38. MUSCLE ENERGY TECHNIQUES (MET) AND PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION (PNF)

− Business involved in these techniques − You do not always have to be original to become successful − You do not always need to come up with something new − With osteoarticular joint mobilizations, no one can claim ownership, it has

existed for too long and has been used by too many professions − Muscle Energy Technique is a clearly osteopathic treatment, created by an

osteopathic doctor (Audrey) in the U.S.A. − Developed originally for neck treatment − The true creator took no steps to claim it as his own − A different osteopath took credit for MET, and changed it into a full

body treatment − He turned it into many books and treatments

− Dr. Pourgul developed Sports Energy Technique based on MET, he did not create a completely new technique − Works on type II muscle fibres to increase speed

− No one knows very much about MET, but Proprioceptive neuromuscular Facilitation (PNF) is well known − MET was stolen by a physiotherapist and renamed PNF − They are the exact same techniques, but PNF sounds more scientific − Now many other health professionals make use of PNF − Very few people offer MET, even though they are the same thing

− MET is slightly more gentle, whereas PNF is usually more aggressive − MET does many things to the joint structures

− Decreases pain, decreased spasm and increases ROM − Main benefits of MET

− Helps with trigger points and other joint problems as well − MET is basically: Contraction followed by relaxation followed by stretch

− Contraction-relaxation-stretching − Patients contract muscle against resistance from practitioners or

objects, then they relax the muscle and immediately stretch it − The amount of time in each phase is individual to practitioner − Dr. Pourgul's 525 Protocol

− 5 seconds contraction, 2 seconds relaxation, 5 seconds of stretching − Phases can be much longer if you want, but this is a good guideline

and simple to follow − Many types of MET, we focus on two types

− Isometric − Working on the muscle you are targeting − When working on the biceps, use the biceps for contraction and

everything − This is the most common one, the best one to use most of the time

− Reciprocal − Working on muscle on opposite side of joint from target muscle − When working on the biceps, work on the triceps for contraction etc − Working on opposite side still reduces spasm etc, without getting more

direct pain in the target muscle − By mixing and matching hundreds of combinations you can have hundreds of

techniques, but this is less effective than the Isometric type − Different Force involved

− PNF generally involves very large forces − MET uses 25-50% of the patients full power for the contraction etc

− MET and PNF started the same, but grew apart in one major thing − MET is gentle, works within ROM of the patient

− Patient starts next stretch from original position − Decreases pain more than PNF

− PNF is progressive, each stretch and contraction is started from where the last stretch ended (more effective but harder, good for athletes) − Increases ROM faster than MET, but most people will not be able to

do it − Contraindications for MET

− Same as joint mobilizations − Not working directly on the joint, working primarily on the muscle

− Check for infection, wounds on the muscle etc − No clear naming for the techniques in MET

− May be named for the movement of the joint − May be named for the movement the therapist is using − Use whichever makes more sense to you

1. SUPINE CERVICAL EXTENSION MUSCLE ENERGY TECHNIQUE Primary muscles worked on: Trapezius, neck extensors Resistance direction from practitioner: Neck flexion Resistance direction from patient: Neck extension Stretching movement: Neck flexion, Patient's chin arcs toward chest Start Position: Patient is supine. Your forearms are crossed under the patients occipital bone, supporting the head from the posterior aspect. Hands rest on anterior aspect of patient's shoulders, pinning shoulders to the table throughout the treatment.

Procedure: 1. With arms in starting position, let the patient's head relax onto your forearms 2. Lift the head slightly posterior to anterior and cephalic to caudal (movement is neck flexion), just enough to provide resistance for the patients neck musculature 3. Ask the patient to resist the force you are applying (they are extending the neck) 4. Have them hold this contraction for five full seconds 5. Instruct them to relax their neck, allow this relaxation for two full seconds 6. Pushing posterior to anterior and cephalic to caudal with your forearms, pressure the patient's neck into flexion to the end of the ROM and just beyond. Hold this stretch for five full seconds 7. Return to start position and allow patient to relax for two full seconds (do soft tissue briefly) 2. SUPINE CERVICAL LATERAL FLEXION MUSCLE ENERGY TECHNIQUE Primary muscles worked on: Sternocleidomastoid and scalene Resistance direction from practitioner: Lateral Flexion Resistance direction from patient: Lateral flexion in opposing direction Stretching movement: Lateral flexion in practitioner's force direction Start Position: Patient is supine. You are seated at a slight angle to the client. You have one hand on the supero-anterior aspect of the patient's shoulder, stabilizing it superior to inferior and anterior to posterior against the table. The palm of your other hand rests on the temporal bone on the same side. Procedure: 1. Ask the patient to push against the hand on their temple. 2. Have them hold the contraction for five full seconds, at 50% of maximal strength 3. Ask the patient to relax. 4. Allow the relaxation to last for two full seconds. 5. Pressure through the hand on the temple from medial to lateral, pushing the neck into full lateral flexion. Make sure you press slightly superior to inferior on the shoulder to get a deeper stretch. Go to the end of the ROM then just beyond it if possible. 6. Hold stretch for five full seconds. 7. Return to start position and allow patient to relax for two full seconds. 3. SUPINE CERVICAL ROTATION MUSCLE ENERGY TECHNIQUE Primary muscles worked on: Sternocleidomastoid, scalene Resistance direction from practitioner: External neck rotation Resistance direction from patient: External neck rotation in the opposite direction

Stretching movement: External neck rotation in the direction of the practitioner's force Start Position: Patient is supine. You are seated at a slight angle to them. Your hand which is closer to their midline should be on the antero-superior aspect of the shoulder, stabilizing it superior to inferior and anterior to posterior. The palm of the opposite hand should rest on the near side mandible with the heel of the palm on the superior aspect of the TMJ. Procedure: 1. Ask the patient to push against the hand on their TMJ, attempting external rotation. 2. Have them hold the contraction for five full seconds, at 50% of maximal strength 3. Ask the patient to relax. 4. Allow the relaxation to last for two full seconds. 5. Pressure through the hand on the TMJ from medial to lateral, pushing the neck into full external rotation. Go to the end of the ROM then just beyond it if possible. 6. Hold stretch for five full seconds. 7. Return to start position and allow patient to relax for two full seconds. 2. CERVICAL MUSCLE ENERGY TECHNIQUES 1. SUPINE UPPER CERVICAL (SUB OCCIPITAL) EXTENSION MUSCLE ENERGY TECHNIQUE

− Great for cervicogenic headaches − Cervical area dysfunction is often responsible for headaches (cervicogenic means

“coming from the neck”) − Biggest area having problems is the suboccipital region

− Lots of tiny muscles that get hypertonic and often have trigger points − Osteopathic treatment can be very effective in treating these headaches

− Focus a lot on upper cervical mobilization with patient's having headaches Primary muscles worked: Trapezius, neck extensors Resistance direction from practitioner: Neck flexion Resistance direction from patient: Neck extension Stretching movement: Neck flexion, Patient's chin arcs toward chest Start Position: Patient is supine. One of your hands has the patient's head resting on it, with thumb and fingers gripping just below the occipital ridge. The other hand rests on the patient's chin.

Procedure: 1. Ask the patient to push their chin posterior to anterior against your hand, while pressuring anterior to posterior to resist their force. 2. Have the patient hold this contraction for five full seconds, using 50% of maximal strength. 3. Ask the patient to relax. 4. Have the patient relax for two full seconds while you move your hand from the chin to the upper forehead (you are now in the position to perform the cervical traction joint mobilization) 5. Pull the occipital ridge inferior to superior while pressing anterior to posterior with the hand on the forehead (this will press the chin downwards, flattening the cervical spine). 6. Hold this stretch for five full seconds. 7. Return to start position and allow patient to relax for two full seconds. 40. SHOULDER MUSCLE ENERGY TECHNIQUES 1. SEATED SHOULDER ABDUCTION MUSCLE ENERGY TECHNIQUE Primary muscles worked: Supraspinatus, Deltoid Resistance direction from practitioner: Lateral to medial on patient's distal forearm (shoulder adduction) Resistance direction from patient: Medial to lateral (shoulder abduction) Stretching movement: Shoulder adduction towards midline Start Position: Patient is seated. Practitioner stands at their side and and slightly behind the patient. One hand rests on the superior aspect of the shoulder and and the other hand grips the posterior side of the distal forearm. The patient's palm is facing their midline. Procedure: 1. Ask the patient to push medial to lateral, against the hand on the forearm which is resisting their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the shoulder, allowing the muscle to relax for two full seconds. 4. Keeping their elbow locked, use the hand on the patient's forearm to adduct the arm behind the patient's back to the end of the ROM and slightly beyond.

