Assistant Professor

MPT (Musculoskeletal)

Rama University

 Kanpur, Uttar Pradesh, India 

MET is a type of osteopathic manipulative treatement used in osteopathic therapy, physical therapy, massage therapy and occupational therapy. - A form of diagnosis and treatment in which the patient's muscles are actively used on request, from a precisely controlled position, in a specific direction, and against a distinctly executed physician counterforce.

History of Muscle Energy Technique

Dr. TJ Ruddy: first osteopathic doctor to use muscle energy in the1940’s and 1950’s, he referred to it as resistive duction, which he defined as a series of muscle contractions againstresistance; used techniques mainly in the C‐1spine.

Dr. Fred Mitchell, Sr.: has been titled the Father ofmuscle energy.He took Dr. Ruddy’s principles and incorporated them into manual medicine to any body region/ articulation. He believed that pelvis was the key to musculoskeletal system. Dr. Phillip Greenman:Believed that any articulation which can be moved by voluntary muscle action can be it  influenced by muscle energy techniques (MET); MET can be used for: lengthening strengthening decreasing local edema .  Dr. Sandra Yale: stated that MET was safe enough for use with fragile and severely ill, or on a spasm from fall.

Effects of Met

1. There are two main effects when performing muscle energy Physiological properties

2. Structure of the muscle fibers-  Intrafusal and Extrafusal muscle fibers

3. Neurological properties

4. Muscle spindle

5. Motor neurons : Afferent and Efferent motor neurons

Location of MS and GTO

Function of GTO

 

Structure of the Muscle fibre

Indications

1. It uses isometric or isotonic contractions as a way of –

i. Lengthening tight muscle;

ii. Strengthening weak muscle;

iii. Mobilising joints

iv. Releasing the trigger points

v. Relieving congestion in the tissues (circulatory functions and helps to reduce Odema)

Contra-Indications

1. Acute musculoskeletal injuries

2. Unstable or fused joints.

3. Unset or unstable fractures,

4. Avulsion Injuries,

5. Severe  osteoporosis

6. Open wounds, or

7. Metastatic disease.

Additionally, because these techniques require active patient participation, they are inappropriate for any patient that is unable to cooperate.

Precautions

1. Unknown pathology

2. Stress fractures  

3. Strains, infections or diseases causing musculoskeletal pain

4. Osteoporosis or tumors in the area of treatment.

Treatment Principles

1. Isometric contraction

i. Distance between the origin and insertion of the muscle is maintained with a fixed amount of tension in the muscle.

ii. Resets the muscle proprioceptors as the muscle lengthens.

Two forms of isometric MET –

i. Post-Isometric Relaxation (PIR) and

ii. Reciprocal Inhibition (RI).

2.a.  Concentric Isotonic Contraction

i. Origin and Insertion of the muscle approximate.

ii. Useful in building muscle strength.

iii. Contraction occurs when the therapist’s counterforce is weaker than the contractile force allowing some movement to occur in the direction of the muscle force, therefore shortening and strengthening the muscle.

2. b. Eccentric Isotonic Contraction (Isolytic)

i. Origin and Insertion of the muscle are separated.

ii. Resistance overcomes the tension in the muscle so the muscle lengthens.

iii. Occurs when the therapist’s counterforce is stronger than the contractile force of the muscle and stretching and lengthening occur in the muscle tissue.

iv. This results in a change to the muscles shortened structure and improves elasticity and circulation.

The Physiology of How The Met Techniques Work

1.a. Post Isometric Relaxation-

i. PIR refers to the subsequent reduction in tone of the agonist muscle after isometric contraction.

ii. This occurs due to stretch receptors -Golgi tendon organs(GTO), located in the tendon of the agonist muscle.

iii. These receptors react to over- stretching of the muscle by inhibiting further muscle contraction. This is naturally a protective reaction, preventing rupture and has a lengthening effect due to the sudden relaxation of the entire muscle under stretch.

iv. The afferent nerve impulse from the Golgi tendon organ enters the dorsal root of the spinal cord and meets with an inhibitory motor neuron.

v. This stops the discharge of the efferent motor neurone’s impulse and therefore prevents further contraction, the muscle tone decreases, which in turn results in the agonist relaxing and lengthening.

vi. The Golgi tendon organs react to both passive and active movements and therefore passive mobilisation of a joint may sometimes have as good an effect on relaxing the muscles.

PIR

2. Reciprocal Inhibition

1.RI refers to the inhibition of the antagonist muscle when isometric contraction occurs in the agonist.

2.This happens due to stretch receptors within the agonist muscle fibres – Muscle Spindles.

