isometric contractions induced by breath­ therefore take careful account of nutritional holding and eye movements only, all the way to requirements. the other extreme of full-blooded, total-strength contractions. Subsequent to isometric contractions The range of choices of methods of stretching, - whether strong or mild - there is an equally irrespective of the form of prelude to this - strong sensitive range of choices, involving either energetic or mild isometric contraction, starting at or short stretching or very gentle movement to a new of the barrier - therefore covers the spectrum from restriction barrier. all-passive to all-active, with many variables in between. We can see why Sandra Yale (in DiGiovanna 1 991 ) speaks of the usefulness of MET in treating Box 1 .5 Fascia l stiffness and water extremely ill patients. As will be reported in subsequent chapters, when used appropriately, Klingler et al (2004) measured the wet, and fi nal d ry MET, a major element in osteopathic care, fits well weight of fresh human fascia, and found that d u ring a n as an integrative tool in physical therapy, chiro­ isometric stretch, water is extruded, refi l l ing d u ring a practic, athletic training and massage therapy subseq uent rest period, making the tissues stiffer. settings. • Using a 6% tissue elongation over 15 min utes, Many patients present with a combination of followed by rest, they noted the fol l owing average recent dysfunction (acute in terms of time, if not weight changes ( n = 21): at end of stretch, -11.8%; in degree of pain or dysfunction) overlaid on after 30 min rest, -0.3%; after 1 h r, 0%; after 21 m, chronic changes that have set the scene for acute +2.1%; after 3 hrs, +3.6%. problems. It seems perfectly appropriate to use • As water extrudes from g round substance during methods that deal gently with hypertonicity, and stretch ing, tem porary relaxation occurs i n the to employ more vigorous methods to help to longitudinal a rra ngement of the collagen fibres and resolve fibrotic change, in the same patient, at the the tissue becomes more supple. same time, using different variations on the theme • If the strai n is moderate, and there a re no m icroinj u ries, of MET. Other variables can be used which focus water soaks back i n to the tissue until it swel ls, on joint restriction, or which utilise RI, pulsed becoming stiffer than before. MET or visual synkinesis, should conditions be • The researchers question whether much manual too sensitive to allow PIR methods, or variations therapy, and the tissue responses experienced, may on Janda's more vigorous stretch methods (see relate to sponge-like squeezi ng and refi l l i ng effects in Box 1 .1 ) . the semi-liquid grou nd substance, with its water bind i ng glycosaminog lycans and proteoglycans. Discussion o f common errors i n application of MET will help to clarify these thoughts.

' CHAPTE R ONE 1 8 An introduction to muscle energy techniques Why M ET might be ineffective at times Erector Abdominals Figure 1.5 Lower spinae Weak crossed synd rome. Poor results from use of MET may relate to an An example of a inability to localise muscular effort sufficiently, Tight Tight common postural since unless local muscle tension is produced in Iliopsoas imbalance pattern, the precise region of the soft tissue dysfunction, Weak involving a chain the method may fail to achieve its objectives. Also, Gluteus reaction of of course, underlying pathological changes may maximas hypertonia and have taken place, in joints or elsewhere, which hypotonia in which make any soft tissue relaxation/release or stretch­ excessively tight ing procedure of short-term value only, since and short muscles pathology may well ensure recurrence of muscu­ are inhibiting their lar spasms, sometimes almost immediately. a n tagonists. MET will be ineffective, or may cause irritation tight muscles act in an inhibitory way on their and pain, if excessive force is used in either the antagonists. Therefore, it does not seem reason­ contraction phase or the stretching phase. able to start with strengthening of the weakened muscles, as most exercise programmes do. It has The keys to successful application of MET there­ been clinically proved that it is better to stretch fore lie in a precise focusing of muscular activity, tight muscles first. It is not exceptional that, after with an appropriate degree of effort