Introduction to muscle energy techniques (METs)

The use of Muscle Energy Techniques (METs) to reduce muscle pain and improve muscle length. Types, physiological mechanisms and practical techniques in clinical settings.

1. Senior Physiotherapist Fared Alkordi BSc (Physiotherapy) MCSP Muscle Energy Techniques (METs)

2. Outline Introduction How it works Types Technique Practical Contraindication and precautions Common Errors References

3. Fernandez-de-las- Penas et al. (2016) Manual Therapy for Musculoskeletal Pain Syndromes Chaitow (2013)   Muscle Energy Techniques

4. Definition MET: A system of manual procedures that utilises active muscle contraction effort from the patient, usually against a controlled matching counterforce from the physiotherapist (Fernandez-de-las- Penas et al. 2016) You can use METs to: Lengthen shortened muscles and promote relaxation Mobilise articulations with restricted movement Strengthen weakened muscles Reduced localised oedema and passive congestion in the tissues Enhance proprioception and motor control in patients with pain

5. Physiological Mechanisms Old school / Traditionally accepted mechanism Produces muscle relaxation via Golgi Tendon Organ (GTO) and muscle spindle reflexes (Mitchell jr and Mitchell, 1995) Resets the neurological resting length of a muscle

6. Suggested Physiological Mechanisms Chaitow (2013); increased flexibility of the muscles is largely attributed to an increase in individual’s tolerance to stretch METs reduce pain perception (hypoalgesia) through the activation of muscles’ and joints’ mechanoreceptors (Fryer and Fossum , 2010) METs induce hypoalgesia via peripheral mechanisms associated with increasing fluid drainage. Rhythmic muscle contractions increase blood and lymph flow rates ( Havaz et al. 1997) which may lead to decreased sensitisation to peripheral nociceptors METs improve proprioception and motor control because they involve active and precise recruitment of muscle activity Malmstrom et al (2010); prolonged unilateral neck muscle contraction task increased the accuracy of head repositioning

7. *In a static stretch: both sensory organs activate leading to initially increased muscle activation (Muscle spindle) then muscle relaxation after 7-10 seconds (GTO) Autogenic Inhibition Autogenic Activation Reciprocal inhibition

8. (Page, 2012)

9. Chaitow (2013); Other muscle energy techniques Concentric isotonic MET Eccentric isotonic MET Pulsed MET

10. MET for myofascial tissues METs can be used to Lengthen and desensitise myofascial tissues; Myofascial trigger points Acute myofascial pain Fibrotic shortened muscles Tight muscles affecting posture

11. Autogenic inhibition MET (PIR) Stretch the involved muscle until you reach the ‘barrier’ Isometric contraction Muscle relaxation Re-engage ‘barrier’ Repeat Re-examine Tight Biceps Limiting elbow extension Contract/resist Biceps

12. Stretch the involved muscle The muscle should be stretched to its ‘barrier’ ( Sense of palpated resistance or possible end range ) A) Light stretching force to the initial or first barrier if the muscle is acutely painful B) Moderate stretching force to a comfortable sensation of stretch experienced by the patient if the muscle is mildly painful or not-painful

13. 2. Isometric Contraction Request the patient to contract the targeted muscle Advise the patient to inhale before they contract the muscles * Push away from the barrier * against your controlled unyielding resistance for 3-5 seconds Light contraction if the muscle is painful or contains active MTrPs (10-30% of Maximum possible contraction) Moderate contraction force for pain-free, fibrotic muscles (50% of maximum possible contraction)

14. 3. Muscle Relaxation The patient should fully relax for several seconds with the stretch maintained (10 seconds) Advise the patient to take a deep exhalation to assess relaxation

15. 4. Re-engage barrier The slack that has developed in the tissues following the contraction and relaxation phase is taken up The muscle then can be stretches to a new barrier without using increased force

16. 5. Repeat Repeat the process 2-4 times OR until a change in tissue texture is noted 6. Re-examine To determine weather the tissues have changed

17. Post Facilitation Stretching (PFS) (The differences) PFS is a technique developed by Dr. Vladimir Janda (1988) that involves a maximal contraction of the muscle at mid-range with a rapid movement to maximal length followed by a static stretch The muscle is placed between a fully stretched and a fully relaxed state A maximum degree of effort is used in the isometric contraction for 5-10 seconds The patient is then asked to relax and a RAPID stretch is applied by the physio to a new barrier and is held for few seconds The patients then relaxes for 20 seconds Repeat from 3-5 times

18. How long you hold the stretch for? Duration of maintaining the stretch ( Chaitow , 2013) At least 30 seconds Up to 60 seconds Neck Shoulder Upper limb muscles Chronically shortened muscles Large muscle groups (lower limb muscles)

19. (Jadav and Patel, 2015): Comparison between the effect of PIR and PFS on tight hamstrings 5 stretches per day, 5 days a week for 6 weeks Measurement of knee extension with hip at 90° flexion Both groups (N=25 each) showed a significant increased in knee ROM PIR mean of 7° improvement PFS mean of 15° improvement Conclusion: PFS is a better and should be used in clinical settings Limitation: Age (18 – 30) Subjects with pathological hip or knee conditions were excluded

20. Reciprocal inhibition MET The affected muscle is placed in a mid-range position The patient pushes towards the restriction/barrier whereas the therapist completely resists this effort (isometric) This is followed by relaxation of the patient along with exhalation, and the therapist applies a passive stretch to the new barrier The procedure is repeated between 3 – 5 times 10-20% of maximum muscle contraction Tight Biceps Limiting elbow extension Contract/resist triceps

