Clinical Thinking - Muscle Energy Technique
Many manual therapists may not realise the intimate relationship that exists between the central-peripheral nervous system and soft-tissue release. This understanding of, and the ability to effect change comes in a large part with understanding of the sensory-motor system and in particular sensory-motor receptors. The ability to manipulate these receptors is at the heart of all soft-tissue facilitated by manual or massage therapists.
Another premise this author would like to make is that lower force techniques often have greater effect than higher force techniques due to the sophistication of the sensory-motor relationship between the two elements of the autonomic nervous system, parasympathetic and sympathetic. What this bodes for the therapist is the ability to create significant change using less effort with less pain for all parties in the delivery of manual and massage therapy.
I will attempt a broad canvass to illustrate my main points.
Concepts & Theory of Afferent Receptors
The last decade has seen significant information and research regarding mechanoreceptors and proprioceptors. This information seen through eyes within the myofascial community as proof that there exists in myofascia more receptors than previously understood. Schleip in his important contribution with his Fascial Plasticity articles Parts 1 and 2 in the Journal of Movement and Bodywork Therapies April 2003, explained that the mechanical properties alone cannot explain the responsiveness of manual therapy manipulation towards myofascia. “Fascia is densely innervated by mechanoreceptors which are responsive to myofascial manipulation. They are intimately connected with the central nervous system and specifically with the autonomic nervous system.”(1)
The concept regarding enabling afferent receptors to be manipulated and intimately entwined with the autonomic nervous system becomes a central premise for this article. Furthermore this author contends this knowledge combined with lower force application and lower force patient effort in the form of modified MET can and will have great significance towards resolving complicated soft-tissue presentations.
Global awareness in the form of myofascial lines of tension, but also nervous system discharge is necessary along with the understanding that all soft-tissue release is predicated on nervous system afferent sensory input. When using less force through the use of compression or light touch to surface or subcutaneous tissue, the practitioner stimulates afferent sensory information in the aforementioned types of mechanoreceptors. This in turn creates a nervous system ‘discharge’.
The observable parasympathetic discharge phenomena that is experienced by both the practitioner and client is usually parasympathetic effects such as changes in breathing or respiration, warmth sensation, tingling, borborygmus or ‘tummy rumbling’ or what is considered peristalsis activity, sudomotor changes including clamminess, sweating, changes in skin coloration including flushing response or ‘reddening’ of the face, a sense of ‘lightness’, ‘streaming’, tingling type sensations that indicate some form of flow. All of this autonomic discharge can precede soft-tissue change, thus is the potency of lighter touch. (2)
Erik Dalton has written many excellent articles over the years, one which has stood out for me was his Receptor Techniques article in the Massage Therapy Journal Winter 2004 in which he explains the reflexogenic effect that receptors have when manipulated. “Recent advances in nerve-staining techniques reveal the presence of tiny nerve receptors embedded in all myoskeletal tissues. These ongoing studies lead neuroscientists to conclude that ligaments, fasciae, discs and joint capsules:
Participate in normal neuromuscular reflexes, such as active balancing of the spine when walking and standing (proprioception).
Warn the brain of pain-producing stimuli that also may be causing tissue damage. Inform the brain of stresses and strains from tension, trauma and poor posture.
Joint dysfunction plays an important role in the development of muscle spasm and related myofascial pain syndromes. Researchers do not know if impaired muscle function is the primary cause of joint dysfunction, or if the reverse holds true. However, a reflexogenic relationship exists between muscles and joints.”(3)
Let us examine this reflexogenic relationship from a nervous system perspective.
Micheal Shea noted Biodynamic Craniosacral instructor, PH.D Somatic Psychology & Advanced Ceritified Rolfer contended in 1995 that “all soft-tissue release is predicated on how the autonomic nervous system discharges its’ impulses.” That this continuum or shunting of biological sensory-motor information between the parasympathetic, ‘rest and repose’ or sympathetic, ‘flight or fight’ is ongoing.
We know this from the origins of the stress response theory originally promulgated by W.B. Cannon in 1915 by coining ‘flight or fight’ and then expanded in his 1932 writings in Wisdom of the Body developed the concept of homeostasis of the body. Hans Seyle then furthered Cannon’s homeostasis work in the 1950’s with his General Adaptation Syndrome (GAS) and his theories on stress.
