1. MUSCLE ENERGY TECHNIQUES (MET)
By:- Dr. Hardik D. Patel
PT, MIAP

2. What Is Manual Therapy…??

3. A great revolution has taken place in manipulative therapy , which involves a movement which is different from high velocity/low amplitude thrusts and it is directed towards gentler methods which mainly involves soft tissue component
Different osteopathic physicians and physical therapists describes all these techniques in its own way....

4. MET is emerged from the osteopathic tradition
Mainly evolution of treatment methods, like involving isometric contraction and stretching, used in physical therapy, called PNF
PNF method tended to stress the importance of rotational components
Usually involving extremely strong contractions

5. Initially, the focus of PNF related to the strengthening of neurologically weakened muscles, with attention to the release of muscle spasticity following on from this, as well as to improving range of motion at intervertebral levels
But Fred Mitchell snr. adapted this technique for use in joint mobilization and release of muscle shortness, and it was a natural evolution which has continued in physiotherapy, manual medicine, osteopathy and right now increasingly in massage therapy and chiropractic settings

6. Two forms of MET Post Isometric Relaxation (PIR) and
Reciprocal Inhibition (RI)

7. Post Isometric Relaxation
The term post isometric relaxation (PIR) refers to the effect of the subsequent reduction in tone experienced by a muscle, or group of muscles, after brief periods during which an isometric contraction has been performed

8. neurological effects of the loading of the Golgi tendon organs of a skeletal muscle by means of an isometric contraction, which produce a postisometric relaxation effect in that muscle

9. Reciprocal Inhibition
When a muscle is isometrically contracted, its antagonist will be inhibited, and will demonstrate reduced tone immediately following this
Thus the antagonist of a shortened muscle, or group of muscles, may be isometrically contracted in order to achieve a degree of ease and additional movement potential in the shortened tissues

10. reciprocal effect of an isometric contraction of a skeletal muscle, resulting in an inhibitory influence on its antagonist

11. Variations on the MET theme
1. Lewit’s postisometric relaxation method
2. Janda’s postfacilitation stretch method
3. Reciprocal inhibition variation
4. Strengthening variation

12. Lewit’s postisometric relaxation method
The hypertonic muscle is taken, and find barrier point where resistance to movement is first noted
Isometrically contracts the affected hypertonic muscle away from the barrier (agonist is used)
The degree of effort is very minimal, say 20% of his available strength
Patient is asked to exhale and relax completely
Muscle is taken to a new barrier with all slack removed but no stretch
Starting from this new barrier, the procedure is repeated two or three times

13. What is happening?
During resistance using minimal force (isometric contraction) only a very few fibers are active, the others being inhibited
During relaxation (in which the shortened musculature is taken gently to its new limit without stretching) the stretch reflex is avoided – a reflex which may be brought about even by passive and non-painful stretch

14. Note:-
According to Lewit, Stretching of muscles during MET, is only required when contracture due to fibrotic change has occurred
Lewit suggests that trigger points and ‘fibrositic’ changes in muscle will often disappear after MET contraction methods
He suggests that, also referred local pain points, resulting from problems elsewhere, will also disappear more effectively than where local anaesthesia or needling (acupuncture) methods are employed

15. Janda’s postfacilitation stretch method
Stronger isometric contraction than that suggested by Lewit
The shortened muscle placed in a mid-range position
Contracts the muscle isometrically, using a maximum degree of effort for 5–10 seconds while the effort is resisted completely
On release of the effort, a rapid stretch is made to a new barrier, without any ‘bounce’, and this is held for at least 10 seconds
The patient relaxes for approximately 20 seconds and the procedure is repeated between three and five times more

16. Reciprocal inhibition variation
Mainly used in acute settings, where tissue damage or pain precludes the use of the usual agonist contraction (use of antagonist)
Muscle is placed in a mid-range position
Isometric or Isotonic muscle contraction
On ceasing the effort, the patient inhales and exhales fully, at which time the muscle is passively lengthened

17. Strengthening variation
Also called isokinetic contraction (also known as progressive resisted exercise)
Patient starts with a weak effort but rapidly progresses to a maximal contraction of the affected muscle(s)
Find area of weakness during full movement range
Strengthening of weak musculature in areas of permanent limitation of mobility is seen as an important contribution in which isokinetic contractions may assist

18. Patterns of function and dysfunction
Why do soft tissues change from their normal elastic, pliable, adequately toned functional status to become short, contracted, fibrosed, weak, lengthened and/or painful………..?????

19. The reasons are many and varied
Usually compound, and may be summarised under broad headings such as biomechanical, biochemical and psychological
Or under more pointed headings such as overuse, abuse, misuse, disuse
Time related - acute, subacute or chronic

20. In order to make sense of what is happening when a patient presents with symptoms, it is necessary to be able to extract information from the patient about his condition

21. Information made available via observation, palpation and examination
Postural (structural)
Motion (functional)
Postural muscle grid
Muscular weakness grid
Fascial patterns
Local dysfunction
Breathing function (and dysfunction)

22. THE EVOLUTION OF MUSCULOSKELETAL DYSFUNCTION
Acquired postural imbalances
stress
Inborn imbalance
The effects of hyper- or hypo mobile joints, including arthritic changes
Trauma, inflammation and subsequent fibrosis
Disuse, immobilization
Reflexogenic influences (viscerosomatic, myofascial and other reflex inputs)
Climatic stress such as chilling
Nutritional imbalances (vitamin C deficiency reduces collagen efficiency)
Infection