5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 2. SEATED SHOULDER INTERNAL ROTATION MUSCLE ENERGY TECHNIQUE Primary muscles worked: Teres minor and infraspinatus Resistance direction from practitioner: External rotation of the shoulder Resistance direction from patient: Internal rotation of the shoulder Stretching movement: Internal rotation at the shoulder Start Position: Patient is seated with arm flexed at the elbow to 90 degrees and abducted to 90 degrees. You are standing to the side and slightly behind the patient. One of your hands is on the superior aspect of the patient's shoulder and the other is on the anterior aspect of the distal forearm. The patient's palm is facing the floor. Procedure: 1. Ask the patient to push against your hand gripping the forearm which is resisting their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the shoulder, allowing the muscle to relax for two full seconds. Make sure you support their arm. 4. Supporting the upper arm (keeping the shoulder abducted to 90 degrees) and push the shoulder into internal rotation to the end of the ROM and slightly beyond. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 3. SEATED SHOULDER EXTERNAL ROTATION MUSCLE ENERGY TECHNIQUE Primary muscles worked: Suprasinatus Resistance direction from practitioner: Internal rotation of the shoulder Resistance direction from patient: External rotation of the shoulder Stretching movement: External rotation at the shoulder Start Position: Patient is seated with arm flexed at the elbow to 90 degrees and abducted to 90 degrees. You are standing to the side and slightly behind the patient. One of your hands is on the superior aspect of the patient's shoulder and the other is on the posterior aspect of the distal forearm. The patient's palm is facing the floor. Procedure:

1. Ask the patient to push against your hand gripping the forearm which is resisting their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the shoulder, allowing the muscle to relax for two full seconds. Make sure you support their arm. 4. Supporting the upper arm (keeping the shoulder abducted to 90 degrees) and push the shoulder into external rotation to the end of the ROM and slightly beyond. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 41. SHOULDER MUSCLE ENERGY TECHNIQUES 1. SEATED SHOULDER EXTENSION MUSCLE ENERGY TECHNIQUE Primary muscles worked: Deltoids, pectoralis major Resistance direction from practitioner: Superior to inferior (shoulder flexion) Resistance direction from patient: Inferior to superior (shoulder extension) Stretching movement: Shoulder hyperflexion behind patient's body Start Position: Patient is seated. Practitioner stands at the patient's side and and slightly in front of the patient. One hand rests on the superior aspect of the shoulder and and the other hand grips the posterior side of the distal forearm. The patient's palm is facing the floor, with the arm in slightly extended position (anterior). Procedure: 1. Ask the patient to pressure inferior to superior, against the hand on the forearm which is resisting their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the shoulder, allowing the muscle to relax for two full seconds. 4. Keeping their elbow locked, use the hand on the patient's forearm to hyperflex the shoulder behind the patient's back to the end of the ROM and slightly beyond. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 2. SEATED SHOULDER FLEXION MUSCLE ENERGY TECHNIQUE

Primary muscles worked: Latissimus dorsi, subscapularis, deltoids Resistance direction from practitioner: Inferior to superior (shoulder extension) Resistance direction from patient: Superior to inferior (shoulder flexion) Stretching movement: Shoulder hyperextension above patient's body Start Position: Patient is seated. Practitioner stands at the patient's side and and slightly in front of the patient. One hand rests on the superior aspect of the shoulder and and the other hand grips the anterior side of the distal forearm. The patient's palm is facing the floor, with the arm slightly extended (anterior). Procedure: 1. Ask the patient to push against your hand gripping the wrist, resisting their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the shoulder, allowing the muscle to relax for two full seconds. Make sure you support their arm. 4. Using your hand on the patient's forearm, keep the patient's elbow locked as you hyperextend the shoulder (arm above the shoulder joint, palm facing forward) to the end of the ROM and just beyond. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 3. SEATED SHOULDER ADDUCTION MUSCLE ENERGY TECHNIQUE Primary muscles worked: Latissimus dorsi, subscapularis Resistance direction from practitioner: Abduction of the shoulder, medial to lateral pressure Resistance direction from patient: Adduction of the shoulder, lateral to medial pressure Stretching movement: Abduction of the shoulder above the shoulder joint Start Position: Patient is seated. Practitioner stands at the patient's side and and slightly in front of the patient. One hand rests on the superior aspect of the shoulder and and the other hand grips the anterior side of the distal forearm. The patient's palm is facing the floor, with the arm slightly abducted (lateral). Procedure: 1. Ask the patient to push against your hand gripping the wrist, resisting their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the shoulder, allowing the muscle to relax for two full

seconds. Make sure you support their arm. 4. Keeping the patient's elbow locked, push the shoulder into abduction to the end of the ROM and slightly beyond. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 42. UPPER ARM MUSCLE ENERGY TECHNIQUES 1. SEATED ELBOW FLEXION (BICEPS) MUSCLE ENERGY TECHNIQUE Primary muscles worked: Biceps brachii Resistance direction from practitioner: Superior to inferior (extension at the elbow) Resistance direction from patient: Inferior to superior (flexion at the elbow) Stretching movement: Elbow hyperextension Start Position: Patient is seated. Patient's arm being treated is flexed at the elbow to approximately 90 degrees, with the hand supinated (palm facing up). Practitioner stands at the side and and slightly in front of the patient. One hand rests on the superior aspect of the shoulder and and the other hand grips the anterior side of the distal forearm. Procedure: 1. Ask the patient to pressure inferior to superior (attempting flexion at the elbow), against the hand on the forearm which is resisting their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the arm, allowing the muscle to relax for two full seconds. 4. Lift the patients arm until it is extended to shoulder height (parallel with the ground). Bracing under the elbow, fully extend the arm at the elbow to the end of the ROM and slightly beyond. The patient's hand should still be supinated and extended (fingers pointing down with palm open) to accentuate the stretch. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 2. SEATEDELBOW FLEXION (BRACHIALIS) MUSCLE ENERGY TECHNIQUE Primary muscles worked: Brachialis Resistance direction from practitioner: Superior to inferior (extension at the elbow)

Resistance direction from patient: Inferior to superior (flexion at the elbow) Stretching movement: Elbow hyperextension Start Position: Patient is seated. Patient's arm being treated is flexed at the elbow to approximately 90 degrees, with the hand neutral (palm facing midline) and clenched in a fist. Practitioner stands at the side and and slightly in front of the patient. One hand rests on the superior aspect of the shoulder and and the other hand grips the lateral side of the distal forearm. Procedure: 1. Ask the patient to pressure inferior to superior (attempting flexion at the elbow), against the hand on the forearm which is resisting their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the arm, allowing the muscle to relax for two full seconds. 4. Lift the patients arm until it is extended to shoulder height (parallel with the ground). Bracing under the elbow, fully extend the arm at the elbow to the end of the ROM and slightly beyond. The patient's hand should still be neutral and in a fist, and you should push the hand into ulnar deviation to accentuate the stretch. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 3. SEATED ELBOW FLEXION (BRACHIORADIALIS) MUSCLE ENERGY TECHNIQUE Primary muscles worked: Brachioradialis Resistance direction from practitioner: Superior to inferior (extension at the elbow) Resistance direction from patient: Inferior to superior (flexion at the elbow) Stretching movement: Elbow hyperextension Start Position: Patient is seated. Patient's arm being treated is flexed at the elbow to approximately 90 degrees, with the hand pronated (palm facing down). Practitioner stands at the side and and slightly in front of the patient. One hand rests on the superior aspect of the shoulder and and the other hand grips the posterior side of the distal forearm. Procedure: 1. Ask the patient to pressure inferior to superior (attempting flexion at the elbow), against the hand on the forearm which is resisting their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their

maximal strength. 3. Instruct the patient to relax the arm, allowing the muscle to relax for two full seconds. 4. Lift the patients arm until it is extended to shoulder height (parallel with the ground). Bracing under the elbow, fully extend the arm at the elbow to the end of the ROM and slightly beyond. The patient's hand should still be pronated and should be flexed (fingers pointing down with palm open) to accentuate the stretch. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 43. UPPER ARM MUSCLE ENERGY TECHNIQUES 1. SEATED ELBOW EXTENSION MUSCLE ENERGY TECHNIQUE Primary muscles worked: Triceps brachii Resistance direction from practitioner: Superior to inferior (flexion at the elbow) Resistance direction from patient: Inferior to superior (extension at the elbow) Stretching movement: Elbow hyperflexion Start Position: Patient is seated. Patient's arm being treated is flexed at the elbow to approximately 90 degrees, with the hand neutral (palm facing midline). Arm being treated is pointing straight up toward the ceiling with elbow bent. Practitioner stands at the side and and slightly in front of the patient. One hand rests on the distal aspect of the triceps and and the other hand grips the posterior side of the distal forearm. Procedure: 1. Ask the patient to pressure inferior to superior (attempting extension at the elbow), use the hand on the forearm to resist their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the arm, allowing the muscle to relax for two full seconds. 4. Pressure the arm into deeper flexion by pressing superior to inferior on the forearm and pulling the arm further behind the patient's back (hyperextension of the shoulder). Flex the arm at the elbow to the end of the ROM and slightly beyond. The patient's hand should still be neutral and in a fist to accentuate the stretch. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles.