used in the stretching of the tight muscles, the strength of the isometric contraction, for an adequate length of weakened antagonists improves spontaneously, time, followed by a safe movement to, or through, sometimes immediately, sometimes within a few the previous restriction barrier, usually with patient days, without any additional treatment. assistance. This well-reasoned, clinical observation, which Use of variations such as stretching chronic directs our attention and efforts towards the fibrotic conditions following an isometric contrac­ stretching and normalising of those tissues which tion and use of the integrated approach (INIT - have shortened and tightened, seems irrefutable, see Ch. 7), mentioned earlier in this chapter, and this theme will be pursued further in Ch. 2. represent two examples of further adaptations of Lewit's basic approach which, as described above, MET is designed to assist in this endeavour is ideal for acute situations of spasm and pain. and, as discussed above, also provides an excellent method for assisting in the toning of weak muscu­ To stretch or to strengthen? lature, should this still be required, after the stretching of the shortened antagonists, by means There exists a tendency in some schools of therapy of isotonic methods. to encourage the strengthening of weakened muscle groups in order to normalise postural and Te n d o n s functional problems as a priority, before attention is given to short/tight antagonists of the inhibited, Aspects of the physiology of muscles and tendons weak muscles. are worthy of a degree of review, in so far as MET and its effects are concerned (see also Box 1 .6). The Janda (1978) has offered reasons why this approach is 'putting the cart before the horse': 'In pathogenesis, as well as in treatment of muscle imbalance and back problems, tight muscles play a more important, and perhaps even primary, role in comparison to weak muscles' (see Fig. 1 .5). He continues with the following observation: Clinical experience, and especially therapeutic results, support the assumption that (according to Sherrington's law of reciprocal innervation)

Putting it together 19 Box 1.6 M uscle tone and contraction being i n n e rvated by a single motor neuron in the extri nsic eye m uscles, to one motor n eu ron i n nervating • Muscles display excitabil ity - the ability to respond 2000 fibres i n major l i m b m uscles (Gray's Anatomy to sti m u l i , and, by means of a sti m u l us, to be able to 1 973). actively cantract, extend (lengthen). or to elastically • Beca use there is a diffuse spread of i nfl uence from a recoil from a distended position, as well as to be able single motor neuron throughout a m uscle (i.e. neural to passively relax when sti m u l us ceases. i nfl uence does n ot necessa rily correspond to fascicu l a r divisions), o n ly a few need t o b e active to i nfl uence • Lederman ( 1 998) suggests that muscle tone in a resting the entire muscle. muscle relates to biomecha nical elements - a mix of • The functional contractile u n it of a m uscle fibre is fascial and connective tissue tension together with its sarcomere, which contains fi laments of actin and intramuscu lar flu i d pressure, with no neurological i n put myosin. These myofi laments (acti n and myosin) (therefore, not measu rable by el ectromyogram (EMG)). interact in order to shorten the muscle fibre. • When a m uscle is idle some of its extrafusal fibres • If a muscle has a ltered morphologica l ly (due to chronic ( i n nervated by motor neu rons) w i l l contract to shortening, for exa mple, or compartment syn d rome). maintai n normal tone while others rest. then muscle tone, even at rest, will be a ltered a nd • The m uscle spind les (i ntrafusal fibres i n n e rvated by pa l pa b l e. gamma fibres) mon itor both the tone and length of the m uscle. When the spind les a re stretched they • Lederman ( 1 998) differentiates this from motor tone report to the cord both the fact of changing length w h ich is measurable by means of EMG, and which is and a lso the rate at which this is taking place. present in a resting muscle only u nder abnormal • The Golgi tendon organs report on muscle tension so circumstances - for exa mple when psychological stress that, as this i ncreases, fin e t u n i n g of tone occurs via or protective activity is involved. the cord. As G reenman ( 1 996) reports: 'The