Dr. Henry Lok, DO.

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Fred Mitchell, Sr. contributed by developing a plan of diagnosis and treatment that he called muscle energy.

Muscle energy technique has been defined as a form of osteopathic manipulative 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 counterforce (1).

Muscle energy techniques involve the patient’s active cooperation to contract a muscle or muscles, inhale or exhale, or move one bone of a joint in a specific direction relative to the adjacent bone (1).

The muscle energy approach is indicated in the presence of somatic dysunfction found on physical exam.

https://www.muscle-energy.com/advanced-met.html

Muscle energy technique cannot be used if the patient is:1) In a coma

2) Uncooperative

3) Too young to cooperate

4) Unresponsive / Deaf

Post-isometric relaxation and joint mobilization using muscle force muscle energy techniques should not be done on a patient who are frail, or that could be compromised by adding active muscle exertion.

Oculocephalogyric reflex techniques are contraindicated in anyone who has undergone recent eye surgery or has recently sustained trauma to the eye (1).

Minor complications such as post treatment muscle or joint soreness tend to be self-limiting and resolve within 24 to 36 hours without additional treatment.

Use of inappropriately excessive force has been reported to result in the complications of tendon avulsion from bone and rib fractures (1).

Inappropriate application of oculocephalogyric reflex cervical range of motion muscle energy techniques has resulted in anterior chamber intraocular hemorrhage in a single patient postcataract removal and lens implant surgery (1).

https://stretchcoach.com/articles/sore-muscles/

Diagnosis

An inaccurate diagnosis may lead to inappropriate treatment and does not achieve the desired improvement in the patient’s condition.

Even if a segmental diagnosis is accurate, complicating factors and the entire clinical picture of the patient need to be considered (1).

https://thedo.osteopathic.org/2017/12/dispelling-myths-omt/

Localization

The localization of force is more important than the intensity of force (1).

Localization depends on the physician’s palpatory perception of movement or about a specific articulation.

Monitoring the localization of forces and confining the direction of force by the diagnosed muscle group to the level of somatic dysfunction are important to achieve desired results (1).

https://www.csuchico.edu/~sbarker/spine/spinealt/page11.html

Amount of Force

Using excessive force is the most common mistake made in applying muscle energy technique.

Excessive force recruits other muscles to assist in stabilization of the body part being treated and may completely negate the intent of the technique (1).

Excessive forces used on older patients may result in tendon avulsion from bone (1).

https://www.physio.co.uk/treatments/physiotherapy/manual-therapy/muscle-energy-techniques.php

Asymmetrical Muscle Strength

If there is asymmetry of range of motion occurs, consider and test the possibility of asymmetrical strength. Some ranges of motion may be asymmetrical because of weakness of a group of muscles rather than the shortness of the antagonist group (1).

If asymmetry of muscle strength is present, employ a method to increase the strength of the weak muscle group (1).

Progressive resistance exercises are used to strengthen weakened muscle groups. If weakness and shortness occur in different muscle groups but on the same side, attend to the shortness first (1).

There are nine different physiologic principles of muscle energy technique:

1. Joint mobilization using muscle force 2. Respiratory assistance 3. Oculocephalogyric reflex 4. Reciprocal inhibition 5. Postisometric relaxation6. Crossed extensor reflex 7. Isokinetic strengthening 8. Isolytic lengthening 9. Using muscle force to move one region of the body achieve movement of another bone or region

Goal: To accomplish restoration of joint motion in an articular dysfunction.

Physiologic Basis: Distortion of articular relationships and motion loss results in a reflex hypertonicity of the musculature crossing the dysfunctional joint. This increase in muscle tone tends to compress the joint surfaces, and results in thinning of the intervening layer of synovial fluid and adherence of the joint surfaces. Restoration of motion to the articulation results in a gapping, or resetting of the distorted joint relations with reflex relaxation of the previously hypertonic musculature (1).

Force of Contraction: Maximal muscle contraction that can be comfortably resisted by the physician (30 to 50 lb of pressure) (1).

Goal: To produce improved body physiology using the patient’s voluntary respiratory motion.

Physiologic Basis: The muscular forces involved in these techniques are generated by breathing. This may involve the direct use of the respiratory muscles themselves, or motion transmitted to the spine, pelvis, and extremities in response to respiration motions. The physician usually applies a fulcrum against which the respiratory forces can work (1).

Force of Contraction: Exaggerated respiratory motion (1).

Goal: To affect reflex muscle contractions using eye motion.

Physiologic Basis: Functional muscle groups are contracted in response to voluntary eye motion on the part of the patient. These eye movements reflexively affect the cervical and truncal musculature as the body attempts to follow the lead provided by eye motion. It can be used to produce very gentle postisometric relaxation or reciprocal inhibition (1).

Force of Contraction: Gentle.

Contraindications: Fracture(s), dislocation, or moderate to severe segmental instability in the cervical spine. Neurologic symptoms or signs on rotation of the neck. Recent eye procedures.

Goal: To lengthen a muscle shortened by cramp or acute spasm.

Physiologic Basis: When a gentle contraction is initiated in the agonist muscle, there is a reflex relaxation of that muscle’s antagonistic group.

Force of Contraction: Very gentle (ounces, not pounds of pressure).

Goal: To accomplish muscle relaxation.

