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FLEX-ABILITY: MUSCLE ENERGY- PNF

STRETCHING

Speaker:

THERESA A. SCHMIDT, DPT,MS,OCS,LMT,CEAS

This Photo by Unknown Author is licensed under CC BY-SA

Provider Disclaimer

• Allied Health Education and the presenter of this webinar do not

have any financial or other associations with the manufacturers of any products or suppliers of commercial services that may be

discussed or displayed in this presentation.

• There was no commercial support for this presentation.

• The views expressed in this presentation are the views and

opinions of the presenter.

• Participants must use discretion when using the information

contained in this presentation.

Course Outline: Hour 1

• Flexibility

• Stretching considerations

• Neuromuscular reflexes

• Reciprocal inhibition

• Indications

• Contraindications 3

2

Course Outline: Hour 2

• Isometric, concentric, eccentric

•MET/PNF technique

•Chaitow's MET technique

•Examples of MET

•Clinical case studies 4

Welcome to Flex-Ability!www.Educise.com

This Photo by Unknown Author is licensed under CC BY

Course Goals & Objectives

• Course Goals:

• This course is intended to instruct the professional through a study of flexibility and

muscle reflexes.

• Professional Objectives:

• At the conclusion of this course the participant will be able to

• Cite flexibility, how it is measured, and provide normative reference values for joint

mobility.

• Recognize the neuromotor reflexes of muscle spindles and golgi tendon organs , and their contribution to muscle length and tension.

• Identify stretching interventions using reciprocal inhibition and post-isometric relaxation

to facilitate the stretching process and improve functional mobility.

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FLEXIBILITY CHALLENGE

FLEXIBILITY

Definition:

The ability to move through a range of motion (ROM) of a joint

or chain of joints

“Stretch-ability”

•What is normal ROM?

•Goniometry

•Flexibility screening

FLEXIBILITY NORMS

• What is normal ROM?

Standardized values are measured using:

• Goniometry*

• Flexibility screening

• Functional testing: performance-based: for work, sport or

physical activity demands

(*American Academy of Orthopedic Surgeons, goniometry chart, 1965)

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NECK & T-L SPINE ROMJOINT MOTION NORMAL degrees

NECK FLEXION 45

EXTENSION 45

ROTATION 60

LATERAL FLEXION 45

TRUNK FLEXION 80 (4” from floor)

EXTENSION 25

ROTATION 45

LATERAL FLEXION 35

SHOULDER ROMJOINT MOTION NORMAL

degrees

SHOULDER FLEXION 180

EXTENSION 60

ABDUCTION 180

MEDIAL ROTATION

70

LATERAL ROTATION

90

ELBOW-FOREARM-WRIST ROMJOINT MOTION NORMAL degrees

ELBOW FLEXION 150

FOREARM PRONATION, SUPINATION

80

WRIST FLEXION 80

WRIST EXTENSION 70

WRIST RADIAL DEVIATION

20

WRIST ULNARDEVIATION

30

5

HIP ROMJOINT MOTION NORMAL degrees

HIP FLEXION 120

EXTENSION 30

ABDUCTION 45

ADDUCTION 30

ROTATION medial, lateral

45

KNEE- ANKLE ROM

JOINT MOTION NORMAL deg.

KNEE FLEXION 135

ANKLE DORSIFLEXION 20

ANKLE PLANTARFLEXION 50

ANKLE ANKLE INVERSION 35

ANKLE ANKLE EVERSION 15

HIP/KNEE/ANKLE STRAIGHT LEG RAISE

80

INTERVIEW

Discuss with client:

• Reason for seeking assistance: performance issues

• Personal needs and goals:

• Determine the need in order to set goals and

design an exercise program

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INTERVIEW

Identify the need: impairment- be specific

• “Do you feel stiff?”• “Is it painful to move?”