control of m uscle tone is h i g h ly complex a nd incl udes afferent • Motor tone is either phasic or tonic, depen d i n g u pon i n formation com ing from mechanoreceptors of the the nature of the activity being dema nded of the a rticu lations, periarticu lar structures, a nd from the muscle - to move something (phasic) or to stabilise it muscle spi n d l e and Golgi tendon apparatus. This (tonic). In normal muscles, both activities vanish when i nformation is processed at the cord level with many g ravitation a l , and activity, demands a re absent. muscle fu nctions being preprog ra m m ed ... through local reflexes a n d propriospi n a l tracts. The cord has the • Contraction occu rs i n response to a motor nerve capacity to learn both normal and abnormal pragrams' impulse acting on muscle fibres. [italics added]. • A motor nerve fibre w i l l a lways activate more than one muscle fibre, and the collection of fibres it i n nervates is the motor unit. • The g reater the degree of fi n e control a m uscle is req u i red to produce, the fewer the n u m ber of m uscle fibres a nerve fibre w i l l i n nervate, i n that m uscle. This can ra nge from between 6 and 12 m uscle fibres tone of muscle is largely the job of the - Golgi stretch. This effect is called the lengthening tendon organs. These detect the load applied to reaction, and is probably a protective reaction to the tendon, via muscular contraction. Reflex effects, the force which, if unprotected, can tear the tendon in the appropriate muscles, are the result of this from its bony attachments. Since the Golgi tendon information being passed from the Golgi tendon organs, unlike the [muscle] spindles, are in series organ back along the cord. The reflex is an with the muscle fibres, they are stimulated by both inhibitory one, and thus differs from the muscle passive and active contractions of the muscles. spindle stretch reflex. Sandler (1 983) describes some of the processes involved: Pointing out that muscles can either contract with constant length and varied tone (isometrically), When the tension on the muscles, and hence the or with constant tone and varied length (isoton­ tendon, becomes extreme, the inhibitory effect ically), he continues: from the tendon organ can be so great that there is sudden relaxation of the entire muscle under 'In the same way as the gamma efferent system operates as a feedback to control the length of

C H APTER ONE 20 An introduction to muscle energy techniques L muscle fibres, the tendon reflex serves as a reflex restored to its anatomically desirable length. The to control the muscle tone'. conclusion is that much joint restriction is a result of muscular tightness and shortening. The relevance of this to soft tissue techniques is explained as follows: The opposite situation may also apply, where damage to the soft or hard tissues of a joint is In terms of longitudinal soft tissue massage, these a key factor. In such cases the periarticular and organs are very interesting indeed, and it is perhaps osteophytic changes, all too apparent in degenera­ the reason why articulation of a joint, passively, tive conditions, are the major limiting factor in to stretch the tendons that pass over the joint, is joint restrictions. In both situations, however, MET often as effective in relaxing the soft tissues as may be useful, although more useful where muscle direct massage of the muscles themselves. Indeed, shortening is the primary feature of restriction. in some cases, where the muscle is actively in spasm, and is likely to object to being pummelled Restriction that takes place as a result of tight, directly, articulation, muscle energy technique, shortened muscles is usually accompanied by some or functional balance techniques, that make use of degree of lengthening and weakening (inhibition) the tendon organ reflexes, can be most effective. of the antagonists (Lewit 1 999a). A wide variety of possible permutations exists, in any given condi­ The use of this knowledge in therapy is obvious tion involving muscular shortening that may be and Sandler explains part of the effect of massage initiating, or be secondary to, joint dysfunction on muscle: combined with weakness of antagonists. A combi­ nation of isometric and isotonic MET methods can The [muscle] spindle and its reflex connections effectively be employed to lengthen and stretch constitute a feedback