3.Muscle spindles work to maintain constant muscle length by giving feedback on the changes in contraction.

4.Due to stretch muscle spindles discharge nerve impulses, which increase contraction, thus preventing over-stretching.

5.The spindles discharge impulses which excite the afferent nerve fibres or the agonist muscle, they meet with the excitatory motor neurone of the agonist muscle (in the spinal cord) and at the same time inhibit the motor neurone of the antagonist muscle which prevents it from contracting.

6.Results in the relaxation of the antagonist therefore is called reciprocal inhibition.

7.When the agonist stops contracting against force, the muscle spindles stop discharging and the muscle relaxes.

RI

Techniques According to the Contractions

1.Isometric‐ Utilizing Autogenic Inhibition

i. Operator Push through the barrier of restriction, utilizing   autogenic inhibition of the target muscle.

ii. Frequency: 3‐5 reps -Intensity:  Operator and patient’s forces are matched.

iii. Patient provides  on effort at 20% of their strength increasing to no more than 50% on subsequent contractions.

iv. Duration: 4‐10 seconds initially, increasing up to 30 seconds in  subsequent contractions.

2.a.Concentric Isotonic Contraction

i. Origin and Insertion of the muscle approximate. Useful in building muscle strength. -Contraction occurs when the therapist’s counterforce is weaker than the contractile force allowing some movement to occur in the direction of the muscle force, therefore shortening and strengthening the muscle.

2.b.Eccentric Isotonic Contraction (Isolytic)

i. Origin and Insertion of the muscle are separated. -Resistance overcomes the tension in the muscle so the muscle lengthens.Occurs when the therapist’s counterforce is stronger than the contractile force of the muscle and stretching and lengthening occur in the muscle tissue.This results in a change to the muscles shortened structure and improves elasticity and circulation.

The Physiology Of How The Met Techniques Work?

1. Post Isometric Relaxation-

1. PIR refers to the subsequent reduction in tone of the agonist muscle after isometric contraction.This occurs due to stretch receptors -Golgi tendon organs(GTO), located in the tendon of the agonist muscle. These receptors react to over- stretching of the muscle by inhibiting further muscle contraction.This is naturally a protective reaction, preventing rupture and has a lengthening effect due to the sudden relaxation of the entire muscle under stretch.The afferent nerve impulse from the Golgi tendon organ enters the dorsal root of the spinal cord and meets with an inhibitory motor neuron.

2. This stops the discharge of the efferent motor neurone’s impulse and therefore prevents further contraction, the muscle tone decreases, which in turn results in the agonist relaxing and lengthening.The Golgi tendon organs react to both passive and active movements and therefore passive mobilisation of a joint may sometimes have as good an effect on relaxing the muscles.

 

2. Reciprocal Inhibition

1.RI refers to the inhibition of the antagonist muscle when isometric contraction occurs in the agonist.This happens due to stretch receptors within the agonist muscle fibres – Muscle Spindles. Muscle spindles work to maintain constant muscle length by giving feedback on the changes in contraction. Due to stretch muscle spindles discharge nerve impulses, which increase contraction, thus preventing over-stretching.

2.The spindles discharge impulses which excite the afferent nerve fibres or the agonist muscle, they meet with the excitatory motor neurone of the agonist muscle (in the spinal cord) and at the same time inhibit the motor neurone of the antagonist muscle which prevents it from contracting.

3.Results in the relaxation of the antagonist therefore is called reciprocal inhibition.

4.When the agonist stops contracting against force, the muscle spindles stop discharging and the muscle relaxes.

RI

Techniques According to the Contractions

1. Isometric‐ Utilizing Autogenic Inhibition

Operator Push through the barrier of restriction, utilizing   autogenic inhibition of the target muscle.

i. Frequency: 3‐5 reps -Intensity:  Operator and patient’s forces are matched.

ii. Patient provides  on effort at 20% of their strength  increasing to no more than 50% on subsequent contractions.

iii. Duration: 4‐10 seconds initially, increasing up to 30 seconds in  subsequent contractions.

2. Isometric‐ Utilizing Reciprocal Inhibition

i. Operator push through the barrier of restriction,utilizing reciprocal inhibition which causes relaxation the target muscle.

ii. Frequency: 3‐5 reps  Intensity: Operator and patient’s forces are matched.

Patient provides  on  effort at 20% of their strength increasing to no more than 50%  subsequent contractions.

iii. Duration: 4‐10 seconds initially, increasing up to 30 seconds in subsequent contractions.