21. Which Method should be used? PIR RI PFS

22. Chaitow (2013); The presence of pain is frequently the deciding factor RI PIR PFS Does not involve contraction of the affected muscle Use in acute conditions where PIR and PFS might cause adverse effect – pain/injury Progress from RI when the affected muscle has become less sensitive and are able to tolerate isometric contraction Use for chronically shortened muscles Use if there is no pain Good if strengthening is desired * Isotonic used for strength (not covered)

23. Upper Trapezius (PIR) Common source of MTrPs related to neck pain and headaches Levator scapulae is normally stretched when applying MET to upper trapezius Subtle fine tuning of neck rotation using palpation and patient feedback to determine the most effective position Picture courtesy of Fernandez-de-las- Penas et al. 2016

24. Upper Trapezius technique The shoulder is firmly depressed and stabilised Neck is flexed and side-bent away from the involved side, with rotation of the neck dependant on the fibre direction and sense of stretch The patient isometric effort is either: Neck extension with side bending towards the involved side Elevation of the shoulder * Can be done in sitting

25. Pectoralis Minor (PIR) Pec minor referral pattern is to anterior deltoid region, ulnar side of the arm, hand and fingers (Simons et al 1999) Shortened pec minor affects posture producing rounded shoulder and forward head posture in upper crossed syndrome Picture courtesy of Fernandez-de-las- Penas et al. 2016

26. Pectoralis Minor technique The tissues over the sternum are firmly stabilised by the physio’s forearm Posterior and lateral force is applied to the anterior shoulder The patient attempts to lift the shoulder against the physio’s unyielding counterforce Note that the physio’s arm is straight and the isometric force is easily resisted by the physio’s body weight * Use a small towel for padding if the contact on the shoulder is uncomfortable

27. Hip Flexor Muscle Group (PIR) Shortness of iliosoas , rectus femoris, pectineus and TFL is common MTrPs in these muscles refer pain to the groin When tight, they restrict hip extension and promote anterior pelvic tilt Picture courtesy of Fernandez-de-las- Penas et al. 2016

28. Hip Flexor Muscle Group technique Patient is treated in the Thomas test position Unaffected leg is fully flexed, held by the patient and stabilised by the physio’s body to ensure stability of the lumbar spine An extension force is applied to the thigh until a ‘barrier’ is felt The patient pushes the thigh up against the physio’s unyielding counterforce Addition of: Hip adduction will localise the stretch to TFL Knee flexion will localise the stretch to Rec Fem Hip abduction will localise the stretch to pectineus and short adductors

29. Hamstrings Muscles (RI) Normally overactive tight muscles Contribute to lower crossed syndrome (poor posture) and related to lower back pain

30. Hamstrings MET technique The patient’s straight leg is flexed until a mild stretch in the hamstrings is experienced by the patient The leg is supported on the physio’s shoulder Brace the patient knee using a cross arm formation around the distal aspect of the quads The patients produces isometric contraction as in active straight leg motion resisted by the physio’s body weight

31. Common errors in muscle energy application Joint barrier is overlocked Patients pushes too hard Patient’s contraction duration is too short Too few repetitions to make a change Patient does not relax Physio does not offer stable support of limb or region Physio allows movement during contraction phase Physio is uncomfortable, awkward, poorly positioned, unbalanced or tense.

32. Contraindications and precautions METs are generally Safe Contraindications Fractures Acute sprains Acute strains Caution Osteoporosis Hypermobility Be aware of use of force and leverage with patient with acute pain Listen to the patient's feedback Stop! If there are any signs of vertebrobasilar insufficiency such as vertigo, visual disturbances, dysphasia, dysarthria, hoarseness, facial numbness, paraesthesia, confusion or drop attacks (Gibbons and Tehan , 2006)

33. References Chaitow , L. (2013).  Muscle energy techniques . Elsevier Health Sciences. Fernández-de-las-Peñas , C., Cleland, J., & Dommerholt , J. (2016).  Manual therapy for musculoskeletal pain syndromes . [ Erscheinungsort nicht ermittelbar ]: Elsevier. Fryer, G & Fossum (2010). Therapeutic mechanisms underlying muscle energy approaches. Cephalalgia . 28. 264-275. Havas, E., Parviainen , T., Vuorela , J., Toivanen , J., Nikula , T., & Vihko , V. (1997). Lymph flow dynamics in exercising human skeletal muscle as detected by scintography .  The Journal of physiology ,  504 (1), 233-239. Jadav, M., & Patel, D. (2015). Comparison of effectiveness of post facilitation stretching and agonist contract-relax technique on tight hamstrings.  Indian Journal of Physical Therapy ,  2 (2), 70-75. [Online] http://indianjournalofphysicaltherapy.in/ojs/index.php/IJPT/article/viewFile/56/59 Janda , V. (1988). Muscles and Cervicogenic Pain Syndromes. In Physical Therapy of the Cervical and Thoracic Spine, ed. R. Grand. New York: Churchill Livingstone. Malmström, E. M., Karlberg, M., Holmström , E., Fransson , P. A., Hansson, G. Å., & Magnusson, M. (2010). Influence of prolonged unilateral cervical muscle contraction on head repositioning–decreased overshoot after a 5-min static muscle contraction task.  Manual therapy ,  15 (3), 229-234. [Online] https://www.sciencedirect.com/science/article/pii/S1356689X09002082 Page, P. (2012). Current concepts in muscle stretching for exercise and rehabilitation.  International journal of sports physical therapy ,  7 (1), 109. [Online] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3273886/ Page, P., Frank, C., & Lardner, R. (2010).  Assessment and treatment of muscle imbalance: the Janda approach . Human kinetics.

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