device which can operate to the shortened groups, and to strengthen and tone maintain constant muscle length, as in posture; if the weak, overlong muscles. the muscle is stretched the spindle discharges increase, but if the muscle is shortened, without a Paul Williams (1965) stated a basic truth that is change in the rate of gamma discharge, then the often neglected by the professions that deal with spindle discharge will decrease, and the muscle musculoskeletal dysfunction: will relax. The health of any joint is dependent upon a Sandler believes that massage techniques cause balance in the strength of its opposing muscles. If a decrease in the sensitivity of the gamma efferent, for any reason a flexor group loses part, or all of and thus increase the length of the muscle fibres its function, its opposing tensor group will draw rather than a further shortening of them; this the joint into a hyperextended position, with produces the desired relaxation of the muscle. abnormal stress on the joint margins. This situa­ MET offers the clinician the ability to influence tion exists in the lumbar spine of modern man. both the muscle spindles and also the Golgi tendon organs. Lack of attention to the muscular component of joints in general, and spinal joints in particular, Joints and M ET results in frequent inappropriate treatment of the joints so affected. Correct understanding of the role Bourdillon ( 1982) tells us that shortening of muscle of the supporting musculature would frequently seems to be a self-perpetuating phenomenon which lead to normalisation of these tissues, without the results from an over-reaction of the gamma­ need for heroic manipulative efforts. MET and other neuron system. It seems that the muscle is inca­ soft tissue approaches focus attention on these pable of returning to a normal resting length as structures and offer the opportunity to correct both long as this continues. While the effective length the weakened musculature and the shortened, of the muscle is thus shortened, it is nevertheless often fibrotic, antagonists (Schlenk et aI 1 994). capable of shortening further. The pain factor seems related to the muscle's inability to then be More recently, Norris (1999) has pointed out that: The mixture of tightness and weakness seen in the muscle imbalance process alters body segment

References 2 1 alignment and changes the equilibrium point of reduced segmental control with chain reactions of a joint. Normally the equal resting tone of the compensation emerging (see Ch. 2). agonist and antagonist muscles allows the joint to take up a balanced position where the joint Several studies will be detailed (see Chs 5 and surfaces are evenly loaded and the inert tissues of 8) showing the effectiveness of MET application the joint are not excessively stressed. However if in diverse population groups, including a Polish the muscles on one side of a joint are tight and the study on the benefits of MET in joints damaged by opposing muscles relax, the joint will be pulled haemophilia, and a Swedish study on the effects out of alignment towards the tight muscle(s). of MET in treating lumbar spine dysfunction, as well as an American/Czech study involving Such alignment changes produce weight­ myofascial pain problems. In the main, the results bearing stresses on joint surfaces, and result also indicate a universal role in providing resolution in shortened soft tissues chronically contracting or relief of such problems by means of the appli­ over time. Additionally such imbalances result in cation of safe and effective muscle energy techniques. References Anderson B 1984 Stretching. Shelter Publishing, Nolinas, Greenman P 1 996 Principles of manual medicine, 2nd edn. California Williams and Wilkins, Baltimore Beaulieu J 1981 Developing a stretching program. Physician Grieve G P 1985 Mobilisation of the spine. Churchill and Sports Medicine 9(11): 59-69 Livingstone, Edinburgh, p 190 Blood S 1 980 Treatment of the sprained ankle. Journal of the Hall CM, Brody LT, 1 999 Therapeutic exercise moving American Osteopathic Association 79( 1 1 ) : 689 toward function. Lippincott, Williams & Wilkins, New York, pp 48-49 Bourdillon J 1982 Spinal manipulation, 3rd edn. Heinemann, London Hodges P, Gandavia S 2000 Activation of the human diaphragm during a repetitive postural task. Journal of Carter A M, Kinzey S J, Chitwood L F 2000 Proprioceptive