• “Do certain motions feel tight or sore?”• “Is there a specific physical activity you are unable to perform or have trouble doing?”• List the intensity of the pain using the pain scale from 0-10:

10 is the worst pain imaginable, 0 is no pain

ASSESS- Measure

Goniometric normative reference values

• Norkin and White: Goniometry- Measurement of Joint

Motion

• Flexibility screening: functional tools in the ergonomic and

sports literature

(Resources: Journal of Biomechanics, Medicine and Science in Sports and Exercise,

Athletic Training, Journal of Strength and Conditioning)

DETERMINE GOALS

Educate client regarding the limitations

Get medical clearance for health issues

Decide what performance is desired or required for the

physical activity

Set measurable, objective goal using the assessment

tools

Determine a timeline for achievement, Document it

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DESIGN A PROGRAM

Standard stretching uses positioning and an outside force or

gravity to place the joint(s) into an end range of motion

Normally a sensation of pulling or stretching discomfort is

observed

Avoid pain during stretching

STRETCING CONSIDERATIONS

• “No pain, no gain” - unnecessary muscle guarding,

protective spasm or even injury

• Keep intensity tolerable. Use Pain Scale, if above a 5/10, ease up on the force and range of stretch

• Begin with single joint stretches prior to moving into multiple joint stretches

PRECAUTIONS

• Injury warm-up prior to stretch to relax the area and

improve circulation

• Injured areas may need cooling after the stretch or workout for anti-inflammatory effects and pain reduction

• Progress gradually and gently with injury

• Never force the motion. If it does not move/ relax, try

something else!

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PRECAUTIONS

• Once medical clearance is obtained, review the record

• Note contraindications, such as unhealed fracture,

bruising, open or sutured wounds, to be avoided unless you have special qualifications to treat (MD, PT, OT, etc.)

• Do not stretch areas of hypermobility, which may be due to environment, injury, overuse, genetic or hormonal

(pregnancy requires gentle motion, ligaments become lax)

STRETCHING TECHNIQUES

• Static stretch- holding the part still waiting for a period of

time for release of tension

• Dynamic stretch- involves adding motion and muscle contraction of agonist of antagonist muscles

• Ballistic stretch- includes a bouncing or jumping, usually high-velocity stretch, be cautious since this is only for

advanced sports and may tear muscle

FACILITATED STRETCH

• Rehab clinicians and trainers may employ neuromuscular

reflexes to improve the effectiveness of stretching and to

help clients to relax and enjoy the stretching process

• Using reflexes helps to minimize muscle guarding and

pain and to achieve greater length during stretch

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NEUROMUSCULAR REFLEXES

• Muscle spindle reflexes

• Proprioceptive reflexes- golgi tendon organs (GTO)

• Developmental reflexes- remember what a baby does when it

moves, or when you place your finger in her palm

• Some reflexes are positional, related to the auditory or

vestibular system for balance sensation

Neuromotor Reflexes

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MUSCLE SPINDLE

• Sensory receptor detects changes in muscle fiber length

and timing of the length change

• Monosynaptic reflex- muscle spindle senses stretch, sends impulse to the alpha motorneuron in the spinal cord

• Alpha motorneuron sends a message to the muscle to contract, protect itself

• Two components

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MUSCLE SPINDLEExtrafusal & Intrafusal Fibers

• Extrafusal: Alpha motoneuron monitors muscle length:

CONTRACTION

• Intrafusal: Gamma mn monitors muscle length and speed:

CONTRACTION

• Spindle bias is the present sensitivity to changes in length

and rate of change

• Some people has higher bias than others

SPINDLE BIAS

• Pre-set sensitivity/ threshold for stimulation with

lengthening

• Related to muscle tone, the underlying activity level of the muscle

Golgi Tendon Organ

• GTOs monitor muscle fiber length at origin/ insertion

• when muscle contracts it stretches the attachments,

• GTOs fire: 1B impulses to the cord,

• results: turns off alpha motoneuron

• Inhibits contraction to relax the muscle

• If overactive, may weaken muscle

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Golgi Tendon Organ

• “GTO”

• Monitors tone

• Inhibits alpha motoneuron

• May cause weakness

• Use to stretch tight muscle

RECIPROCAL INHIBITION

• Joints are innervated by reflexes which allow for contraction

of a single action muscle group (flexors)

• or of paired opposing muscles actions across both sides of the joint (flexors and extensors)

RECIPROCAL INHIBITION

• Agonist or Synergist muscles work together to

perform a specific motion such as flexion

• Antagonist or opposing muscles perform the

opposite action of the specific motion, such as

extension

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RECIPROCAL INHIBITION

• When a single action muscle group fires,

• (flexors) the reflexes turn off the opposing muscles

(extensors) to facilitate flexion and inhibit the activity of extension

• This allows for greater coordination and precision of

movements

POST-ISOMETRIC INHIBITION

• After muscle contracts, latency period

• unable to activate a forceful contraction due to refractory

period.