Selye conceptualized the physiology of stress as having two components: a set of responses which he called the "general adaptation syndrome”, and the development of a pathological state from ongoing, unrelieved stress. Selye discovered and documented that stress differs from other physical responses in that stress is stressful whether one receives good or bad news, whether the impulse is positive or negative. He called negative stress "distress" and positive stress "eustress". The system whereby the body copes with stress, the hypothalamic-pituitary-adrenal axis (HPA axis) system, was also first described by Selye. He also pointed to an "alarm state", a "resistance state", and an "exhaustion state", largely referring to glandular states. Later he developed the idea of two "reservoirs" of stress resistance, or alternatively stress energy. (4)
How does this information regarding stress pertain to clinical practice and manipulating sensory-motor receptors? Shea (1995) contends that every time we lay our hands on an individual we are through touch application affect and access this reservoir of stress. We can simply effect it by realizing ‘rest and respose’ is a parasympathetic state favorable to the body and the release of soft-tissue. This state also is important in the relaxation of the body, but also in the ability to change tone and tension in corresponding soft-tissue. (5)
In Fascial Therapy we use what is called the Two Point. This technique is the use of light touch with two hands placed strategically in areas on the body to first and foremost facilitate a parasympathetic effect. Two Point is used for other applications as well. For our purposes the reflexive effect allows the practitioner through parasympathetic response to facilitate soft-tissue change.
Let us return to this reflexogenic relationship. If the premise is of clinical significance, then knowledge of how receptors responding to lighter tactile stimulation as we monitor flux between sympathetic and parasympathetic has strong import.
Let us examine some of the typical receptors manual/massage therapists encounter.
Dalton states, “Receptors detect sensory stimuli such as touch, pain, heat, sound, light, and cold, and communicate this information to the central nervous system. An efficient neurological feedback system then informs the brain of changes in the person’s overall body environment. Sensory receptors of greatest concern to massage therapists can be classified according to the mechanism of their actions. Besides GTOs and muscle spindles, these include mechanoreceptors, thermoreceptors, nociceptors, electromagnetic receptors, and chemoreceptors.”
This table was extracted from Daltons article.
GTO = Golgi tendon organ
MCR = Mechanoreceptor
NOC = Nociceptor
CMR = Chemoreceptor
SPD = Spindle
Golgi tendon organs: Measure tension buildup in muscles. GTOs are found in a series within muscle fibers, and are stimulated by both passive and active muscular contraction. When tendon tension becomes extreme, the inhibitory effect from the GTO can be so great that there is a sudden relaxation of the entire muscle under stretch.
Mechanoreceptors: All three types of mechanoreceptors are activated by mechanical pressure from distortions in facet joint capsules, ligaments, discs and fascia. Mechanoreceptors, by nature, respond to loads (stretching or compression) placed on the tissues in which they lie.
Nociceptors: Commonly regarded as pain generators, these receptors warn the brain of the possibility of tissue injury. Under normal circumstances, the nociceptive system is silent, which means it is not receiving enough sensory stimuli to elicit a painful sensation.
But when adequately stimulated, nociceptors fire continually in a nonadapting way until the stimulus is removed. There are three types of stimuli that excite nociceptors: mechanical, thermal and chemical. Prolonged nociceptive irritation can cause clients’ bodies to twist and distort in an effort at pain avoidance.
Unfortunately, these distorted postures can be relearned as normal, leading to conditions called neuroplasticity, reflex entrainment. or spinal learning.
Chemoreceptors: Receptors that become activated by a buildup of chemical substances. Hyperexcited chemoreceptors react by flooding the spinal cord with noxious afferent stimuli. Toxic waste byproducts from prolonged tissue damage cause inflammation. Fibrin deposition in muscles, ligaments, joint capsules and fasciae occurs as the inflammation dries.
Muscle spindles: The muscle spindle, the third-most-complex sensory organ, after the eyes and ears, is the receptor responsible for the stretch reflex or myotatic reflex arc. Muscle spindles’ parallel arrangement within muscle fibers allows them to\ respond to passive muscle stretch, but they cease to discharge if the muscle contracts isotonically. (6)
Schleip in his Fascial Plasticity articles looked at the receptors located in myofascia. He found through various studies that “only less than 10% of the Golgi receptors are found wholly within tendon. The remaining 90% are located in the muscular portions of myotendinous junctions, in the attachment transitions of aponeuroses, in capsules, as well as in ligaments of peripheral joints (Burke and Gandeva 1990).”
Schleip also viewed the tactile stimulation response from Ruffini and Pacini corpuscles. Ruffini respond to tangential stretch and are found in ligaments, dura mater and tissues associated with stretch.
Pacini respond to rapid pressure changes and vibration. (7)
What do we make of this information? How can it assist us clinically to understand my earlier premise less force can create greater effect and patient effort can be harnessed to create quick soft-tissue change? I’ve stated that you can manipulate the sensory-motor apparatus through lighter force. This is always achieved due to the reflexogenic effect of the autonomic nervous system.
The key is to understand that all soft-tissue is orchestrated in relationship.