2. SEATED ELBOW LATERAL/EXTERNAL ROTATION (SUPINATION) MUSCLE ENERGY TECHNIQUE Primary muscles worked: Pronator teres Resistance direction from practitioner: External rotation (supination) Resistance direction from patient: Internal rotation (pronation) Stretching movement: External rotation (supination) Start Position: Patient is seated. Patient's arm being treated is flexed at the elbow to approximately 90 degrees, with the hand neutral (palm facing midline) and open, upper arm is at the patient's side. Practitioner stands at the side and and slightly in front of the patient. One hand rests on the proximal aspect of the forearm and and the other hand grips the patient's hand in a handshake grip. Procedure: 1. Ask the patient to pressure against your hand with internal rotation (attempting pronation), against your hand which is resisting their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the arm, allowing the muscle to relax for two full seconds. 4. Rotate the patient's hand externally until you reach the end of the supination ROM. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 3. SEATED ELBOW MEDIAL (INTERNAL) ROTATION (PRONATION) MUSCLE ENERGY TECHNIQUE Primary muscles worked: Supinator, biceps brachii Resistance direction from practitioner: Internal rotation (pronation) Resistance direction from patient: External rotation (supination) Stretching movement: Internal rotation (pronation) Start Position: Patient is seated. Patient's arm being treated is flexed at the elbow to approximately 90 degrees, with the hand neutral (palm facing midline) and open, upper arm is at the patient's side. Practitioner stands at the side and and slightly in front of the patient. One hand rests on the proximal aspect of the forearm and and the other hand grips the patient's hand in a handshake grip. Procedure:

1. Ask the patient to pressure against your hand with external rotation (attempting supination), against your hand which is resisting their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the arm, allowing the muscle to relax for two full seconds. 4. Rotate the patient's hand internally until you reach the end of the pronation ROM. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 44. UPPER ARM MUSCLE ENERGY TECHNIQUES 1. SEATED WRIST EXTENSION MUSCLE ENERGY TECHNIQUE Primary muscles worked: Wrist extensors Resistance direction from practitioner: Superior to inferior (flexion at the wrist) Resistance direction from patient: Inferior to superior (extension at the wrist) Stretching movement: Elbow hyperflexion Start Position: Patient is seated. Patient's arm being treated is flexed at the elbow to approximately 90 degrees, with the hand pronated (palm facing floor) and in a fist. Practitioner stands at the side and and slightly in front of the patient. One hand rests on the posterior aspect of the elbow and and the other hand grips the palm of the hand (open hand – handshake grip). The patient's wrist should be slightly extended to begin. Procedure: 1. Ask the patient to pressure inferior to superior (attempting extension at the wrist), use the hand on the forearm to resist their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the arm, allowing the muscle to relax for two full seconds. 4. Pressure the arm into deep flexion at the wrist by pressing superior to inferior on the dorsum of the hand, going to the end of the ROM and slightly beyond. The patient's hand should still be in pronation and open when performing the stretch to accentuate the stretch. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles.

2. SEATED WRIST FLEXION MUSCLE ENERGY TECHNIQUE Primary muscles worked: Wrist flexors Resistance direction from practitioner: Superior to inferior (extension at the wrist) Resistance direction from patient: Inferior to superior (flexion at the wrist) Stretching movement: Elbow hyperextension Start Position: Patient is seated. Patient's arm being treated is flexed at the elbow to approximately 90 degrees, with the hand supinated (palm facing up). Practitioner stands at the side and and slightly in front of the patient. One hand rests on the posterior aspect of the elbow and and the other hand grips the palm of the hand (open hand over the palm – handshake grip). The patient's wrist should be slightly flexed to begin. Procedure: 1. Ask the patient to pressure inferior to superior (attempting flexion at the wrist), use the hand on the forearm to resist their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the arm, allowing the muscle to relax for two full seconds. 4. Pressure the arm into deep extension at the wrist by pressing superior to inferior on the palm of the hand, going to the end of the ROM and slightly beyond. The patient's hand should still be in supination and open when performing the stretch to accentuate the stretch. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 3. SEATED WRIST LATERAL FLEXION MUSCLE ENERGY TECHNIQUE Primary muscles worked: Wrist medial flexors Resistance direction from practitioner: Medial to lateral (radial deviation at the wrist) Resistance direction from patient: Lateral to medial (ulnar deviation at the wrist) Stretching movement: Medial to lateral (radial deviation at the wrist) Start Position: Patient is seated. Patient's arm being treated is flexed at the elbow to approximately 90 degrees, with the hand supinated (palm facing up). Practitioner stands at the side and and slightly in front of the patient. One hand rests on the anterior aspect of the forearm and the other hand grips the palm in a handshake grip. The patient's wrist should be neutral to begin. Procedure:

1. Ask the patient to pressure against your hand with ulnar deviation force (pulling toward midline), against your hand which is resisting their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the arm, allowing the muscle to relax for two full seconds. 4. Move the patient's hand externally (radial deviation) until you reach the end of the ROM. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 45. WRIST MUSCLE ENERGY TECHNIQUES 1. SEATED WRIST MEDIAL FLEXION MUSCLE ENERGY TECHNIQUE Primary muscles worked: Wrist lateral flexors Resistance direction from practitioner: Lateral to medial (Ulnar deviation) Resistance direction from patient: Medial to lateral (Radial deviation) Stretching movement: Ulnar deviation Start Position: Patient is seated. Patient's arm being treated is flexed at the elbow to approximately 90 degrees, with the hand supinated (palm facing up). Practitioner stands at the side and and slightly in front of the patient. One hand rests on the anterior aspect of the forearm and the other hand grips the palm in a handshake grip. The patient's wrist should be neutral to begin. Procedure: 1. Ask the patient to pressure against your hand with radial deviation force (pulling away from midline), against your hand which is resisting their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the arm, allowing the muscle to relax for two full seconds. 4. Move the patient's hand medially (ulnar deviation) until you reach the end of the ROM. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 2. SEATED FINGER FLEXION MUSCLE ENERGY TECHNIQUE

Primary muscles worked: Finger flexors Resistance direction from practitioner: Superior to inferior (extension at the metacarpal-phalangeal joints and interphalangeal joints) Resistance direction from patient: Inferior to superior (flexion at the metacarpal-phalangeal joints and interphalangeal joints) Stretching movement: Extension at the metacarpal-phalangeal joints and interphalangeal joints Start Position: Patient is seated. Patient's arm being treated is flexed at the elbow to approximately 90 degrees, with the hand supinated (palm facing up). Practitioner stands at the side and and slightly in front of the patient. One hand rests on the anterior aspect of the distal forearm and and the other hand grips the distal phalanges of the hand (Palm resting on the anterior side of the fingers). The patient's fingers should be slightly flexed to begin. Procedure: 1. Ask the patient to pressure inferior to superior (attempting flexion at the phalanges), use the hand on the fingers to resist their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the arm, allowing the muscle to relax for two full seconds. 4. Pressure the fingers into deep extension at the MP , IP and wrist joints by pressing superior to inferior on the palm of the hand, going to the end of the ROM and slightly beyond. The patient's hand should still be in supination and open when performing the stretch to accentuate the stretch. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 3. SEATED FINGER EXTENSION MUSCLE ENERGY TECHNIQUE Primary muscles worked: Finger extensors Resistance direction from practitioner: Superior to inferior (Flexion at the metacarpal-phalangeal joints and interphalangeal joints) Resistance direction from patient: Inferior to superior (Extension at the metacarpal-phalangeal joints and interphalangeal joints) Stretching movement: Flexion at the metacarpal-phalangeal joints and interphalangeal joints Start Position: Patient is seated. Patient's arm being treated is flexed at the elbow to approximately 90 degrees, with the hand pronated (palm facing down). Practitioner

stands at the side and and slightly in front of the patient. One hand rests on the anterior aspect of the distal forearm and and the other hand grips the posterior aspect of the distal phalanges of the hand (Palm resting on the posterior side of the fingers). The patient's fingers should be slightly flexed to begin. Procedure: 1. Ask the patient to pressure inferior to superior (attempting extension at the phalanges), use the hand on the fingers to resist their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the arm, allowing the muscle to relax for two full seconds. 4. Pressure the fingers into deep flexion at the MP, IP, and wrist joints by pressing superior to inferior on the palm of the hand, going to the end of the ROM and slightly beyond. The patient's hand should still be in pronation and open when performing the stretch to accentuate the stretch. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 46. TEMPOROMANDIBULAR JOINT MUSCLE ENERGY TECHNIQUES 1. SUPINE TEMPOROMANDIBULAR JOINT (CLOSING THE MOUTH) MUSCLE ENERGY TECHNIQUE (INFERIOR TO SUPERIOR) Primary muscles worked: Masseter, Temporalis, Pterygoideus medialis Resistance direction from practitioner: Superior to inferior (opening the jaw) Resistance direction from patient: Inferior to superior (closing the jaw) Stretching movement: Opening the jaw (superior to inferior end of ROM) Start Position: Patient is supine, with the mouth slightly open. The practitioner has one hand resting on the top of the patient's head and the other hand has the heel of the palm hooked into the superior mandible just over the chin. Procedure: 1. Ask the patient to pressure against your hand with inferior to superior force (attempting to clench the jaw), against your hand which is resisting their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength.