• time for relaxation in preparation for the next contraction.

• Wastes must be removed, CO2 transported out, O2

supplied,

• neurotransmitters cross membranes, actin/myosin unlink,

etc.

• This is a great time to stretch muscle, it cannot fight you.

LET’S USE THE REFLEXES TO TRICK THE BODY INTO ALLOWING MORE EFFECTIVE OR LESS

PAINFUL STRETCH:

Using the energy of muscle contraction, myotatic stretch or GTO reflex or other

reflexes

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MUSCLE ENERGY TECHNIQUE

Neuromuscular Reflex Principles

Facilitation and Inhibition:

•Sherrington, Kabat

•Mitchell, DO as MET

•Knott and Voss as PNF

•PIR, AIS, ART, etc.

SO MANY NAMES

• Muscle Energy Technique- Osteopathic

• Proprioceptive Neuromuscular Facilitation- PT

• Active Release Technique- Chiropractic

• Active Isolated Stretching- Massage, Trainers

• using reflexes to trick the body into doing what we want in a

physical performance

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Definition of MET: by Dr. Phil Greenman, DO:

• “A manual medicine treatment using voluntary

contraction”

“Contracts the Muscle in a Precisely

Controlled Direction at varying levels of intensity”

“Against a Distinctly Executed

Counterforce”Greenman, p.93

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PRECISION

It’s all about precision, specificity, exactitude in o direction,

o duration,

o intensity,

o quality,

o type of stretch

STRETCHING CONCEPTS

TYPES OF STRETCH:

Range of Motion (ROM)

• Passive

• Active assistive

• Active

PASSIVE STRETCHES

• Client is relaxing

• Practitioner performs the work

• Very effective to release the fascia

• Typically held for a period of time, from 3 secs. to several minutes

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ACTIVE ASSISTIVE STRETCH

• Practitioner assists client to move through a range of

motion

• Client controls the end range

• Easier to manage if client is guarding or too weak to

work through a range of motion alone

• Helps client learn proper direction and force of stretch

prior to teaching home program

ACTIVE STRETCHES

• Client is independent in performing stretches

• Client controls force, direction, duration and length of stretch

• If client has restricted ROM or weakness, it may limit the

end range or duration of stretch

INDICATIONS

• Use reflexes to assist with stretch when client guards motion or has pain

• Poor flexibility

• Limited ROM

• Post-immobilization

• Functional limitation due to scarring, stiffness, fibrosis

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CONTRAINDICATIONS

ANY CONDITION FOR WHICH

MOTION OR CONTRACTION MAY BE INJURIOUS:

• Unhealed fracture, open wound, recent surgery, infection, rash, unknown diagnoses, instability or hypermobility, severe pain

• Obtain medical clearance first if unsure

CONTRACTION TYPES

• Isometric

•Concentric

•Eccentric or isolytic

ISOMETRIC

• Muscle length remains the same

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CONCENTRIC

• Muscle shortens,

• positive contraction

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ECCENTRIC

• Muscle lengthens while the muscle attempts to shorten

• Typically more painful, greater delayed onset muscle soreness

• Builds strength faster

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WHEN TO USE WHICH

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MET TECHNIQUE

• Resist short muscle at barrier

• Use 20% MVC Maximum Voluntary Contraction (intensity/

effort)

• Hold isometric contraction 2-3 secs

• Relax, follow with stretch of short muscle

• HOLD stretch 30 secs.