Physiology 522( 1 ) : 165-175 neuromuscular facilitation decreases muscle activity during the stretch reflex in selected posterior thigh Hodges P et al 2001 Postural activity of the diaphragm is muscles. Journal of Sport Rehabilitation 9: 269-278 reduced in humans when respiratory demand increases. Journal of Physiology 537(3): 999-1008 Chaitow L 1993 Integrated neuromuscular inhibition technique (INIT) in treatment of pain and trigger points. Jacobs A, Walls W 1997 Anatomy. In: Ward R (ed) British Journal of Osteopathy 1 3: 1 7-21 Foundations of osteopathic medicine. Williams and Wilkins, Baltimore Chaitow L, DeLany J 2005 Clinical applications of neuromuscular techniques: Practical case study exercises. Janda V 1978 Muscles, central nervous regulation and back Churchill Livingstone, Edinburgh problems. In: Korr I (ed) Neurobiological mechanisms in manipulative therapy. Plenum Press, New York DiGiovanna E 1991 Osteopathic approach to diagnosis and treatment. Lippincott, Philadelphia Janda V 1989 Muscle function testing. Butterworths, London Janda V 1 990 Differential diagnosis of muscle tone in respect Evjenth 0, Hamberg J 1984 Muscle stretching in marrual therapy. Alfta, Sweden of inhibitory techniques. In: Paterson J K, Burn L (eds) Back pain, an international review. Kluwer, New York, Galantino ML, Bzdewka TM, Eissler-Russo JL et al 2004 pp 196-199 The impact of modified hatha yoga on chronic low back Janda V 1993 Presentation to Physical Medicine Research pain: a pilot study. Alternative Therapies in Health and Foundation, Montreal, Oct 9-11 Medicine 10(2): 56-59 Kabat H 1959 Studies of neuromuscular dysfunction. Kaiser Permanente Foundation Medical Bulletin 8: 1 21-143 Gaymans F 1980 Die Bedeuting der atemtypen fur Klingler W, Schleip R, Zorn A 2004 European Fascia mobilisation der werbelsaule maanuelle. Medizin 1 8: 96 Research Project Report. 5th World Congress Low Back and Pelvic Pain, Melbourne, November 2004 Goodridge J P 1 981 Muscle energy technique: definition, Knebl J 2002 The Spencer sequence. Journal of the American explanation, methods of procedure. Journal of the Osteopathic Association 102(7): 387-400 American Osteopathic Association 81 (4): 249-254 Knott M, Voss 0 1 968 Proprioceptive neuromuscular facilitation, 2nd edn. Harper and Row, New York Goodridge J, Kuchera W 1997 Muscle energy treatment Kolar P 1 999 Sensomotor nature of postural functions. techniques. In: Ward R (ed) Foundations of osteopathic Journal of Orthopaedic Medicine 212: 40-45 medicine. Williams and Wilkins, Baltimore Gray's Anatomy 1973 Churchill Livingstone, Edinburgh Greenman P 1989 Manual therapy. Williams and Wilkins, Baltimore

CHAPTER ONE 22 An introduction to muscle energy techniques [ Korr I M 1976 Spinal cord as organiser of disease process. Moore M , Kukulka C 1 99] Depression of Hoffman reflexes In: Academy of Applied Osteopathy Yearbook. Newark, following voluntary contraction and implications for Ohio proprioceptive neuromuscular facilitation therapy. Physical Therapy 71(4): 321-329 Lederman E ] 998 Fundamentals of manual therapy. Churchill Livingstone, Edinburgh Moritan T 1987 Activity of the motor unit during concentric and eccentric contractions. American Journal of Levi.ne M et al 1954 Relaxation of spasticity by physiological Physiology 66: 338-350 techniques. Archives of Physical Medicine 35: 2 ] 4-223 Nixon P, Andrews J 1 996 A study of anaerobic threshold in Lewit K 1986 Muscular patterns in thoraco-Iumbar lesions. chronic fatigue syndrome (CFS). Biological Psychology Manual Medicine 2 : 1 05 43(3): 264 Lewit K 1985 Manipulative therapy in rehabilitation of the Norris C 1 999 Functional load abdominal training (part 1 ). motor system. Butterworths, London Journal of Bodywork and Movement Therapies 3(3): 1 50-158 Lewit K 1999a Manipulative therapy in rehabilitation of the motor system, 3rd edn. Butterworths, London Patriquin D 1992 Evolution of osteopathic manipulative technique: the Spencer technique. Journal of the Lewit K 1999b Chain reactions in the locomotor system in American Osteopathic Association 92: 1 1 34-1 146 the light of coactivation patterns based on developmental neurology. Journal of Orthopaedic Pereira 0 1988 The hazards of heavy breathing. New Medicine 21 (2): 52-58 Scientist, Dec: 46-48 Lewit K, Simons D 1984 Myofascial pain: relief by post Pryor J, Prasad S 2002 Physiotherapy for respiratory and isometric