3. Instruct the patient to relax the jaw, allowing the muscle to relax for two full seconds. 4. Move the patient's mandible inferiorly (opening the jaw) until you reach the end of the ROM. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 2. SUPINE TEMPOROMANDIBULAR JOINT (OPENING OF MOUTH) MUSCLE ENERGY TECHNIQUE (SUPERIOR TO INFERIOR) Primary muscles worked: Pterygoideus lateralis Resistance direction from practitioner: Inferior to superior (closing the jaw) Resistance direction from patient: Superior to inferior (opening the jaw) Stretching movement: Opening the jaw (superior to inferior end of ROM) Start Position: Patient is supine, with the mouth slightly open. The practitioner has one hand resting on the top of the patient's head and the other hand has the palm against the inferior mandible just under the chin. Procedure: 1. Ask the patient to pressure against your hand with superior to inferior force (attempting to clench the jaw), against your hand which is resisting their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the jaw, allowing the muscle to relax for two full seconds. 4. Move the patient's mandible inferiorly (opening the jaw) until you reach the end of the ROM. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 3. SUPINE TEMPOROMANDIBULAR JOINT SIDE TO SIDE MUSCLE ENERGY TECHNIQUE (MEDIAL TO LATERAL) Primary muscles worked: Pterygoideus lateralis and medialis, Masseter, Temporalis Resistance direction from practitioner: Medial to lateral (Jaw away from midline) Resistance direction from patient: Lateral to medial (Jaw towards midline) Stretching movement: Medial to lateral (Jaw away from midline) Start Position: Patient is supine, with the mouth slightly open. The practitioner has one hand resting on the far side of the patient's superior temporal bone and the other hand

has the palm against the inferio-lateral mandible just beside the chin. Procedure: 1. Ask the patient to pressure against your hand with lateral to medial force (attempting to move the jaw towards the midline), against your hand which is resisting their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the jaw, allowing the muscle to relax for two full seconds. 4. Move the patient's mandible medial to lateral (moving jaw away from the midline) until you reach the end of the ROM. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 47. KNEE JOINT MUSCLE ENERGY TECHNIQUES 1. SUPINE KNEE EXTENSION MUSCLE ENERGY TECHNIQUE Primary muscles worked: Hamstrings (Reciprocal) Resistance direction from practitioner: Superior to inferior (Flexion at the knee) Resistance direction from patient: Inferior to superior (Extension at the knee) Stretching movement: Extension at the knee, flexion at the hip Start Position: Patient is supine, with soles of the feet on the table and knees bent to 90 degrees. The practitioner rests the cephalic side hand on the patella of the far side knee. The close side leg rests on top of the forearm, acting as a hinge and supporting under the knee (The knee should still be flexed to almost 90 degrees). The practitioner's other hand rests on the anterior aspect of the distal tibia. Procedure: 1. Ask the patient to pressure against your hand with knee extension force (pushing cephalic to caudal), against your hand which is resisting their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the leg, allowing the muscle to relax for two full seconds. 4. Move the patient's knee into full extension and hip flexion, while keeping the leg straight until you reach the end of the ROM.

5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 2. SUPINE KNEE FLEXION MUSCLE ENERGY TECHNIQUE Primary muscles worked: Hamstrings Resistance direction from practitioner: Inferior to superior (Extension at the knee) Resistance direction from patient: Superior to inferior (Flexion at the knee) Stretching movement: Extension at the knee, flexion at the hip Start Position: Patient is supine, with soles of the feet on the table and knees bent to 90 degrees. The practitioner rests the cephalic side hand on the patella of the far side knee. The close side leg rests on top of the forearm, acting as a hinge and supporting under the knee (The knee should still be flexed to almost 90 degrees). The practitioner's other hand rests on the posterior aspect of the distal tibia. Procedure: 1. Ask the patient to pressure against your hand with knee flexion force (pushing caudal to cephalic), against your hand which is resisting their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the leg, allowing the muscle to relax for two full seconds. 4. Move the patient's knee into full extension and hip flexion, while keeping the leg straight until you reach the end of the ROM. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 3. PRONE KNEE EXTENSION MUSCLE ENERGY TECHNIQUE Primary muscles worked: Quadriceps Resistance direction from practitioner: Caudal to cephalic (anterior to posterior on the shin, attempting knee flexion) Resistance direction from patient: Cephalic to caudal (posterior to anterior on the shin, attempting knee extension) Stretching movement: Knee hyperflexion Start Position: Patient is prone. Practitioner hold the near side leg at the distal tibia, gripping from the anterior aspect. The cephalic side hand pressures slightly posterior to anterior on the near side sacroiliac joint to prevent rotation of the sacrum. The patient's knee is flexed to 90 degrees.

Procedure: 1. Ask the patient to pressure against your hand with knee extension force (pushing cephalic to caudal), against your hand which is resisting their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the leg, allowing the muscle to relax for two full seconds. 4. Move the patient's knee into full flexion until you reach the end of the ROM. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 48. KNEE AND HIP JOINT MUSCLE ENERGY TECHNIQUES 1. PRONE KNEE FLEXION MUSCLE ENERGY TECHNIQUE Primary muscles worked: Quadriceps (Reciprocal) Resistance direction from practitioner: Cephalic to caudal (Extension at the knee) Resistance direction from patient: Caudal to cephalic (Flexion at the knee) Stretching movement: Hyperflexion at the knee Start Position: Patient is prone. The leg being treated is flexed at the knee to 90 degrees. The practitioner's cephalic side hand is placed on the posterior superior iliac spine to stabilize the hip. The caudal side hand is supporting the leg being treated at the 90 degree angle, with the palm against the posterior aspect of the distal calf. Procedure: 1. Ask the patient to pressure against your hand with knee flexion force (pushing caudal to cephalic), against your hand which is resisting their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the leg, allowing the muscle to relax for two full seconds. 4. Move the patient's knee into full flexion, while keeping the hip pinned as you reach the end of the ROM. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles.

2. PRONE INTERNAL ROTATION (HIP) MUSCLE ENERGY TECHNIQUE Primary muscles worked: Gluteus maximus and medius Resistance direction from practitioner: Lateral to medial (external rotation at the hip) Resistance direction from patient: Medial to lateral (internal rotation at the hip) Stretching movement: Full external rotation at the hip (foot towards the midline) Start Position: Patient is prone. The leg being treated is flexed at the knee to 90 degrees. The practitioner's cephalic side hand is placed on the posterior superior iliac spine to stabilize the hip. The caudal side hand is supporting the leg being treated at the 90 degree angle, with the palm against the lateral aspect of the distal calf. Procedure: 1. Ask the patient to pressure against your hand with hip external rotation force (Trying to move foot towards midline), against your hand which is resisting their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the leg, allowing the muscle to relax for two full seconds. 4. Move the patient's knee into hip internal rotation (foot moving further from midline), while keeping hip pinned as you reach the end of the ROM. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 3. PRONE EXTERNAL ROTATION (HIP) MUSCLE ENERGY TECHNIQUE Primary muscles worked: Hamstrings, psoas major, pectineus Resistance direction from practitioner: Medial to lateral (internal rotation at the hip) Resistance direction from patient: Lateral to medial (external rotation at the hip) Stretching movement: Full internal rotation at the hip (Foot away from the midline) Start Position: Patient is prone. The leg being treated is flexed at the knee to 90 degrees. The practitioner's cephalic side hand is placed on the posterior superior iliac spine to stabilize the hip. The caudal side hand is supporting the leg being treated at the 90 degree angle, with the palm against the medial aspect of the distal calf. Procedure: 1. Ask the patient to pressure against your hand with hip internal rotation force (Trying to move foot away from midline), against your hand which is resisting their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength.

