In the previous (#4 in this series) article we followed a simple assessment routine in which by using abduction of the leg as a model it was possible to learn to assess the point at which ‘bind’ or increased tension began.
Since the normal excursion of the straight leg into abduction is around 45º it is possible, by testing both legs in the manner described, to quickly evaluate whether they are both tight and short, or whether one is and the other is not. Even if both are tight and short one set of muscles may be more restricted than the other and this is the one to treat first, possibly using one of the various Muscle Energy Techniques (MET) which this article will describe.
It is suggested that before using MET clinically you practice performing palpation exercises for ‘ease’ and ‘bind’ on many muscles, until you are comfortable with your skill in palpating changes in tone. Subsequent articles in this series will explore assessment methods for shortness in specific muscles in greater detail.
Different Starting Points for MET
In order to use MET successfully the identification of the first sign of the barrier of resistance – where bind is first noted – is necessary – either as the starting point for MET in treating acute conditions, or as a marker when a starting point short of the barrier is selected in treatment of chronic conditions.
Goodridge continues his beginners exercise in MET application as follows:
‘By individually abducting the legs of the supine patient the operator compares the arc on one side with the arc produced on the opposite side. For example, if the abducted right femur reaches resistance sooner than the left, then restriction of abduction exists on the right. To reduce this restriction, the patient’s limb is positioned in that arc of movement, where resistance is first perceived, and at this point the operator employs MET to lessen the sense of resistance, and increase the range of movement.’1
How is MET Used?
The following exercises in MET variations include the key features emphasised by some of the leading contributors to MET methodology.
Post Isometric Relaxation (PIR).
Having established the barrier of resistance where, in Goodridge’s words, ‘resistance is first perceived’:
- The patient/model is asked to use no more than 20% of their available strength to try to take the leg gently back towards the table, i.e. to adduct the leg, against your firm, unyielding resistance.
- In this example they are trying to pull the limb away from the barrier, while you hold it at the barrier.
- The patient/model should be using (contracting) the agonist, the muscle(s) which requires to be released because its shortness is preventing a full range of movement. In this example it is the inner thigh muscles, adductors and medial hamstrings which need releasing and which therefore are asked to contract during MET.
- As the patient holds the light contraction they are commonly asked to hold their breath.
- The isometric contraction should be introduced slowly and resisted without any jerking, wobbling or bouncing.
- Maintaining the resistance to the contraction should produce no strain in the operator.
- The contraction should be held for at least 7, and ideally 10, seconds – the time it is thought necessary for the ‘load’ on the Golgi tendon organs to become active and to neurologically influence the intrafusal fibres of the muscle spindles which inhibits muscle tone, so providing the opportunity for the area (muscle, joint) to be taken to a new resting length/resistance barrier without effort, or to stretch it through the barrier of resistance, if this is appropriate (see below).2
- The instruction is given, ‘Now let your breath go and release your effort, slowly and completely’ – while you maintain the limb (in this example) at the same barrier.
- The patient/model is asked to breathe in and out once more and to completely relax, and as they exhale you gently guide the limb to the point where you now sense a resistance barrier/bind.
You should almost always have created an increased range, by a significant degree.
- After Post Isometric Relaxation (PIR) a refractory or latency period of anything from 15 to 30 seconds exists during which the muscle can be taken to its new resting length (where ‘bind’ begins) , or it can be tretched more easily than would have been the case before the contraction.3
What Alternative MET Methods are There?
You could repeat the exercise precisely as described above, working from the resistance barrier. This is Lewit’s PIR method and is ideal for releasing tone, for relaxing spasm, in acute conditions.4
Janda’s Approach for Chronic/Fibrotic Tissues5
A less stressful method suggests that following a contraction of anything up to 20 seconds, which starts in a mid-range position, uses between 20% and 50% of the patient’s available strength. A short (2 to 3 seconds) rest period is then allowed for complete relaxation, before stretch is introduced to a point just beyond the previous barrier of resistance. This is held for 10 seconds or so.
The procedure is repeated until no more gain is being achieved.
The Difference Between MET and Lewit’s PIR?
All elements of the procedures as described for PIR are maintained except –
- for chronic conditions the contractions starts short of the barrier
- contractions should be longer and stronger than in acute conditions, and
- the muscle(s) should be taken beyond rather than just to, the new barrier of resistance (with or without patient assistance) to begin to reduce shortening/contracture.
This procedure is much enhanced by using some patient participation during the stretching procedure – so that they help to take the limb/muscle(s) past the restriction barrier, so minimising the chances of a myotatic stretch reflex being triggered.6
Reciprocal Inhibition (R.I.)
A variation exists involving use of physiological mechanisms called reciprocal inhibition (RI) which also produces a neurologically induced a latency (‘refractory’) period of muscle relaxation.
- R.I. is advocated for acute problems, especially where the muscle(s) requiring release are traumatised, or painful and cannot safely be involved in sustained contractions.
- To use RI according you need to place the area in a ‘mid-range’ position, short of the resistance barrier because.7
- a/ It is easier to start a contraction from a mid-range position, and
- b/ there is a reduction in risk of cramp, particularly in lower extremity muscles such as the hamstrings.
- a/ It is easier to start a contraction from a mid-range position, and
Treating Leg Abduction Restriction Using R.I.
- Test for the sense of bind or increased effort as you abduct the limb, note the degree of excursion of the limb as it reaches this barrier, and then back off a few degrees.