relaxation. Archives of Physical Medical cardiac problems, 3rd edn. Churchill Livingstone, Rehabilitation 65: 452-456 Edinburgh, p 8] Liebenson C 1989 Active muscular relaxation techniques Royal Society of Medicine 1983 Connective tissues: the (part 1 ) . Journal of Manipulative and Physiological natural fibre reinforced composite material. Journal of Therapeutics 1 2(6): 446-451 the Royal Society of Medicine 76 Liebenson C 1990 Active muscular relaxation techniques Ruddy T 1961 Osteopathic rhythmic resistive duction (part 2). Journal of Manipulative and Physiological therapy. Yearbook of Academy of Applied Osteopathy Therapeutics 1 30 ) : 2-6 1961, Indianapolis, p 58 Liebenson C (ed) 1996 Rehabilitation of the spine. Williams Sandler S 1983 Physiology of soft tissue massage. British and Wilkins, Baltimore Osteopathic Journal 1 5: 1-6 Liebenson C 2000 The quadratus lumborum and spinal Schafer R 1987 Clinical biomechanics, 2nd edn. Williams stability. Journal of Bodywork and Movement Therapies and Wilkins, Baltimore 4 0 ) : 49-54 Schlenk R, Adelman K, Rousselle 1 994 The effects of muscle McAtee R, Charland J 1999 Facilitated stretching, 2nd edn. energy technique on cervical range of motion. Journal of Human Kinetics, Champaign, Illinois Manual and Manipulative Therapy 2(4): 1 49-155 Magnusson S P, Simonsen E B, Aagaard P et al 1996 Schmitt G D, Pelham T W, Holt L E 1 999 From the field. Mechanical and physiological responses to stretching A comparison of selected protocols during with and without preisometric contraction in human proprioceptive neuromuscular facilitation stretching. skeletal muscle. Archives of Physical Medicine and Clinical Kinesiology 530): 1 6-21 Rehabilitation 77: 373-377 Stiles E 1 984a Manipulation - a tool for your practice? Maitland G D 1998 Vertebral manipulation, 5th edn. Patient Care May 1 5 : 1 6-97 Butterworth-Heinemann, Oxford Stiles E 1 984b Manipulation - a tool for your practice? Mattes A 1 995 Flexibility - active and assisted stretching. Patient Care August 1 5: 1 1 7-164 Mattes, Sarasota Surburg P 1981 Neuromuscular facilitation techniques in Mitchell F L Snr 1958 Structural pelvic function. Yearbook of sports medicine. Physician and Sports Medicine 9(9): the Academy of Osteopathy 1958, Carmel, p 71 1 1 5-]27 (expanded in references in 1967 yearbook) Travel! J, Simons D 1 983 Myofascial pain and dysfunction, Mitchell F L Snr 1967 Motion d iscordance. Yearbook of the vol l . Williams and Wilkins, Baltimore Academy of Applied Osteopathy 1 967, Carmel, pp 1-5 Voss D, [onta M, Myers B 1985 Proprioceptive Mitchell F Jnr, 1976 Tutorial on biomechanical procedures, neuromuscular facilitation, 3rd edn. Harper and Row, Yearbook American Academy of Osteopathy, Carmel Philadelphia Mitchell F Jnr, Moran P S, Pruzzo N 1 979 An evaluation Williams P ] 965 The lumbo-sacral spine. McGraw Hill, and treatment manual of osteopathic muscle energy New York procedures. Valley Park, Illinois

Patterns of 2 function and dysfunction CHAPTER CO NTENTS Why do soft tissues change from their normal elastic, pliable, adequately toned functional status Cellular adaptation - including gene expression 25 to become shortened, contracted, fibrosed, weak­ Constructing a credible story 25 ened, lengthened and/or painful? The reasons may Maps and grids 26 be many and varied, and are usually compound. Questions 26 The causes of somatic dysfunction may be sum­ Viewing symptoms in context 31 marised under broad headings, such as biomechan­ Fascial considerations 39 ical, biochemical and psychosocial - or under more Postural (fascial) patterns 42 pointed headings such as 'overuse, abuse, misuse, disuse', and usually with some sort of status distinc­ Functional evaluation of common compensatory 43 tion (acute, subacute or chronic) which is com­ (fascial) patterns 43 monly time-related. 