3. Instruct the patient to relax the leg, allowing the muscle to relax for two full seconds. 4. Move the patient's knee into hip external rotation (foot moving towards from midline), while keeping hip pinned as you reach the end of the ROM. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 49. HIP JOINT MUSCLE ENERGY TECHNIQUES 1. SUPINE HIP EXTENSION MUSCLE ENERGY TECHNIQUE Primary muscles worked: Gluteus maximus and medius Resistance direction from practitioner: Caudal to cephalic (Flexion at the hip) Resistance direction from patient: Cephalic to caudal (Extension at the hip) Stretching movement: Hyperflexion at the hip Start Position: Patient is supine. The leg being treated is flexed at the knee and hip to 90 degrees. The practitioner places the caudal side hand on the posterior aspect of the distal thigh, and the cephalic side hand rests on the knee. Procedure: 1. Ask the patient to pressure against your hand with hip extension force (pushing cephalic to caudal), against your hand which is resisting their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the leg, allowing the muscle to relax for two full seconds. 4. Move the patient's hip into full flexion until you reach the end of the ROM, with both hands on the anterior aspect of the proximal tibia. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 2. SUPINE HIP INTERNAL ROTATION MUSCLE ENERGY TECHNIQUE Primary muscles worked: Hamstrings, psoas major, pectineus, piriformis Resistance direction from practitioner: Lateral to medial (external rotation at the hip) Resistance direction from patient: Medial to lateral (internal rotation at the hip) Stretching movement: Full external rotation at the hip (Foot toward the midline) Start Position: Patient is supine. The leg being treated is flexed at the knee and hip to

90 degrees. The practitioner places the caudal side hand on the lateral aspect of the distal calf, and the cephalic side hand rests on the knee. Procedure: 1. Ask the patient to pressure against your hand with hip internal rotation force (Trying to move foot away from midline), against your hand which is resisting their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the leg, allowing the muscle to relax for two full seconds. 4. Move the patient's knee into hip external rotation (foot moving towards the midline) until you reach the end of the ROM. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 3. SUPINE HIP EXTERNAL ROTATION MUSCLE ENERGY TECHNIQUE Primary muscles worked: Gluteus maximus and medius Resistance direction from practitioner: Medial to lateral (Internal rotation at the hip) Resistance direction from patient: Lateral to medial (External rotation at the hip) Stretching movement: Full internal rotation at the hip (Foot away from midline) Start Position: Patient is supine. The leg being treated is flexed at the knee and hip to 90 degrees. The practitioner places the caudal side hand on the medial aspect of the distal calf, and the cephalic side hand rests on the knee. Procedure: 1. Ask the patient to pressure against your hand with hip external rotation force (Trying to move foot towards the midline), against your hand which is resisting their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the leg, allowing the muscle to relax for two full seconds. 4. Move the patient's knee into hip internal rotation (foot moving away from midline) until you reach the end of the ROM. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles.

50. HIP JOINT MUSCLE ENERGY TECHNIQUES 1. SUPINE HIP ADDUCTION MUSCLE ENERGY TECHNIQUE Primary muscles worked: Psoas major, pectineus, adductor magnus, brevis and longus, gracilis Resistance direction from practitioner: Anterior to posterior (Abduction at the hip) Resistance direction from patient: Posterior to anterior (Adduction at the hip) Stretching movement: Abduction at the hip Start Position: Patient is supine. The leg being treated is flexed at the knee to 90 degrees, with the ankle crossed over the opposite leg just above the knee. The practitioner places the caudal side hand on the medial aspect of the distal thigh, and the cephalic side hand rests on the near side ASIS (stabilizing it against the table. Procedure: 1. Ask the patient to pressure against the hand on their knee with hip adduction force (attempting to move the knee posterior to anterior). Your hand is resisting their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the leg, allowing the muscle to relax for two full seconds. 4. Move the patient's hip into full abduction until you reach the end of the ROM, with the hand on the ASIS still stabilizing anterior to posterior. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 2. SUPINE BILATERAL HIP ADDUCTION MUSCLE ENERGY TECHNIQUE (FROGLEG) Primary muscles worked: Psoas major, pectineus, adductor magnus, brevis and longus, gracilis Resistance direction from practitioner: Medial to lateral, bilaterally (Abduction at the hip) Resistance direction from patient: Lateral to medial, bilaterally (Adduction at the hip) Stretching movement: Bilateral abduction at the hip Start Position: Patient is supine. The leg are flexed at the knee to 90 degrees, with the soles of the feet on the table joined at the midline. The practitioner places the caudal side hand on the medial aspect of the far side thigh and the cephalic side hand rests on the medial aspect of the far side thigh, just superior to the knee.

Procedure: 1. Ask the patient to pressure against your hands with hip adduction force (attempting to move the knees lateral to medial). Your hands are resisting their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the legs, allowing the muscle to relax for two full seconds. 4. Move the patient's hips into full abduction until you reach the end of the ROM, push the thighs as close to the table as possible until you reach the restrictive barrier (the knees are both travelling away form the midline, towards the table). 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 3. LATERAL RECUMBENT HIP ABDUCTION MUSCLE ENERGY TECHNIQUE Primary muscles worked: Gluteus maximus, medius and minimus Resistance direction from practitioner: Lateral to medial (Abduction at the hip) Resistance direction from patient: Medial to lateral (Adduction at the hip) Stretching movement: Adduction at the hip Start Position: Patient is in lateral recumbent, facing away from the edge of the table. Both legs are straight. The caudal side hand rests on the lateral aspect of the distal thigh and the cephalic side hand rests on the lateral hip. Procedure: 1. Ask the patient to pressure against your hand (on the thigh) with hip abduction force from a slightly abducted position (Trying to move foot away from the midline), against your hand which is resisting their force. If the patient is elderly or not very strong, they can just hold the lieg in a slightly abducted position, using gravity as resistance. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the leg, allowing the muscle to relax for two full seconds. 4. Move the patient's thigh into hip adduction (foot moving towards and past the midline) until you reach the end of the ROM. The leg is being pushed down over the edge of the table. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles.

51. HIP JOINT MUSCLE ENERGY TECHNIQUES 1. SUPINE HIP FLEXION (PSOAS) MUSCLE ENERGY TECHNIQUE, WITH OPPOSITE KNEE TO CHEST --> MOST IMPORTANT MET (GRAVITY AND RESISTANCE) Primary muscles worked: Psoas major Resistance direction from practitioner: Anterior to posterior (Extension at the hip) and caudal to cephalic on other leg (Flexion at the hip) Resistance direction from patient: Leg being treated pushes posterior to anterior (flexion at the hip) Stretching movement: Anterior to posterior (Extension at the hip) on near leg and Caudal to cephalic on far leg (Flexion at the hip) Start Position: Patient is supine. Lying at the edge of the table with one leg very close to the edge. The leg in the centre of the table is flexed at the knee to 90 degrees, with the sole of the foot on the table. The practitioner's caudal side hand rests on the anterior aspect of the distal thigh and the cephalic side hand rests on the anterior aspect of the distal thigh on the other leg. Procedure: 1. Ask the patient to pressure against the hand on their leg with hip flexion force, while keeping the leg straight. If they are elderly or not very strong, gravity will provide enough resistance as they hold at about 30 degrees of hip flexion. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the leg, allowing the muscle to relax for two full seconds and the leg to drift downwards over the edge of the table as you support it. 4. Move the patient's hip into full extension until you reach the end of the ROM, with the hand on the other leg pushing the leg up into full hip flexion with the knee flexed, going to the end range here as well. This means that the legs are moving in opposite directions. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 2. LATERAL RECUMBENT HIP ADDUCTION MUSCLE ENERGY TECHNIQUE (GRAVITY AND RESISTANCE) Primary muscles worked: Adductor magnus, longus and brevis, pectineus and piriformis Resistance direction from practitioner: Medial to lateral (Abduction at the hip)

Resistance direction from patient: Lateral to medial (Adduction at the hip) Stretching movement: Abduction at the hip Start Position: Patient is in lateral recumbent, facing away from the edge of the table. Both legs are straight. The caudal side hand supports the upper leg by holding the medial aspect of the lower leg. The cephalic side hand rests on the patients hip. The upper leg is held in slight abduction. Procedure: 1. Ask the patient to pressure against your hand (on the distal lower leg) with hip adduction force from a slightly abducted position (Patient is trying to move foot toward the midline), against your hand which is resisting their force. If the patient is elderly or not very strong, they can just hold the leg in a slightly abducted position, using gravity as resistance for hip abduction force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the leg, allowing the muscle to relax for two full seconds. 4. Move the patient's thigh into hip abduction (foot moving away from midline) until you reach the end of the ROM. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 3. PRONE HIP FLEXION MET MUSCLE ENERGY TECHNIQUE (GRAVITY AND RESISTANCE) Primary muscles worked: Psoas major Resistance direction from practitioner: Anterior to posterior (Extension at the hip) Resistance direction from patient: Posterior to anterior (Flexion at the hip) Stretching movement: Hyperextension at the hip Start Position: Patient is prone, with the leg being treated (Near side leg) flexed at the knee to 90 degrees. The leg being treated will begin in slight extension at the hip. The practitioner has the cephalic side hand on the PSIS (Stabilizing posterior to anterior) and the caudal side hand on the anterior aspect of the distal thigh, supporting the hip in partial extension. Procedure: 1. Ask the patient to pressure against your hand (on the thigh) with hip flexion force from the slightly extended position (Trying to move foot toward the table), against your

hand which is resisting their force. If the patient is elderly or not very strong, they can just hold the leg in a slightly extended position at the hip, using gravity as resistance to hold the hip extension. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the leg, allowing the muscle to relax for two full seconds. 4. Move the patient's thigh into hip hyperextension (Leg moving away from the table) until you reach the end of the ROM. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 52. ANKLE JOINT MUSCLE ENERGY TECHNIQUES 1. SUPINE ANKLE PLANTARFLEXION MUSCLE ENERGY TECHNIQUE (GASTROC) Primary muscles worked: Gastrocnemius Resistance direction from practitioner: Caudal to cephalic (Dorsiflexion) Resistance direction from patient: Cephalic to caudal (Plantarflexion) Stretching movement: Dorsiflexion Start Position: Patient is supine. The legs are flat on the table. The practitioner's caudal side hand rests on the distal plantar aspect of the foot being treated (ball of the foot), and the cephalic side hand is resting on the anterior aspect of the proximal tibia. The foot being treated should begin in slight dorsiflexion. Procedure: 1. Ask the patient to pressure against the hand on the ball of their foot with plantarflexion force (attempting to move the ball of the foot caudally). Your hand is resisting their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the leg, allowing the muscle to relax for two full seconds. 4. Move the patient's foot into full dorsiflexion (ball of the foot moves cephalic) until you reach the end of the ROM. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles.