• 15-30 sec latency period allows easier stretch after it is

released

• Repeat 3-5 reps (Chaitow, DiGiovanna)

USING OTHER REFLEXES

• Contract antagonist for reciprocal inhibition of short muscle

• Press/ stretch muscle tendon of short muscle to elicit GTO

reflex to inhibit the short muscle

• Ask client to visualize moving in the desired direction

• Contract contralateral agonist to radiate facilitation into agonist

muscle

STRENGTHENING MET

NEXT: TO INCREASE STRENGTH:

• Activate antagonist (long muscle) to go beyond barrier

• Facilitate using automatic reflexes:

-Quick stretch

-Tapping or vibration

-Developmental reflexes

-Righting reflexes

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PRECAUTIONS

1. Do not overdo it, be gentle

2. Keep precise control of joint position, no substitutions

3. Use specific direction of force

4. Do not begin lengthening until they relax or may cause damage

MET TECHNIQUES

•Evaluate: measure ROM

•Check functional performance

•Problem solve: is goal to increase ROM

or strength or both? Today’s focus: ROM

Increase SHOULDER FLEXION stabilize scapula neutral

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Short SHOULDER EXTENSORS

GUIDELINES FOR ROM

• STATE LIMITATION: Shldr. flexion 0-120

• NAME SHORT MUSCLES: Latissimus, teres major, triceps long head

• CONTRACT SHORT MUSCLES: resist extension

• RELAX, STRETCH SHORT MUSCLES: flex into barrier as tolerated, avoid back arching/pain by bending hips/knees

• REPEAT 3-5 reps until improved ROM

Increase ABDUCTION stabilize scapula

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Short SHOULDER ADDUCTORS

GUIDELINES FOR ROM

• STATE LIMITATION: Shldr abduction limited 0-110 deg.

• NAME SHORT MUSCLES: pectoralis, latissimus, teres major

• CONTRACT SHORT MUSCLES: resist adduction

• RELAX, STRETCH SHORT MUSCLES: abduct into barrier

as tolerated, avoid side-bending to opposite side or hiking scapula up

• REPEAT 3-5 reps until improved ROM

Increase HIP STRAIGHT LEG RAISE

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Short HIP EXTENSORS

Short KNEE FLEXORS

Short ANKLE

PLANTARFLEXORS

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GUIDELINES FOR ROM

• STATE LIMITATION: SLR 60 degr

• NAME SHORT MUSCLES: Hamstrings, gluteus maximus,

gastrocnemius, soleus

• CONTRACT SHORT MUSCLES: resist knee flexion and/or hip

extension, ankle plantarflexion

• RELAX, STRETCH SHORT MUSCLES: extend into barrier as

tolerated, avoid back pain, keep pelvis neutral, modify by allowing

bend at hip, knee, ankle, add dorsiflexion to get triple joint stretch

• CAUTION: numbness may signal disc or neural tension problems

• REPEAT 3-5 reps until improved ROM

ANKLE DORSIFLEXION / SLR

GUIDELINES FOR ROM

• STATE LIMITATION: Ankle dorsiflexion 10 deg.

• NAME SHORT MUSCLES: gastrocnemius, soleus, Achilles

tendon

• CONTRACT SHORT MUSCLES: resist plantarflexion

• RELAX, STRETCH SHORT MUSCLES: flex into barrier as

tolerated, avoid twisting ankle or rotation of entire leg

• REPEAT 3-5 reps until improved ROM

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Increase WRIST EXTENSION

Short WRIST FLEXORS

GUIDELINES FOR ROM

• STATE LIMITATION: Wrist extension 35 degr.

• NAME SHORT MUSCLES: flexors: flexor capri radialis &

ulnaris, flexor digitorum longus/brevis, flexor indicis,

flexor digiti minimi, palmaris longus

• CONTRACT SHORT MUSCLES: resist flexion of wrist and fingers

• RELAX, STRETCH SHORT MUSCLES: extend into barrier,

include finger extension with or without wrist extension

• REPEAT 3-5 reps for ROM

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Increase HIP ADDUCTION

Short HIP ABDUCTORS

Increase HIP ABDUCTION

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Short HIP ADDUCTORS

Increase HIP INTERNAL ROTATION

Short HIP EXTERNAL ROTATORS

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Increase HIP EXTERNAL ROTATION

Short HIP INTERNAL ROTATORS

Increase HIP EXTENSION

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Short HIP FLEXORS

HIP EXTENSION: Thomas test

HIP EXTENSION: Prone, sidelying or

supine: if back pain: flex opposite hip or place pillow under pelvis to keep spine neutral