Physiologic Basis: Mitchell Jr. postulated that immediately after an isometric contraction, the neuromuscular apparatus is in a refractory state during which passive stretching may be performed without encountering strong myotatic reflex opposition. All the operator needs to do is resist the contraction and then take up the slack in the muscles during the relaxed refractory period. With muscle contraction, there may also be increased tension on the Golgi organ proprioceptors in the tendons; this inhibits the active muscle’s contraction (1).

Force of Contraction: Sustained gentle pressure (10 to 20 lb of pressure).

1. The physician positions the body part to be treated at the position of initial resistance. It is important that only the “feather edge” of the restrictive barrier is engaged for maximal efficacy of these techniques. The “feather edge” of the restrictive barrier is the point where the restrictive barrier is just beginning to be engaged or where the tissue tension is just palpable (1).

2. The physician instructs the patient about his or her participation and helps the patient to obtain an effective direction of movement for the limb, trunk, or head. The patient is instructed in the intensity and duration of the muscle contraction (1).

3. The physician directs the patient to contract the appropriate muscle(s) or muscle group (1).

4. The physician uses counterforce in opposition to and equal to the patient’s muscle contraction (1).

5. The physician maintains forces until an appropriate patient contraction is perceived at the critical articulation or area. This generally takes 3 to 5 seconds, but the duration varies with the size of the muscle being treated (1).

6. The patient is directed to relax by gently ceasing the contraction while the physician simultaneously matches the decrease in patient force (1).

7. The physician allows the patient to relax and senses the tissue relaxation with his or her own proprioceptors (1).

8. The physician takes up the slack permitted by the procedure. The slack is allowed by the decreased tension in the tight muscle, allowing it to be passively lengthened. The physician notes increased range of motion (1).

9. Steps 1 to 8 are repeated three to five times until the best possible increase in motion is obtained. The quality of response often peaks at the third excursion, with diminishing return thereafter (1).

10. The physician reevaluates the original dysfunction (1).

Type I- rotation and sidebending coupled in OPPOSITE directions.

https://www.youtube.com/watch?v=OF2koDeFbRQ

Type II- rotation and sidebending coupled in SAME directions.

https://www.youtube.com/watch?v=OF2koDeFbRQ

https://www.youtube.com/watch?v=OF2koDeFbRQ

• Diagnosis is in the position of ease: NSRRL

• How would you treat this somatic dysfunction?

Treatment Position = NSL RR

OMT Manual: Muscle Energy Technique

• Diagnosis is in the position of ease: ERLSL

• How would you treat this somatic dysfunction?

Treatment position = FRRSR

OMT Manual: Muscle Energy Technique

• Diagnosis is in the position of ease: FRLSL

• How would you treat this somatic dysfunction?

Position = ERRSR

OMT Manual: Muscle Energy Technique

• Diagnosis is in the position of ease: L2-4 NSLRR

• How would you treat this somatic dysfunction?

Treatment Position = NSR RL

OMT Manual: Muscle Energy Technique

• Diagnosis is in the position of ease: L2-4 ESLRL

• How would you treat this somatic dysfunction?

Treatment Position = FSR RR

OMT Manual: Muscle Energy Technique

• Treat with the patient lying on the side of the rotational diagnosis.

• Type II Extended: Flex the patient’s knees and hips to the segment, then add additional hip Flexion

• Type II Flexed: Flex the patients knees and hips to the segment, then induce extension at the segment by pushing the patient’s knees and hips posteriorly.

• Not monitoring motion of the joint.

• Not allowing patient to totally relax before repositioning into new restrictive barrier.

• Forgetting to Re-test.

http://www.tsitherapy.com/metinfo.html

Muscle energy techniques are great techniques for the treatment of somatic dysfunction. They are often combined and augment with other techniques.

Muscle energy techniques can be useful in creating the soft tissue relaxation, which is necessary to accomplish HVLA Thrust techniques. Many muscle energy and HVLA techniques are done in the same position, so no repositioning of the patient is required (1).

Muscle energy techniques are used to lengthen muscles shortened by both hypertonicity and contracture. Once the hypertonicity has been eliminated using the muscle energy technique, the practioner can apply direct myofascial release techniques to the passive connective tissue elements of that same muscle (1).

Muscle energy techniques are used to balance muscle tone, strengthen weakened musculature, improve symmetry of articular motion, and enhance the circulation of body fluids (1).

1. Chila, A. G. (2011). Foundations of osteopathic medicine. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.2. Advanced MET. (n.d.). Retrieved from http://www.muscle-energy.com/advanced-met.html3. Customers. (2016, October 06). Home. Retrieved from https://stretchcoach.com/articles/sore-muscles/4. Dispelling the myths about OMT. (2017, December 07). Retrieved from https://thedo.osteopathic.org/2017/12/dispelling-myths-omt/5. (n.d.). Retrieved from https://www.csuchico.edu/~sbarker/spine/spinealt/page11.html6. Muscle Energy Techniques. (n.d.). Retrieved from https://www.physio.co.uk/treatments/physiotherapy/manual-therapy/muscle-energy-techniques.php7. EducatedPT. (2017, January 23). What are Fryette's 3 Laws? Retrieved from https://www.youtube.com/watch?v=OF2koDeFbRQ8. (n.d.). Retrieved from http://www.tsitherapy.com/metinfo.html