2. SUPINE ANKLE PLANTARFLEXION WITH LEG LIFT MUSCLE ENERGY TECHNIQUE (SOLEUS) Primary muscles worked: Soleus Resistance direction from practitioner: Caudal to cephalic (Dorsiflexion) Resistance direction from patient: Cephalic to caudal (Plantarflexion) Stretching movement: Dorsiflexion Start Position: Patient is supine. The leg being treated is flexed to 90 degrees at the hip and the knee. The practitioner's caudal side hand rests on the distal plantar aspect of the foot being treated (ball of the foot), and the cephalic side hand is resting on the anterior aspect of the proximal tibia. The foot being treated should begin in slight dorsiflexion. Procedure: 1. Ask the patient to pressure against the hand on the ball of their foot with plantarflexion force (attempting to move the ball of the foot caudally). Your hand is resisting their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the leg, allowing the muscle to relax for two full seconds. 4. Move the patient's foot into full dorsiflexion (ball of the foot moves cephalic) until you reach the end of the ROM. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 3. SUPINE ANKLE DORSIFLEXION MUSCLE ENERGY TECHNIQUE Primary muscles worked: Tibialis anterior Resistance direction from practitioner: Cephalic to caudal (Plantarflexion) Resistance direction from patient: Caudal to cephalic (Dorsiflexion) Stretching movement: Plantarflexion Start Position: Patient is supine. The legs are flat on the table. The practitioner's caudal side hand rests on the distal dorsal aspect of the foot being treated, and the cephalic side hand is resting on the anterior aspect of the proximal tibia. The foot being treated should begin in slight plantarflexion. Procedure: 1. Ask the patient to pressure against the hand on the distal foot with dortsiflexion

force (attempting to move the ball of the foot cephalic). Your hand is resisting their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the leg, allowing the muscle to relax for two full seconds. 4. Move the patient's fut into full plantarflexion (ball of the foot moves caudal) until you reach the end of the ROM. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 53. ANKLE JOINT MUSCLE ENERGY TECHNIQUES 1. SUPINE FOOT INVERSION MUSCLE ENERGY TECHNIQUE Primary muscles worked: Tibialis anterior, tibialis posterior Resistance direction from practitioner: Lateral to medial (Inversion) Resistance direction from patient: Medial to lateral (Eversion) Stretching movement: Inversion Start Position: Patient is supine. The legs are flat on the table. The practitioner has one hand on the anterior aspect of the distal tibia to stabilize, and one hand gripping the foot around the metatarsal-phalangeal joints (ball of the foot). Procedure: 1. Ask the patient to pressure against the hand on the ball of their foot with eversion (medial to lateral rotation of the sole of the foot) force. Your hand is resisting their force (lateral to medial/inversion force). 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the leg, allowing the muscle to relax for two full seconds. 4. Move the patient's foot into full inversion (sole of the foot faces medial) until you reach the end of the ROM. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 2. SUPINE FOOT EVERSION MUSCLE ENERGY TECHNIQUE

Primary muscles worked: Extensor digitorum longus Resistance direction from practitioner: Medial to lateral (Eversion) Resistance direction from patient: Lateral to medial (Inversion) Stretching movement: Eversion Start Position: Patient is supine. The legs are flat on the table. The practitioner has one hand on the anterior aspect of the distal tibia to stabilize, and one hand gripping the foot around the metatarsal-phalangeal joints (ball of the foot). Procedure: 1. Ask the patient to pressure against the hand on the ball of their foot with inversion (lateral to medial rotation of the sole of the foot) force. Your hand is resisting their force (medial to lateral/eversion force). 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the leg, allowing the muscle to relax for two full seconds. 4. Move the patient's foot into full eversion (sole of the foot faces lateral) until you reach the end of the ROM. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 3. SUPINE TOES EXTENSION MUSCLE ENERGY TECHNIQUE Primary muscles worked: Extensor digitorum longus, extensor hallucis longus Resistance direction from practitioner: Cephalic to caudal (Flexion of the digits) Resistance direction from patient: Caudal to cephalic (Extension of the digits) Stretching movement: Flexion of the digits Start Position: Patient is supine. The legs are flat on the table. The practitioner's caudal side hand rests on the distal dorsal aspect of the digits of the foot being treated, and the cephalic side hand is resting on the anterior aspect of the proximal tibia (to stabilize). Procedure: 1. Ask the patient to pressure against the hand on the distal phalanges with extension force (attempting to move the digits of the foot cephalic). Your hand is resisting their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the leg, allowing the muscle to relax for two full

seconds. 4. Move the patient's digits into full flexion (phalanges of the foot move caudal) until you reach the end of the ROM. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 4. SUPINE TOES FLEXION MUSCLE ENERGY TECHNIQUE Primary muscles worked: Flexor digitorum longus, flexor hallucis longus Resistance direction from practitioner: Caudal to cephalic (Extension of the digits) Resistance direction from patient: Cephalic to caudal (Flexion of the digits) Stretching movement: Extension of the digits Start Position: Patient is supine. The legs are flat on the table. The practitioner's caudal side hand rests on the distal ventral aspect of the digits of the foot being treated, and the cephalic side hand is resting on the anterior aspect of the proximal tibia (to stabilize). Procedure: 1. Ask the patient to pressure against the hand on the distal phalanges with flexion force (attempting to move the digits of the foot caudal). Your hand is resisting their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the leg, allowing the muscle to relax for two full seconds. 4. Move the patient's digits into full extension (phalanges of the foot move cephalic) until you reach the end of the ROM. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 54. THORACIC MUSCLE ENERGY TECHNIQUES 1. SEATED UPPER THORACIC MUSCLE ENERGY TECHNIQUE Primary muscles worked: Erector spinae, abdominal complex Resistance direction from practitioner: Posterior to anterior on the back, inferior to superior on the arms Resistance direction from patient: Superior to inferior (Flexion at the trunk/thoracic

region) Stretching movement: Extension of the thoracic spine Start Position: Patient is seated, with the hands crossed over the opposite shoulders. Practitioner supports the patients bodyweight by gripping under the arms with the hand resting on the far side triceps. The patient is slightly flexed at the hip and spine, leaning the bodyweight onto the practitioners arm. The practitioner's other hand is perpendicular to the patient's back with the heel of the palm against the thoracic spine. You are standing at one side of the patient. Procedure: 1. Ask the patient to pressure against the arm supporting their weight with trunk flexion force. Your resistance force will be pressing inferior to superior. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the trunk, allowing the muscle to relax for two full seconds and the leg to drift downwards over the edge of the table as you support it. 4. Move the patient's spine into full extension until you reach the end of the ROM, with the hand on the spine pushing posterior to anterior and the other arm lifting the patient's weight inferior to superior, going to the end range of extension. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 2. SEATED MID THORACIC MUSCLE ENERGY TECHNIQUE Primary muscles worked: Multifidis, rotatores, erector spinae, internal and external obliques Resistance direction from practitioner: Lateral rotation (Rotation at the lumbar spine) Resistance direction from patient: Medial rotation (Opposing the rotation of your pressure) Stretching movement: Lateral/external rotation Start Position: Patient is seated with arms crossed (hands on shoulders). The practitioner has one hand on the dorsal aspect of the patient's hand resting on the near side shoulder. The other hand rests on the scapula of the far side. You are standing at one side of the patient. Procedure: 1. Ask the patient to pressure against your hands (You are pressuring them into external/lateral rotation and they are trying to remain facing forward).