43 Observed CCP signs 46 Much musculoskeletal dysfunction can be Assessment of tissue preference shown to emerge out of adaptive processes, as the The evolution of musculoskeletal dysfunction 48 body - or part of it - compensates for what is Fitness, weakness, strength and hypermobility 49 being demanded of it - suddenly or gradually - in 50 its daily activities. As a rule these adaptive influences 50 demands relate to a combination of processes Characteristics of altered movement patterns 52 including repetitive use patterns, effects of past 53 trauma, postural habits, emotional turmoil, chronic Different stress response of muscles 54 degenerative changes (e.g. arthritic) and so on. Postural and phasic muscles 55 Onto such evolving patterns, sudden blows and 59 strains are all too often superimposed, adding new Characteristics of postural and phasic muscles 59 adaptive demands of, and compensation responses Rehabilitation implications 60 by, the body. Stabilisers and mobilisers Global and local muscles 64 Our bodies compensate (often without obvious Patterns of dysfunction 65 symptoms) until the adaptive capacities of tissues Upper crossed syndrome 68 Lower crossed syndrome 69 are exhausted, at which time decompensation begins, 72 Identification and normalisation of patterns 73 and symptoms become apparent: pain, restriction, of dysfunction limitation of range of movement, etc. (Grieve 1986, Trigger points Lewit 1999). The processes of decompensation then progress towards chronic dysfunction and possibly Fibromyalgia and trigger points disability. Schamberger (2002) for example describes Summary how back dysfunction can emerge from a back­ ground of 'minor insults (e.g. repetitive lifting, Integrated neuromuscular inhibition technique (INIT) References

CHAPTER TWO 24 Patterns of function and dysfunction [ bending and squatting) superimposed on tissue follows: The stress applied to stretch or compress already tender from chronic compression, distrac­ a body is proportional to the strain, or change in tion and/or torsional forces'. length thus produced, so long as the limit of elas­ ticity of the body is not exceeded' (Bennet 1952, Grieve (1986) explains how a patient presenting Stedman 1998). with pain, loss of functional movement or altered patterns of strength, power or endurance, will In simple terms, this means that tissue capable probably either have suffered a major trauma of deformation will absorb or adapt to forces which has overwhelmed the physiological toler­ applied to it, within its elastic limits, beyond which ances of relatively healthy tissues, or will be dis­ it will break down or fail to compensate (leading playing 'gradual decompensation, demonstrating to decompensation). Grieve rightly reminds us that slow exhaustion of the tissue's adaptive potential, while attention to those tissues incriminated in with or without trauma'. As this process continues, produ�ing symptoms often gives excellent short­ progressive postural adaptation, influenced by time term results, 'unless treatment is also focused factors, and possibly by trauma, leads to exhaus­ towards restoring function in asymptomatic tissues tion of the body's adaptive potential and results in responsible for the original postural adaptation dysfunction and, ultimately, symptoms. and subsequent decompensation, the symptoms will recur '. Grieve reminds us of Hooke's law (see Box 2.1), which states that within the elastic limits of any Examples of gradual structural and functional substance, the ratio of the stress applied to the strain adaptation include: produced is constant. Hooke's law is expressed as • Tendon remodels in response to different Box 2.1 laws affecting tissues forms of exercise, although it remains unclear whether this has the effect of decreasing the The fol lowing su mmary of terms and basic laws affecting likelihood of damage, increasing strength, or tissues has d i rect i m p l ications i n relation to the enhancing elastic energy storage (Buchanan & appl ication of stretching forces as used in M ET: Marsh 2002). Mechan ical terms • Muscle responds to aerobic exercise with • Stress: force normalised over the a rea on which it acts. increased mitochondrial content and respiratory • Strain: change in shape as a result of stress. capacity of muscle fibres, while resistance • Creep: contin ued deformation (i ncreasing strai n ) of a exercise (strength training) results in muscle hypertrophy and higher contractile force viscoelastic material over time under constant load (Booth & Thomason 1991). (traction, compression, twist). All tissues exh ibit stress/strai n responses. • Depending on the type and level of exercise, Tissues com prise water-absorbing collagen and there will be either beneficial or detrimental g round substance (g lycosa m i noglycans, g l ycoproteins, effects on bone remodelling (Wohl et aI 2000). etc.). Examples of adaptation responses include: Biomechan ica l laws • Wolffs law states that