- At this point the patient/model would be asked to try to abduct the leg themselves (20% of strength only), taking it towards the barrier, while you resist the effort.
- Following the end of the contraction a degree of release will occur in the short muscles. Following complete relaxation guide the limb to the new barrier.
Greenman summarises several of the component elements of MET as follows8
- There is a Patient-active muscle contraction
- From a controlled position
- in a specific direction (away from the barrier = PIR/towards the barrier = RI)
- met by operator applied counterforce
- involving a controlled intensity of contraction.
Patient Errors During MET
- Contraction is too hard (remedy : give specific guidelines – e.g. use only ‘20% of strength’)
- Contraction is in wrong direction (remedy : give accurate instructions)
- Contraction is not sustained for long enough (remedy : instruct the patient to hold the contraction until told to ease off, and say how long this will be)
- Patient does not relax completely after the contraction (remedy : have them release and relax, inhale and exhale and ‘let go completely’)
To this list add –
- Starting and/or finishing the contraction too hastily. There should be a slow build-up of force and a slow letting go, easily achieved if a rehearsal is carried out to educate the patient.
Operator Errors in Application of MET Include:
- Inaccurate control of position of joint or muscle in relation to the resistance barrier (remedy: have clear image of what is required and apply it)
- Inadequate counterforce to the contraction (remedy: meet and match the force precisely)
- Counterforce is applied in an inappropriate direction (remedy: ensure precise direction needed for best effect)
- Moving to a new position too hastily after the contraction (there is around 25 seconds of refractory muscle tone release during which time a new position can easily be adopted or stretch introduced – haste is unnecessary and counter-productive)
- Inadequate patient instruction is given (remedy: get the words right so that the patient can cooperate)
Whenever force is applied, by the patient, in a particular direction, and when it is time to release that effort, the instruction must be to do so gradually. Any quick effort is self-defeating. The coinciding of the forces at the outset (patient and operator) as well as at release is important. The operator must be careful to use enough, but not too much, effort, and to ease off at the same time as the patient.
Contraindications and Side-effects of MET
If pathology is suspected no MET should be used until an accurate diagnosis has been established.
Pathology (osteoporosis, arthritis etc) does not rule out the use of MET, but its presence needs to be established so that dosage of application can be modified accordingly (amount of effort used, number of repetitions, stretching introduced or not etc)
As to side effects, Greenman explains, ‘All muscle contractions influence surrounding fascia, connective tissue ground substance and interstitial fluids, and alter muscle physiology by reflex mechanisms. Fascial length and tone is altered by muscle contraction. Alteration in fascia influences not only its biomechanical function, but also its biochemical and immunological functions. the patient’s muscle effort requires energy and the metabolic process of muscle contraction results in carbon dioxide, lactic acid and other metabolic waste products which must be transported and metabolised. It is for this reason that the patient will frequently experience some increase in muscle soreness within the first 12 to 36 hours following MET treatment. Muscle energy procedures provide safety for the patient since the activating force is intrinsic and the dosage can be easily controlled by the patient, but it must be remembered that this comes at a price. It is easy for the inexperienced practitioner to overdo these procedures and in essence to overdose the patient.’
DiGiovanna9 states that side-effects are minimal with MET, ‘MET is quite safe. Occasionally some muscle stiffness and soreness after treatment. If the area being treated is not localised well or if too much contractive force is used pain may be increased. Sometimes the patient is in too much pain to contract a muscle or may be unable to cooperate with instructions or positioning. In such instances MET may be difficult to apply.’
Note for Beginners
If beginners to MET stay within the very simple guideline which states categorically – cause no pain when using MET – and stick to light (20% of strength) contractions, and do not stretch over-enthusiastically but only take muscles a short way past their restriction barrier when stretching, no side effects are likely apart from the soreness mentioned above, and this is a normal part of all manual methods of treatment.
In the next article in this series an introduction will be given to the ultra-safe methods of ‘positional release’ including Strain/ counterstrain.
Leon Chaitow DO, former editor of JACM, practices at The Hale Clinic London (0171-631-0156). He teaches widely in the UK, Europe and the USA, and is author of major textbooks including ‘Soft tissue Manipulation’ (available from Green Library). He is a senior lecturer on the University of Westminster’s MA in Therapeutic Bodywork course.
1. Goodridge J MET, Definition, explanation, methods of procedure. Journal American Osteopathic Association, Vol. 81, No. 4, P249 1981
2. Scariati P Neurophysiology relevant to osteopathic manipulation in DiGiovanna E(ed) Osteopathic Approach to Diagnosis and treatment Lippincott Philadelphia 1991
3. Guissard N et al Muscle stretching and motorneurone excitability. European journal of applied Physiology 58pp47-52 1988
4. Lewit K Muscular and articular factors in movement restriction Manual medicine 1:83-85 1985
5. Janda V (in Grant R) Physical Therapy of the cervical and thoracic spine. Churchill Livingstone New York 1988
6. Mattes A Active and assisted stretching Mattes Sarasota Florida 1990
7. Liebenson C Active Muscular Relaxation Methods J Manipulative and Physiological Therapeutics 12(6)198
8. GreenmanP Principles of Manual Medicine Williams&Wilkins Baltimore 1989
9. DiGiovanna E An Osteopathic Approach to Diagnosis and Treatment Lippincott 1991