2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the trunk, allowing the muscle to relax for two full seconds. 4. Move the patient's trunk into full lateral rotation (shoulders facing away from midline) until you reach the end of the ROM. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 3. SEATED LOWER THORACIC MUSCLE ENERGY TECHNIQUE Primary muscles worked: Internal/external obliques, Latissimus dorsi, erector spinae, multifidis, rotatores Resistance direction from practitioner: Superior to inferior and medial to lateral (Trunk lateral flexion) Resistance direction from patient: Inferior to superior and lateral to medial Stretching movement: Lateral flexion Start Position: Patient is seated, with the hands crossed over onto the opposite shoulders. The practitioner has one hand on the lateral aspect of the far side deltoid, and the other hand on the superior aspect of the near side shoulder. You are standing at one side of the patient. Procedure: 1. Ask the patient to pressure against your hands (You are pressing the near shoulder down and bring the trunk medial to lateral into trunk flexion, they are resisting). The patient is attempting to keep the trunk upright. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the trunk, allowing the muscle to relax for two full seconds. 4. Move the patient's trunk into full lateral flexion to your side until you reach the end of the ROM. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 55. LUMBAR MUSCLE ENERGY TECHNIQUES

1. SEATED LUMBAR LATERAL FLEXION MUSCLE ENERGY TECHNIQUE Primary muscles worked: Internal/external obliques, Latissimus dorsi Resistance direction from practitioner: Superior to inferior and medial to lateral (Trunk lateral flexion) Resistance direction from patient: Inferior to superior and lateral to medial Stretching movement: Lateral flexion of the trunk Start Position: Patient is seated, with the hands crossed over onto the opposite shoulders. The practitioner has one hand on the lateral aspect of the far side deltoid, and the other hand on the superior aspect of the near side shoulder. You are standing at one side of the patient. Procedure: 1. Ask the patient to pressure against your hands (You are pressing the near shoulder down and bring the trunk medial to lateral into trunk flexion, they are resisting). The patient is attempting to keep the trunk upright. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the trunk, allowing the muscle to relax for two full seconds. 4. Move the patient's trunk into full lateral flexion to your side until you reach the end of the ROM. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 2. SEATED LUMBAR ROTATION MUSCLE ENERGY TECHNIQUE Primary muscles worked: Erector spinae, miltifidis, rotatores Resistance direction from practitioner: External/lateral rotation of the trunk Resistance direction from patient: Internal rotation of the trunk Stretching movement: Lateral/external rotation of the trunk Start Position: Patient is seated with arms folded, and hands rest on the opposing shoulders. The practitioner is standing at the patient's side. The practitioner has one hand on the anterior aspect of the near side shoulder, with the hand lying on top of the patient's hand. The other hand is resting on the scapula. Procedure: 1. Ask the patient to pressure against your hands (You are pressuring them into external/lateral rotation and they are trying to remain facing forward).

2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the trunk, allowing the muscle to relax for two full seconds. 4. Move the patient's trunk into full lateral rotation (shoulders facing away from midline) until you reach the end of the ROM. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 3. SEATED LUMBAR FLEXION MUSCLE ENERGY TECHNIQUE Primary muscles worked: Erector spinae, miltifidis, rotatores Resistance direction from practitioner: Inferior to superior (Extension of the spine) Resistance direction from patient: Superior to inferior (Flexion of the spine) Stretching movement: Posterior to anterior against the lumbar spine, inferior to superior to reach full spinal extension Start Position: Patient is seated with arms folded, and hands rest on the opposing shoulders. The practitioner is standing at the patient's side. The practitioner reaches under the arms and grips the far side triceps. The other hand is resting on the lumbar spine. Procedure: 1. Ask the patient to pressure against the arms under their arms with trunk flexion force (superior to inferior). Resist their force with inferior to superior force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the trunk, allowing the muscle to relax for two full seconds and the leg to drift downwards over the edge of the table as you support it. 4. Move the patient's spine into full extension until you reach the end of the ROM, with the hand on the back pushing slight posterior to anterior to keep the lumbar segment straight. You will have to lift the patient's arms up, inferior to superior, to reach the end of this ROM (arms will likely be above the level of the head). 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 56. LUMBAR MUSCLE ENERGY TECHNIQUES

1. SEATED LUMBAR EXTENSION MUSCLE ENERGY TECHNIQUE Primary muscles worked: Erector spinae, multifidis and rotatores Resistance direction from practitioner: Posterior to anterior (Flexion of the spine) Resistance direction from patient: Extension of the spine Stretching movement: Flexion of the spine, trunk and hip Start Position: Patient is seated, with the torso flexed forward slightly over the legs. The practitioner stands at the patient's side, with the hands on the upper back between the scapulae. Procedure: 1. Ask the patient to pressure against the hands on their back with spine and hip extension force, while the practitioner resists the force, holding the spine in a slightly flexed position. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the trunk, allowing the muscle to relax for two full seconds and the leg to drift downwards over the edge of the table as you support it. 4. Move the patient's trunk into full flexion until you reach the end of the ROM. As the spine flexes, the hip joint is also flexing. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 2. SUPINE LUMBAR ROTATION MUSCLE ENERGY TECHNIQUE patient hip abducts, then you hyper adduct into lateral recumb Primary muscles worked: Gluteus maximus and medius, erector spinae, miltifidis, rotatores Resistance direction from practitioner: Lateral to medial (Adduction at the hip) Resistance direction from patient: Medial to lateral (Abduction at the hip) Stretching movement: Adduction at the hip Start Position: Patient is supine. Practitioner stands at the patient's side, and lifts the far side leg into a position of 90 degree flexion at the hip and the knee. The patient's hands are folded over their upper stomach, and the practitioner stabilizes anterior to posterior on the patient's hands. The practitioners caudad hand grips the lateral aspect of the distal femur of the raised leg. Procedure: 1. Ask the patient to pressure against your hand on their thigh (pressing medial to

lateral) with hip abduction force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the leg, allowing the muscle to relax for two full seconds. 4. Move the patient's thigh into hip hyper-adduction (foot moving across the midline), enough to cause the lower back and hips to rotate with the leg, until you reach the end of the ROM. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 3. SUPINE LUMBAR ROTATION MUSCLE ENERGY TECHNIQUE both knees up, they extend then you hyperflex/traction Primary muscles worked: Erector spinae, multifidis, rotatores Resistance direction from practitioner: Inferior to superior (Flexion at the hip and spine) Resistance direction from patient: Superior to inferior (Extension at the hip and spine) Stretching movement: Flexion at the hip and spine Start Position: Patient is supine, with both legs flexed at the hip and knee to 90 degrees. The patients hands are lying at their sides, on the table. The practitioner stands at the patients side and has the cephalad forearm lying across the anterior aspect of the proximal tibias. The cadual hand is supporting the patient's legs by contacting the soles of the feet. Procedure: 1. Ask the patient to pressure against your forearm and hand (attempting to extend the hips and spine) by pressuring superior to inferior. The practitioner resists this force and holds the patient in the starting position. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the legs and back, allowing the muscle to relax for two full seconds. 4. Move the patient's legs in a superior direction, moving the hip and spine into deep flexion until you reach the end of the range of motion (the patient's knees should be approaching the chest) 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles.

57. LUMBAR MUSCLE ENERGY TECHNIQUES 1. LATERAL RECUMBENT LUMBAR LATERAL FLEXION MUSCLE ENERGY TECHNIQUE Primary muscles worked: Quadratus lumborum Resistance direction from practitioner: Lateral to medial (Extension of the trunk) Resistance direction from patient: Medial to lateral (Lateral flexion of the trunk) Stretching movement: Adduction of the hip and abduction of the shoulder Start Position: Patient is lying on their side, facing away from the practitioner, at the edge of the table. The practitioner has their more cephalad hand resting on the patient's lateral shoulder, and the more caudad hand on the lateral aspect of the hip. Procedure: 1. Ask the patient to lift the shoulders off the table by laterally flexing the trunk. The practitioner can resist this force if necessary by pressuring lateral to medial on the patient's shoulder. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the trunk, allowing the muscle to relax for two full seconds and the leg to drift downwards over the edge of the table as you support it. 4. Move the patient's upper leg off the edge of the table and press downwards (contacting the lateral aspect of the distal thigh), pushing the patients hip into adduction. Simultaneously, take the patient's upper arm over their head, into abduction and press to the end of the ROM (contacting the proximal aspect of the triceps). Push both the arm and the leg to the end of the ROM simultaneously. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 2. LATERAL RECUMBENT LUMBAR ROTATION MUSCLE ENERGY TECHNIQUE Primary muscles worked: Gluteus maximus and medius, erector spinae, multifidis, rotatores Resistance direction from practitioner: Lateral to medial (Adduction of the hip) Resistance direction from patient: Medial to lateral (Abduction at the hip) Stretching movement: Adduction at the hip, rotation of the lumbar spine Start Position: Patient is lying on their side in lateral recumbent position, facing the edge of the table and practitioner. The practitioner's caudad hand rests on the lateral aspect of the distal femur, and the cephalad hand is holding the far side shoulder of the

patient against the table. Procedure: 1. Ask the patient to abduct the upper leg (which is flexed at the knee past 90 degrees, and flexed at the hip to 90 degrees) against your hand which is resisting their force. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the leg, allowing the muscle to relax for two full seconds. 4. Place the the knee on the patient's knee and extend your hip to rotate their lumbar spine, while simultaneously placing the fingers of your caudad hand against the upper TVP of the lumbar spine to assist in rotating the lumbar spine. Instead of using the knee assist, the practitioner may choose the simply press lateral to medial on the distal femur to rotate the lumbar spine. 5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 3. LATERAL RECUMBENT LUMBAR FLEXION MUSCLE ENERGY TECHNIQUE Primary muscles worked: Erector spinae, abdominal complex Resistance direction from practitioner: Posterior to anterior (extension of the lumbar spine) Resistance direction from patient: Superior to inferior and inferior to superior (Flexion of the trunk) Stretching movement: Extension of the lower back Start Position: The patient is lying in lateral recumbent position. The practitioner places the heel of the caudad hand against the transverse processes of the lumbar spine. Procedure: 1. Ask the patient to flex the trunk by contracting the abdominal muscles. The hand holding the patient's shoulder into the table is the resistance for this movement. 2. Have them hold the contraction for five full seconds at approximately 50% of their maximal strength. 3. Instruct the patient to relax the trunk, allowing the muscle to relax for two full seconds. 4. Pressure posterior to anterior on the patient's lumbar spine to push the lumbar spine into full extension. Go to the end of the ROM and use the knee assist if necessary for greater force.