biologica l systems (including • Research shows that damage to any muscle results in the patient either (1) compensating soft a n d hard tissues) deform i n relation to the l ines for the damaged muscle by retraining other of force i mposed on them. muscles to perform the same motion, or (2) • Hooke's law states that deformation (resulting from changing the motion drastically in order to strain) i m posed on an elastic body is i n proportion to reduce the work required of the damaged the stress (force/load) placed on it. muscle (Lieber 1992). • Newton's third law states that when two bod ies i nteract, the force exerted by the first on the second • Change in the maximal muscle force of a is equal in magnitude and opposite in d i rection to the damaged iliopsoas affects not only the hip force exerted by the second on the fi rst. joint, but also all of the joints of the leg. For example when iliopsoas is injured this

Cellular ada ptation - including gene expression 2S leads to a large reduction in force in the Figu re 2.1 A ipsilateral soleus (Komura et al 2004). tensegrity model showing the Cellular adaptation - including compressive (e) and gene expression tension (T) forces that maintain its structural In rehabilitation the phrase 'specific adaptation to stability. imposed demands' (SAID) is commonly used to describe what happens as tissues adapt to imposed down to the cellular level - and this, over time, tasks and loads, when particular responses are may be as harmful to normal cellular function, called for (Norris 2000a). and therefore gross tissue function, and ultimately general health, as would be changes caused by Clearly if gross and global tissue changes occur, spending time in zero gravity (Bhatia 1999, cellular modification is also occurring. But how? Ruwhof 2000). Cells have been shown to generate, transmit and Constructing a credible story sense mechanical tension, and to use these forces to control their shape and behaviour (including In order to make sense of what is happening when genetic expression). A mechanism has been a patient presents with symptoms, it is necessary discovered in which, on a cellular level, mechanical to be able to extract information, to construct a stress is communicated from stressed to unstressed story - or possibly several stories - based on what cells, in order to elicit a specific remodelling the patient says, what the history suggests, and response (Swartz et al 2001). what can be palpated and tested. These 'stories' should ideally tally, supporting each other to offer Much of this process involves integrins, a family direction as to where therapeutic efforts should be of cell surface receptors that attach cells to the concentrated. matrix, and mediate mechanical and chemical signals from it. Many integrin signals converge on Out of this should emerge a rationale for treat­ cell cycle regulation, directing cells to live or die, ment, involving objectives that might reasonably to proliferate, or to exit the cell cycle and differen­ be reached. Achievable objectives might sometimes tiate (Chicural et aI 1998). involve complete recovery, or, in other circum­ stances, no more may be possible than a partial A dramatic example is offered by Chen & Ingber degree of improvement in the present condition. (1999) who have shown that the 'tensegrity'­ In other settings, ensuring that, for the time being, designed cytoskeletons (fascia) of cells become matters do not worsen may be the best possible distorted in a gravity-free environment, such as scenario. W hatever the plan of action involves, it occurs when astronauts and cosmonauts spend should be discussed and agreed with the patient, time in space. This altered shape modifies cellular and should ideally involve active patient partici­ genetic behaviour, and also the way the cells pation in the process. process nutrients. It seems that a distorted cell cannot absorb and metabolise nutrients (including calcium) normally, and that this is a primary cause of one of the major health risks of space travel, loss of bone density. This has enormous implications for general health. We do not need to indulge in space travel to create changes in soft tissue structure, since the processes of general and local adaptation, compensation, ageing and disease, which affect us all, create global and localised fascial warping, crowding, compression and distortion - right