23. Deterioration of muscle function can be demonstrated by three syndromes
Hypotonia which can be determined by inspection and palpation
Decrease in strength which can be determined by MMT
Changed sequence of activation in principal movement patterns, which can be more easily observed and evaluated

24. Characteristics of altered movement patterns
The start of a muscle’s activation is delayed, resulting in an alteration in muscles activation sequence
Overall decrease in activity in the affected muscle
In extreme cases, EMG readings shows completely silent. This can lead to a misinterpretation that muscle strength is totally lacking when in fact, after proper facilitation, it may be capable of being activated towards more normal function. (Janda calls these changes ‘pseudoparesis’.)
Non-inhibited synergists or stabilizers often activate earlier

25. Mainly two types of muscles, we have to consider when we are talking about MET

26. Postural / phasic muscle characteristics
Postural muscles
Phasic
muscles
Type
Slow twitch –
red
Fast twitch - white
Respiration
Anaerobic
Aerobic
Function
Static/
supportive
Phasic/
active
Dysfunction
Shorten
Weaken
Treatment
Stretch/relax
Facilitate/
strengthen

27. Postural muscles that shorten under stress

28. PATTERNS OF
DYSFUNCTION

29. Upper Crossed Syndrome

30. All tighten and shorten
All weaken
Pectoralis major and minor
Upper trapezius
Levator scapulae
Sternomastoid
Lower and middle trapezius
Serratus anterior
Rhomboids

31. Lower Crossed Syndrome

32. All tighten and shorten
All weaken
Iliopsoas
Rectus femoris
TFL
Short adductors
Erector spinae group of the trunk
Abdominal
Gluteal muscles

33. Fibromyalgia and trigger points

34. Temporalis, Masseter, SCM, Splenius Capitis, Upper & Lower Trepezius, Levator Scapulae, Post. Cervical

35. ECR, Supinator, Multifidus, Gluteus Medius, Scaleni, Infraspinatus, Supraspinatus

36. Pectoralis Major, Serratus Ant. , Deltoid, Tibialis Ant
Pectoralis Major, Serratus Ant., Deltoid, Tibialis Ant., Gastrocnemius, Soleus, Peroneus Longus

37. Gluteus Minimus, Vastus Medialis, Biceps Femoris, Adductor Longus

38. Eyes can not see what mind doesn't know

39. How to use MET……..??? PALPATION SKILLS IDENTIFY BASIC BARRIER
MET USING IN……
 ACUTE CONDITIONS
 CHRONIC CONDITIONS

40. COMMON ERRORS DURING APPLICATION

41. Patient`s errors during MET
Contraction is too hard
Contraction is in the wrong direction
Contraction is not sustained for long enough
Does not relax completely after the contraction

42. Practitioner's errors in application of MET
Inadequate patient instruction is given
Inaccurate control of position of joint or muscle in relation to the resistance barrier
Inadequate counterforce to the contraction

43. Counterforce is applied in an inappropriate direction
Moving to a new position too hastily after the contraction
The practitioner fails to maintain the stretch position for a period of time which allows connective tissue to begin to lengthen

44. Contraindications And Side Effects Of MET
If any pathology is suspected, no MET should be used until an accurate diagnosis has been established
According to pathology, dosage of application can be modified accordingly
like…..amount of effort used, number of repetitions, stretching introduced or not, etc

45. As to side-effects, Greenman explains………
muscle contractions ↓
influence surrounding fascia, connective tissue ground substance and interstitial fluids
influences its biomechanical function, but also its biochemical and immunological functions

46. muscle effort requires energy by the metabolic process↓
results in carbon dioxide, lactic acid and other metabolic waste products which must be transported and metabolized
reason that the patient will frequently experience some increase in muscle soreness within the first 12 to 36 hours following MET treatment

47. If beginners to MET, then….
Follow statement “cause no pain when using MET “
Stick to light (20% of strength) contractions
Do not stretch over-enthusiastically
Have the patient's assistance in stretch

48. Sequential assessment and MET treatment of main postural muscles
Mainly musculoskeletal system pain ↓
related to muscle shortening
eg. When any muscle is weak (reduction in tone)
antagonists of these weak muscles get shortened (reciprocal inhibited tone)

49. So………….. ↓ Prior to any effort to strengthen weak muscle
shortened one should be dealt with appropriate means
then toning of weak muscle is emphasized

50. mostly seen that……..
tight muscles never loose its tone ( maintain their strength ) ↓
which leads to rapid recovery, when toning is emphasized

51. Key points ♥ proper positioning of patient
Eg. Patient of shoulder instability behaves different in supine and standing
♥ observation of particular movement
♥ note if there is any joint restriction
remember – muscle shortening is only be correctly evaluated when joint range is not decreased

52. Important Points While Applying MET
1. find proper barrier
2. acute or chronic
3. proper assistance from patient and proper command and proper explanation
4. no pain during treatment (mild discomfort is acceptable)
5. breathing co-operation
6. contraction of muscle – strength, time, repetition etc
7. proper relaxation

53. PRACTICAL DEMONSTRATION
1. TRAPEZIUS
2. PECTORALIS MAJOR
3. SUPRASPINATUS
4. HIP ADDUCTORS
6. PIRIFORMIS
7. QUADRICEPS

55. ANY QUESTIONS…..????