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

What Is Manual Therapy…??

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....

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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………..?????

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

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

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)

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

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

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

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

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

Postural muscles that shorten under stress

PATTERNS OF DYSFUNCTION

Upper Crossed Syndrome

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

Lower Crossed Syndrome

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

Fibromyalgia and trigger points

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

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

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

Gluteus Minimus, Vastus Medialis, Biceps Femoris, Adductor Longus

Eyes can not see what mind doesn't know

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

COMMON ERRORS DURING APPLICATION

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

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

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

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

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

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

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

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)

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

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

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

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

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

ANY QUESTIONS…..????