1. Mechanical Low Back Pain and Muscle Energy Technique
Briana Baldino
VCU DPT 2016

2. What is Mechanical Back Pain?
Misalignment or dysfunction of structures within the spine
Vertebral bodies, intervertebral discs, zygapophysial joints, sacroiliac (SI) joints, spinal ligaments, paraspinal muscles, dura, spinal cord, and nerve roots
Zygapophysial Joints

3. Review of Normal Mechanics
Flexion: Open position
Extension: Closed position
Coupled motions: Rotation and sidebending occur ipsilateral when a segment in is flexion or extension

4. Mechanical Examination
Observe posture(standing and seated) and gait for asymmetries
Active range of motion
Weightbearing and non-weightbearing
Palpation of transverse processes, PSIS, ASIS, sacral base, inferior lateral angle, and medial malleoli

5. Assessing Lumbar Dysfunctions
Assess the depth of the transverse processes in NWB- flexion in sitting and extension in prone prop
If a transverse process feels more prominent/posterior, the segment is rotated to that side
Osteopathic texts also advocate assessing segmental tenderness, restricted ROM, and altered tissue texture

6. Positional Diagnosis
If the rotation is found in seated flexion, it is an ERS- the segment is stuck in Extension, Rotation, and Sidebending
The dysfunctional facet is on the side that the vertebra has rotated towards
If the rotation is found in prone prop extension, it is an FRS- the segment is stuck in Flexion, Rotation, and Sidebending
The dysfunctional facet is on the side that the vertebra has rotated away from

7. Sacral Dysfunctions
Sacral dysfunctions always occur with a L5 dysfunction
Palpate the sacral base and the inferior lateral angles
The SB and ILA on the same side will move together- whichever side feels more prominent is the side that the sacrum has rotated to

8. Sacral Dysfunctions
Right on Right (ROR)/Left on Left(LOL) torsions are always found with an ipsilateral ERS at L5
Found in trunk flexion
Right on Left (ROL)/Left on Right (LOR) torsions are always found with an ipsilateral FRS at L5
Found in trunk extension

9. MET Therapeutic Mechanisms
Increase tissue extensibility
Research has shown that it is more likely due to increased tolerance to stretching rather than reflex relaxation
Influence pain mechanisms to promote hypoalgesia
One theory is that it activates mechanoreceptors that are involved with centrally mediated pathways
Proposedly promotes changes in proprioception, motor planning, and control
Pain inhibits the deep stabilizers and the superficial muscles overreact

10. Treatment
Muscle energy techniques should facilitate movement in the opposite direction of the dysfunctional segment
3-5 seconds contractions repeated 3-5 times
Monitor the movement barrier by palpating the inferior and superior interspinous spaces of the dysfunctional vertebra

11. MET for Lumbar ERS
Position the patient in side lying on the side that the vertebra has rotated towards
Add flexion until you feel the barrier at the inferior space by flexing the hips
Add opposite rotation by rotating the trunk away from you until you feel the barrier at the superior space
Add opposite side bending by lifting the ankles until you feel the barrier at the inferior space
Have the patient push their ankles down towards the ground

12. MET for Sacral ROR/LOL Dysfunctions
Position the patient in side lying on the opposite side than the sacrum has rotated towards
Palpating the PSIS and SI joint, introduce flexion, rotation, and side bending the same as with lumbar ERS
Have the patient push their ankle down into your hand

13. MET for Lumbar FRS Seated or side lying
Position the patient in side lying on the side that the vertebra has rotated towards
Add extension until you feel the barrier by pulling hips towards you and pushing shoulders and legs away
Add opposite rotation by rotating the trunk away from you until you feel the barrier at the superior space
Add opposite side bending by lifting the top leg until you feel the barrier at the inferior space
Have the patient pull their leg down towards the ground

14. MET for Sacral ROL/LOR Torsions
Position the patient in side lying on the opposite side than the sacrum has rotated towards
Palpating PSIS and SI joint, introduce extension, side bending, and rotation the same as with lumbar FRS
Flex the top leg and resist the patient doing a clam shell

15. Now what?
MET is just one tool- if the dysfunction occurred secondary to poor mechanics or muscle imbalances, its likely to reoccur

16. Interventions with Strong Evidence
Manual therapy (soft tissue mobilizations, thrust and non-thrust mobilizations, strain-counter strain, etc)
Trunk coordination, strengthening, and endurance exercises
Centralization and directional preference exercises
Patient education
Progressive fitness and endurance exercise

17. Any Questions?

18. Sources
Chien, J., & Bajwa, Z. (2008). What is mechanical back pain and how best to treat it? Current Pain and Headache Reports, 12(6),
Day, J., McKeon, P., & Nitz, A. (2010). The efficacy of cervical/thoracic active range of motion for detecting changes associated with individuals receiving muscle energy techniques. Physical Therapy Reviews, 15(6),
Delitto, A., George, S., Van Dillen, L., Whitman, J., Sowa, G., Shekelle, P., Godges, J. (2012). Low back pain clinical practice guidelines linked to the international classification of functioning, disability, and health.Journal of Orthopaedic and Sports Physical Therapy, 42(4), A1-A57.
Fryer, G. (2010). Muscle energy technique: An evidence-informed approach. International Journal of Osteopathic Medicine, 14(1), 3-9.
Licciardone, J., Minotti, D., Gatchel, R., Kearns, C., & Singh, K. (2013). Osteopathic manual treatment and ultrasound therapy for chronic low back pain. Annals of Family Medicine, 11(2),