5. Hold this position for five full seconds. 6. Allow the patient to relax back in the neutral position for two full seconds. 7. Repeat for 2-3 more contractions-relaxation cycles. 58. Prone Unilateral Sacrum Flexion MET in sphinx position with breathing assist Diagnosis Seated flexion test: Positive left Left sacral sulcus: Dorsal, posterior Left ILA: Ventral, anterior Spring test: Positive Sphinx test: Increased asymmetry Technique

− The patient lies in the sphinx position (propped up with the elbows supporting the upper body), and the physician stands at the left side of the table.

− The index finger of the physician's cephalad hand palpates the patient's left sacral sulcus while the caudad hand abducts and adducts the patient's left leg to find the loosest-packed position for the left sacroiliac joint (usually about 15 degrees of abduction).

− The physician internally rotates the patient's left hip and instructs the patient to maintain this abducted, internally rotated position throughout the treatment.

− The hypothenar eminence of the physician's cephalad hand is placed on the patient's left sacral sulcus and is reinforced by the caudad hand.

− The physician's hands exert a sustained anterior (downward) force on the patient's left sacral sulcus to rotate the sacrum anteriorly, and to disengage the lumbosacral joint caudally.

− The patient inhales and then exhales forcefully. During exhalation, the physician's hands encourage sacral flexion.

− The patient inhales slowly. During inhalation, the physician's hands increase the anterior force on the sacral sulcus to prevent sacral extension.

− Steps 5 to 7 are repeated five to seven times. − The diagnostic parameters of the dysfunction are reevaluated to determine the

effectiveness of the technique. Bilaterally Flexed Sacrum, Respiratory Assist Diagnosis

Sacral rock test: Positive Both sacral sulci: Ventral, anterior Both ILAs: Dorsal, posterior Spring test: Negative Sphinx test: Decreased asymmetry Bilaterally flexed sacrum Technique

1. The patient lies prone and the physician stands beside the patient. 2. The physician places the thenar and hypothenar eminences of the caudad hand on

the ILAs of the patient's sacrum. 3. The physician's cephalad hand reinforces the caudad hand. 4. The physician applies a continuous anterior (downward) force on the ILAs of the

patient's sacrum. 5. When patient breaths out press downward until the end of flexion or ROM.

Prone Unilateral PA Sacrum Flexion MET with ASIS lift. Region of body being treated: Sacral Spine Point of contact on body: Superior Lateral border of sacrum on opposite side Position of client: Prone Technique type: MET, unilateral (perform on each side of the client) Pressure: Posterior to Anterior Contact on practitioner: Proximal heel of palm Technique 1. Locate superior lateral border of sacrum on side opposite of practitioner 2. Place heel of cephalic palm on the sacrum (thumbs pointing caudal) 3. Reach caudal hand under the client's far side hip, gripping the ASIS 4. Hold sacrum steady while you ask patient to resist your hand on the ASIS 5. Use 5-2-5 technique as in other MET’s 6. Move to other side of the table and repeat for the other side 59. Prone PA Ilium Flexion MET with Leg lift

− The patient lies prone and the physician stands beside the table. − The physician flexes the patient's knee on the side to be treated 90 degrees and

then grasps the patient's thigh just above the knee. − The physician's cephalad hand is placed over the patient's PSIS(or lateral to the

SI joint) to stabilize the pelvis. − The physician's caudad hand gently lifts the patient's thigh upward until the

psoas muscle begins to stretch, engaging the edge of the restrictive barrier. − The patient holds up their knee and practitioner can use down force if required. − This isometric contraction is held for 5 seconds, and then the patient is

instructed to stop and relax. (Use 5-2-5 technique) 7. Once the patient has completely relaxed, the physician extends the patient's hip to the edge of the new restrictive barrier. 8. Steps 5 to 7 are repeated three to five times or until motion is maximally improved at the dysfunctional hip and psoas. 9. Success of the technique is determined by reevaluating passive hip extension. Prone PA Ilium Flexion MET with Respiratory Assist Diagnosis Seated flexion test: Positive left Left sacral sulcus: Ventral, anterior Left ILA: Dorsal, posterior Spring test: Negative Sphinx test: Decreased asymmetry Technique 1. The patient lies prone and the physician stands at the left side of the table. 2. The heel of the physician's caudad hand is placed on the patient's left ilum and is reinforced by the cephalad hand. 3. The physician's caudad hand exerts a sustained force downward on the left ilium. 4. The patient inhales maximally while the physician's caudad hand maintains constant ventral pressure on the left ilium. 5. The patient exhales slowly. During exhalation, the physician's caudad hand increases the ventral pressure on the left ilium 6. Steps 5 to 7 are repeated five to seven times. 7. The diagnostic parameters of the dysfunction are reevaluated to determine the effectiveness of the technique. Prone PA Sacrum Extension MET with respiratory Assist Diagnosis Both sacral sulci: Dorsal, posterior Both liAs: Ventral, anterior Spring test: Positive Sphinx test: More asymmetry Bilaterally Extended sacrum Technique

1. The patient lies prone and the physician stands beside the patient.

2. The physician places the index finger on the patient's left sacral sulcus and the long finger on the right sacral sulcus.

3. The physician's other hand reinforces the first hand. 4. A continuous anterior (downward) force is placed on the sacral sulci. 5. The patient inhales and then exhales deeply. 6. The physician exaggerates flexion during exhalation and attempts to resist

extension during inhalation. 7. Steps 4 to 6 are repeated 7 to 10 times. 8. The diagnostic parameters of the dysfunction are reevaluated to determine the

effectiveness of the technique. 60. Lateral Recumbent Sacrum MET with Shoulder resistance Diagnosis Seated flexion test: positive left Left sacral sulcus: shallow, posterior Right lLA: deep, anterior Spring test: positive Sphinx test: more asymmetry Left-on-right sacral torsion Technique 1. The patient is in the right lateral recumbent position with the pelvis close to the edge of the table and the left knee resting slightly flexed on the table in front of the right leg. 2. The physician stands facing the patient's pelvis, and the cephalad hand palpates the LS-S1 interspinous space while the caudad hand gently moves the patient's right leg posteriorly, extending the hip until motion is felt at the LS-S1 interspace. 3. The physician's caudad hand and forearm stabilizes the patient's pelvis as the patient gently rotates the trunk to the left. 4. The patient then resists the practitioner at the shoulders (5-2-5 technique) and practitioner stabilizes patient holding their left knee. 5. Then patient relaxes for 2 seconds and then practitioner uses PA on the ilium with their right hand 6. Repeat 3 to 5 times and this can be done with lumbar spine as well. Prone PA Unilateral Sacrum MET with Breathing Assist and hip internal rotation Diagnosis Seated flexion test: Positive left Left sacral sulcus: Dorsal, posterior

Left ILA: Ventral, anterior Spring test: Positive Sphinx test: Increased asymmetry Technique 1. The patient lies prone. 2. The index finger of the physician's cephalad hand palpates the patient's left sacral sulcus while the caudad hand abducts and adducts the patient's left leg to find the loosest-packed position for the left sacroiliac joint (usually about 5 degrees of abduction).

− The physician internally rotates the patient's left hip and instructs the patient to maintain this abducted, internally rotated position throughout the treatment.

− The hypothenar eminence of the physician's cephalad hand is placed on the patient's left sacral sulcus and is reinforced by the caudad hand.

5. The physician's hands exert a sustained anterior (downward) force on the patient's left sacral sulcus to rotate the sacrum anteriorly, and to disengage the lumbosacral joint caudally. 6. The patient inhales and then exhales forcefully. During exhalation, the physician's hands encourage sacral flexion. 7. The patient inhales slowly. During inhalation, the physician's hands increase the anterior force on the sacral sulcus to prevent sacral extension. 8. Steps 5 to 7 are repeated five to seven times. 9. The diagnostic parameters of the dysfunction are reevaluated to determine the effectiveness of the technique.