Muscle Energy Technique- An Overview

Loren H. "Bear" Rex, DO Edmonds, Washington

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I";., n recent years we have seen a resurgence in the use of manual techniques to treat disorders of the musculoskeletal system. Not only has this occurred in the 0s- teopathic profession but in many other fields as well. With the real- ization that surgery is not indi- cated for many soft tissue problems, manual approaches such as muscle energy technique (MET) are starting to dominate the thinking in the field.

Not so long ago the allo- pathic/physical therapy/athletic training model consisted mainly of applying various forms of heat, cold, electricity, whirlpool baths, taping, and therapeutic exercise under the direction of a physician. Today athletic therapists are able to explore and utilize new and var- ied forms of treatment, and MET has been applied to athletic inju- ries with great success.

While MET is primarily osteo- pathic in nature, it has close par- allels in the field of physical therapy under the heading of "proprioceptive neuromuscular fa- cilitation" (PNF). Many of the same principles, concepts, and theories apply to both.

Since most therapists may al- ready be familiar with PNF, it should be fairly easy for them to transfer the skill and integrate both approaches into an even more effective treatment modality.

Muscle energy as an osteo- pathic technique is usually cred- ited to Fred L. Mitchell, Sr., DO (1909-1974). However, it can be traced to several doctors of oste- opathy (DO), including Paul Kimberly, Thomas J. Ruddy, Karl Kettler, and Fred L. Mitchell, Jr. Within the allopathic systeni of healing, Herman Kabat, MD, Margaret Knott, PT, and Margaret Rood are commonly credited with being instrumental in the development of PNF.

Somatic Dysfunction as a Cause of Pathology

All treatment is ultimately directed to the correction of "somatic dys- function" of some kind. Somatic dysfunction can be defined as an impaired or altered function of related components of the body. - This impairment may involve skeletal, joint, and/or myofascial components.

The related vascular, lym- phatic, and neural elements of the body may also be involved. Therefore somatic dysfunction may involve one or more seg- ments of the spinal column, pelvis, or extremities. The dys- function may produce limited motion, associated muscle in- volvement, pain, and autonomic involvement such as swelling and edema. Remote structures that

are embryologically related may be affected.

Many models have been de- veloped to deal with somatic dys- function, but MET is unique among these in that it has proven effective in both acute and chronic conditions. This is be- cause MET is based on feedback loops between the extrafusal and intrafusal fibers that set the muscle spindles for a predicted need and monitor the contrac- tion to assure that it has been ac- complished correctly.

When there is a misreading of this information, it prohibits the muscle from relaxing to a length that is balanced with its antagonist. This in turn limits the joint's ability to return to a neu- tral position.

Muscle Energy Assessment Concepts

Although MET is useful for all joints except the cranial sutures, we will look at avertebral segment that has undergone strain and can- not return to a neutral position. Multiple theories have been pro- posed over the years as to how, when, and why muscle energy is used, but this article is based on the Ursa Foundation concept that MET is a gentle, sophisticated spindle technique that uses precise positioning and light contractions.

0 1996 Human Kinetics

38 Athlehc ;87zea apy Eday November 1996

Muscle energy uses standard biomechanical rules of motion for vertebrae. In the osteopathic com- munity these are referred to as Fryette's Laws:

A vertebral segment that is in neutral will sidebend to one side and rotate to the oppo- site side. This is normal adap- tive behavior and is the body's attempt to move the spine closer to the midline for sta- bility. When the involved seg- ments cannot return to neu- tral and stay in this position, it is called a Type 1 group adaptive lesion.

2. A vertebral segment that has the superior part flexed or extended prior to the initia- tion of motion will sidebend and rotate to the same side. This is normal behavior unless some traumatic event has locked the segment in this position. This case is called a Type 2 single segment trau- matic lesion.

3. Law 3 states that any intro- duction of motion results in a decrease in all remaining motions in the segment.

Although there are different ways to test the position of verte- brae, I prefer to use the transverse processes to make decisions on position in space. This calls for examining the vertebrae in all three ranges of motion. The deci- sion to use MET is usually based on an examination of the spine and finding that part of it is dys- functional. This could either be a group of, say, three or more verte- brae that are found to be in a neu- tral position, or a segment that upon motion testing does not move fully or correctly.