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HIP EXTENSION: Prone, sidelying or

supine: if back pain: flex opposite hip or place pillow under pelvis to keep spine neutral

FUNCTIONAL OUTCOMES

Tight hip flexors create multiple functional deficits:

• short step length

• Short stride length

• Slower gait speed

• Slower transfers to upright position

• Posture malalignment, excess lordosis, anterior innominate

• Potential trigger points in psoas and gluteus maximus

Functional Measures after releasing hip flexors

• 30 second chair rise test

• Unilateral stance test

• Timed Up and Go test

• 5 times sit to stand test

• Gait analysis, step and stride length, support time, degrees of hip extension

• Balance tests

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GUIDELINES FOR ROM

• STATE LIMITATION: Hip extension 5deg.

• NAME SHORT MUSCLES: Iliopsoas, rectus femoris, TFL,

adductor brevis, pectineus, sartorius

• CONTRACT SHORT MUSCLES: resist flexion

• RELAX, STRETCH SHORT MUSCLES: extend into barrier as

tolerated, avoid back arching or pain, keep pelvis flat or neutral

• REPEAT 3-5 reps until improved ROM

NECK LATERAL FLEXION Left

resist scapula elevation and move into depression, easy to do in sitting

NECK LATERAL FLEXORS R

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GUIDELINES FOR ROM

• STATE LIMITATION: Neck Left lateral flexion 25 degr.

• NAME SHORT MUSCLES: Right trapezius, scalenes, levator

scapula, SCM, splenius, erector spinae

• CONTRACT SHORT MUSCLES: resist Right lateral flexion

OR resist R scapular elevation

• RELAX, STRETCH SHORT MUSCLES: extend into barrier

into scapular depression

• REPEAT 3-5 reps until improved ROM

NECK ROTATION Left (EYE met)

resist R Rotation, ask patient to look R

GUIDELINES FOR ROM

• STATE LIMITATION: Neck rotation left is restricted

• NAME SHORT MUSCLES: Left trapezius, L scalenes, R

levator scapula, L SCM, R splenius, R erector spinae

• CONTRACT SHORT MUSCLES: resist Right rotation or ask

client to look to the right for 3 secs.

• RELAX, STRETCH SHORT MUSCLES: extend into barrier

into L rotation, ask client to help turn head L

• REPEAT 3-5 reps until improved ROM

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SPINAL LATERAL FLEXION, ILIAC DEPRESSIONResist iliac elevation

Correct iliac upslip, short QL

Short quadratus lumborum, erector spinae

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GUIDELINES FOR ROM

• STATE LIMITATION: Lateral flexion R is restricted

• NAME SHORT MUSCLES: Left quadratus lumborum,

erectors, obliques

• CONTRACT SHORT MUSCLES: resist L lateral flexion or L

hip hiking

• RELAX, STRETCH SHORT MUSCLES: extend into barrier

into R lateral flexion, bend over a pillow, ask client to hip hike

against your resistance (at ilium or pulling leg) No sudden or jerky motions!

• REPEAT 3-5 reps (avoid for joint replacements/instability)

CORRECT SOMATIC DYSFUNCTION

Abnormal Position: Anterior rotation R ilium:

•Low R ASIS, High L ASIS

•High R PSIS, Low L PSIS

Anterior Innominate Torsion, anterior rotation

If both true leg lengths are equal:

• Anterior Longer Lying, Anterior Shorter Sitting

• Anterior side leg may be externally rotated

• Lumbar spine is hyperextended

• Tight anterior hip flexors

• Typical complaint of pain in sustained standing or supine positions

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Short Hip Flexors on anterior side

CORRECT SOMATIC DYSFUNCTION

Supine longsitting test:

Anterior is longer in lying, shorter in longsitting

Standing: anterior side leg is externally rotated, abducted

to functionally shorten it

Intervention:

• Contract: R hip extensors

• Contract: L hip flexors

Contract R Hip Extensors isometrically

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Contract L Hip Flexors Isometrically

NOT recommended, may damage disc, psoas with strong contractions

Follow with Stabilization Exercise

Pelvic bridges

with knees flexed to work glutes

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Follow with Stabilization

Exercise

Adductor and

abductor isometrics

using pillow and band

Interesting Cases

• 39 y/o female in car accident, auto rolled over 2x, she has whiplash and back strain. Unable to rotate her trunk to the left or to flex forward fully due to pain and stiffness. Her thoracic spine is locked in R rotation and extension

(in the position of ESR R)

• What can we do to help her to move?