Isotonic Concentric‐ Utilizing Autogenic Inhibition

i. Target muscle is allowed to contract with some resistance from the  operator. This technique utilizes autogenic inhibition of the target  muscle. Frequency: 5‐7 reps .

ii. Intensity: Patient’s force  is greater than operator’s resistance.Patient  utilizes maximum effort and force is built slowly, not suddenly.

iii. Duration- 3-4 seconds.

Isotonic Eccentric‐Utilizing Reciprocal Inhibition

1.Target muscle is prevented from contracting by superior operator force, utilizing reciprocal inhibition which causes relaxation of the target muscle.  

Frequency: 3‐5 reps as long as tolerable .

Intensity: Operator’s force is greater than patient’s force. Patient utilizes maximal force  initially and subsequent contractions build towards patient’s maximal force. Duration: 2‐4 seconds

Factors

1.a. Common Patient Errors

i. Contraction too hard

ii. Contraction in Wrong Direction

iii. Contraction for too short a time

iv. Does not relax fully following contraction

1.b. Common Operator Errors

i. Inaccurate control of joint position

ii. Counterforce in the incorrect direction

iii. Not giving the patient accurate instructions

iv. Moving the joint to a new position too soon after the  contraction stops

v. Good results of MET depend on:  accurate diagnosis, appropriate levels of force, and sufficient  localization.

vi. Poor results of MET are attributed to: inaccurate diagnosis, improperly localized force, or forces  that are too strong.

Simple Guidelines to Follow MET

1. No pain should be caused byMET

2. Keep contractions light (20-30% of strength)

3. Communicate effectively and ensure patient is not     experiencing discomfort at any time

4. Client can help to locate tissue tension or restriction   barrier

5. Never over-stretch

Related Articles For Results While Using The Technique(MET)

1. Fiona Ballantyne,Gary  Fryer et al- The Effect Of Muscle Energy Technique On Hamstring Extensibility: The Mechanism Of Altered Flexibility

2. Purpose – To investigate the effectiveness of MET in increasing passive knee extension.

40 asymptomatic subjects -control or experimental groups. Hamstring muscle stretched to the onset of discomfort by passive knee extension.

Knee range of motion -recorded with digital photography and passive torque recorded with a hand-held dynamometer.

The experimental group received MET to the hamstring muscle, after which the resistance to stretch and the ROM were again measured. The knee was extended to the original passive torque and the angle at the knee recorded. If the onset of discomfort was not produced at this angle, the knee was further extended and the new angle was recorded.

Results-significant increase in ROM observed at the knee (p<0.019) following a single application of MET to the experimental group. No change was observed in the control group.

When an identical torque was applied to the hamstring both before and after the MET, no significant difference in range of motion of the knee was found in the experimental group.

Conclusions-MET produced an immediate increase in passive knee extension. This observed change in ROM is possibly due to an increased tolerance to stretch as there was no evidence of viscoelastic change.

To determine if a 4 week treatment period of (MET) would significantly increase cervical flexion, extension, side bending, and rotation in asymptomatic persons with limited range of motion (ROM). 18 subjects for the study following screening for neck ROM limitation. These subjects were then random assigned to either a control or MET group. A series of six, mixed, two-way analyses variance (ANOVA) were used to test for significant cervical ROM increases.

The two factors examined were Group (MET vs. control) and Test (pre vs. post). Significant interactive effects for both left and right rotation were found (both F's > 4.8 and p's < 0.05) indicating a significantly greater ROM in the MET group. Treatment groups showing an increase between pre-test and post-test. These results support MET as an effective technique for increasing cervical range of motion.

References

Text book of THE PHYSIOLOGY AND APPLICATION OF MUSCLE ENERGY TECHNIQUES by Gill Webster.

1. John Gibbons-text book of Muscle Energy, Issue 97   July 2011

2. Short-Term Effect of Muscle Energy Technique  on Pain in Individuals with Non-Specific  Lumbopelvic Pain: A Pilot Study Noelle M. Selkow, Terry GriNdSTaff,Spine Journal

3. Grubb ER, Hagedorn EM, Book of Muscle Energy  Technique.

4. A comparison of two muscle energy techniques for increasing flexibility of the hamstring muscle group.Madeleine Smith,B.Clin.Sc, Gary Fryer Journal of Body work and movement therapiesOctober 2008, Pages 312–317

5. Text book of Grieve’s Modern Manual Therapy by DG Lee.

6. Textbook of Human Physiology by AK Jain,3 rd Edition

7. The Effects of Muscle Energy Technique on Cervical Range of Motion by -Kimberly, Rousselle, John Journal of Manual & Manipulative Therapy Volume 2, Number 4, 1994 , pp. 149-155