The basic rule for all verte- brae is that motion should be free in three planes: flexion/exten- sion, rotation, and sidebending. Therefore a vertebra should be able to go completely into flexion, stop in neutral, and go into exten- sion without any rotation. If ro- tation occurs with testing, the vertebra must be treated to re- store full motion.

When deciding to use MET, you are assuming that the reason for these restrictions is the fact that there are some muscles with excessive tension forcing the ver- tebra to be held in an incorrect position so that it cannot return to neutral.

Naming a Ve~eQraB Restriction

The examiner places the thumbs over the transverse processes of one vertebra to note how it moves in relation to the vertebra below. Remember, you need to examine in all three positions to establish an accurate assessment.

On motion testing, avertebra that fails to extend correctly will rotate to one side because it is be- ing held in aflexed position. Since lesions are named for the position in which they are held, we would say the superior vertebra is flexed. We then name the lesion for the most posterior transverse process.

Assume that the vertebra is rotated to the right. This would make the right transverse process move posteriorly compared to the left side. Thus it would be named rotated right. Since it is a single segment, it is a Type 2 lesion, and sidebending would be to the same side. Thus the segment would have a positional diagnosis offlexed rotated right and sidebent right.

The motion restriction of this vertebra is that it cannot extend, rotate left, or sidebend left. If it could do these motions, it would have stayed in the midline and not rotated. A vertebra that is held extended would react just the o p posite. In other words, it would rotate in flexion along with sidebending and rotating to the same side.

A vertebra that is held in a neutral lesion will be part of a group of three or more and able to move freely into flexion or ex- tension, but not be able to stop in neutral without rotating. In this case the sidebending and rotation will always be opposite. Therefore if several segments of the spine were all rotated to the right when the spine was in a neutral position, we could state the positional diag- nosis of the lesion as neutral sidebent left and rotated right.

Muscle energy techniques attempt to return these to their pre-injury state by a series of pre- cisely controlled contractions after positioning the patient in a position of greatest laxity and maximum separation of the in- volved joint. This is often referred to as the "loose pack" or resting position.

MET Concept

Muscle energy treatment is based on the concept that light, precisely controlled isometric muscle con- tractions will reset the gamma gain to a lower and more appropriate level that will allow the vertebral segment to assume a neutral posi- tion. Therefore you are not at- tempting to "pull" some vertebra into a different position by means of a hard contraction, since that type of contraction would only

lock up the joint and still fail to reset the intrafusal fibers.

MET is based on two basic moves on the part of the practitio- ner. The ability to feel tissue ten- sion changes so that the segment can be placed in a loose pack po- sition in all three planes and the treatment can be controlled with a series of light contractions.

Although there are many more things to learn about MET, it has stood the test of time and become a mainstay in the reper- toire of the truly competent manual practitioner. It is a manual technique that can be easily incor- porated into the athletic training setting. It is quick and effective and can be used by athletic thera- pists in both game and training room situations. It is very reliable because of its specificity for mus- culoskeletal dysfunction.

Although this discussion has been limited to the vertebral col- umn, there are many areas where MET is indicated or would be the treatment of choice. I have found it excellent for treating the spine; it is the preferred treatment in problems involving the pelvis, es- pecially iliosacral restrictions. Re- member, when performing MET you and the patient both need to be relaxed and in a balanced posi- tion for best results.

Effective application of MET involves:

1. The practitioner's precise localization of the joint to be treated;

2. The practitioner's specific direction to the patient;

3. The patient's active contrac- tion;

4. The practitioner's monitoring

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of controlled contraction in- tensity;

5. The practitioner's distinct counterforce to make the con- traction isometric;

6. A series of three contractions at the loose pack position of all three planes.

I hope that this picture of muscle energy concepts, though obviously incomplete, will encour- age athletic therapists to broaden the scope of their approach to treating athletic injuries related to the spinal muscles.

Loren H. "Bear" Rex has more than 25 years of clinical experience. As president and a founder of the Ursa Foundation, he is re- nowned for his contribution to manual medi- cine through his lectures and course presenta- tions of manual techniques. He has a private practice in Edmonds, WA.

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40 Athle6c nzmapy Today November 1996