MET TRUNK ROTATION

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MET LUMBAR ESR R

How to Treat ESR R

• Need to go to barriers of flexion, sidebending and/or rotating to the left

• The opposite of her dysfunctional position

• Contract the short muscles, resist extension/SB/Rot R

• Passively move her into barriers of flexion/SB/Rot L

• More to it, this is a simplified model

• More courses on isolating a joint dysfunction, learn it in a live class!

MET LUMBAR NEUTRAL NLRRS

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MET IMPROVES ROM & STRENGTH

•Be gentle: Identify the limitation

•Position into restricted range

•Resist the tight muscle

•Rest, release, stretch into the range

•Follow with exercise and functional activity

•May need ice if sore post treatment

CLINICAL CASE STUDIES

• Identify a limitation of range of motion on your partner, or use a patient case

• Identify the short and/or weak muscles

•Position the joint for MET to increase ROM and strength

•Use active contraction to increase ROM and strength of the affected joint

•Design a functional activity to follow MET, include a home program

RESEARCH ON MET

This Photo by Unknown Author is licensed under CC BY-SA

This Photo by Unknown Author is licensed under CC BY-SA

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Comparison of MET to Positional Release for Hams Tightness

• RCT 24 adults in 2 groups: MET or PRT to hams: 2 wks of 5- 10 minute interventions

• Result active knee extension and active SLR: both improved significantly,

• More improvement in MET group

• (Sailor, 2019)

MET for Respiratory Muscle Strength , Endurance FMS

• 37 females with fibromyalgia

• Measures: pain, fatigue severity, resp. muscle strength, endurance, disability

• MET to SCM, scalene, Up trap with heat 3x/wk x 3 wks

• Result: increased respir. Strength and endurance, increased

expiratory strength, decreased pain, fatigue, disability, improved

neck ROM

• Not a RCT

(Uysal, et al, 2018)

MET with SCS for Acute Low Back Pain

• RCT 50 people with ALBP received wither MET or MET+SCS strain

counterstrain 2x for 2 days

• Results: ODI Oswestry Disability Index, Roland Morris disability Q,

VAS pain, ROM all improved significantly, no difference between

groups

• No added benefit of SCS + MET

• (Patel, VD, et al, 2018)

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MET or Ischemic Compression IC for Shoulder Pain TPs

• RCT 60 patients with shoulder TPs in 2 groups: either IC or MET

• Outcomes: VAS pain, ROM

• Tx 6 wks.

• Results: MET had greater effect on ROM than IC

• IC more effective to reduce pain

• (Gupta 2018)

Case Studies

27 y/o athlete, female, injured R hamstring on last workout prepping for track season.

SLR 0-45 with pain 4/10, cannot run or jump, ambulates with shorter steps on R, difficulty driving car, cannot sit > 5 mins.

Can run after warmup but has pain to walk up to ¼ mile.

List 2 interventions to improve gait and range of motion

CLINICAL CASE STUDIES

• Identify a limitation of range of motion on your

partner, or use a patient case

• Identify the short and/or weak muscles

• Position the joint for MET to increase ROM and

strength

• Use active contraction to increase ROM and

strength of the affected joint

• Design a functional activity to follow MET, include

a home program

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COPYRIGHT THANKS

• Sam Barrow of Primal Pictures Ltd. provided copyright permission to use the anatomy pictures from the Primal Pictures. Ltd. DVD: Interactive Functional Anatomy,

Second Edition

www.primalpictures.com

• Primal Pictures Ltd. 4th Floor, Tennyson House, 159-165 Great Portland St.

London, W1W5PA, UK

124

To Comply with professional board and association standards, I

declare I do have a financial interest in products and or services

discussed in my presentation occurring in the last 12 months.

FLEX-ABILITY: MUSCLE ENERGY-

PNF STRETCHING

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