Vladimir Janda has influenced most of the most influential manual and massage therapists in the world today, crossing Bodywork, Rolfing, Chiropractic and Physiotherapy disciplines. Although quite modest, Janda is credited with discovering the upper cross syndrome which realized that muscles are in orchestrated balance with each other. Those prone to contracture are balanced with those prone to weakness or inhibition. Understanding these patterns led many to realize that function is often more important than structure. That function cause structural change. Of course many proponents would argue the opposite is true, and they would have sufficient grounds for contention. However the importance is in understanding all soft-tissue is related in causing muscular tension, not only are muscles in relationship in complex patterns but so is all soft-tissue.
Janda taught that muscle imbalance is based on neurophysiological principles of motor development and control. He believed that the sensorimotor system, composed of the sensory system and motor system, could not be functionally divided, and he emphasized the importance of proper proprioception. Janda describes the critical role of the sensorimotor system in controlling human movement as well as in mediating muscle imbalance syndromes. One of Janda's most important clinical contributions to evaluation and treatment was the recognition of muscular chains and their influence on pathology and function. (8)
Janda’s Chain Reaction
In patients with chronic musculoskeletal pain, the source of the pain is rarely the actual cause of the pain. In fact, Czech physician Karel Lewit noted, "He who treats the site of pain is often lost." Lewit's colleague Vladimir Janda conceptualized of musculoskeletal pathology as a chain reaction. He was a strong proponent of looking elsewhere for the source of pain syndromes, often finding symptoms distant from the site of the primary complaint. Janda noted that due to the interactions of the skeletal system, muscular system, and CNS dysfunction of any joint or muscle is reflected in the quality and function of others, not just locally but also globally.
Janda recognized that muscle and fascia are common to several joint segments; therefore, movement and musculoskeletal pathology are never isolated. He often spoke of muscle slings, groups of functionally interrelated muscles. Because muscles must disperse load among joints and provide proximal stabilization for distal movements, no movement is truly isolated. (9)
Indirect Osteopathic Approaches
Indirect technique in Osteopathy has long been utilized with the knowledge of the aforementioned relexogenic relationship. Its premise is to co-opt the reflexogenic mechanisms and harness these autonomically to create soft-tissue change. Whether using from osteopathic tradition Positional Release technique methods (PRT) such as Lawrence Jones’ Strain-Counterstrain SCS, Arthur Lincoln Paul’s Orthobionomy, or TJ Ruddy/Fred Mitchell Sr. Muscle Energy Technique MET.
These approaches have understood the potency derived from indirect technique, lighter touch, less force to stimulate the afferent receptors which in turn creates system ‘discharge via the autonomic nervous system.
MET Muscle Energy Technique- Some History
Dr. TJ Ruddy: was the first osteopathic doctor to use muscle energy in the 1940’s and 1950’s, he referred to it as rapid rhythmic resistive duction or ‘Pulsed MET’ which he defined as a series light rapid contractions of muscle (2 per second up to 20 contractions) against resistance; used techniques mainly in the C‐spine.
Dr. Fred Mitchell, Sr.: has been titled the father of muscle energy, he took Dr. Ruddy’s principles and incorporated them into manual medicine applied to all body regions or articulations. He believed the pelvis was the key to the musculoskeletal system. His first seminars were 2 days long in the 1950’s and 1960’s. He died in 1974 at which point his students continued his work by developing three courses for the American Academy of Osteopathy.
His son, Fred Mitchell, Jr., continued his work with The Muscle Energy Technique. Mitchell defined muscle energy as when the patient uses his/her muscles on request from a precisely controlled position in specific direction against distinctly executed counterforce.
Dr. Phillip Greenman: believed that any articulation which can be moved by voluntary muscle action can be influenced by muscle energy techniques (MET). MET can be used for: lengthening strengthening, decreasing local edema.
What I have found interesting is that muscle energy technique was not used solely and directly for muscles alone, but often for joints with the use of directional application. (10)
Leon Chaitow in his blog ‘Chaitow’s Chat’ went onto discuss comments made by Fred Mitchell Sr. son, Fred Mitchell Jr., who has gone onto continue and expand his father’s groundbreaking application of MET.
“The few who better understand the MET paradigm give their patient instructions that include a target for the patient’s effort. The patient may be instructed to “Make an eight ounce push with your forehead toward your left hip.” These detailed instructions are addressed (through imagery) to the global reflex systems which impact the somatic dysfunction being treated, with the goal of using imagery to re-program spinal cord internuncial neurons involved in the spinal effector mechanisms of core muscle and synergist participants.” (11)
Integrative Fascial & Soft-Tissue Release IFSTR rebranded to Fascial Therapy
Within the modality that I instruct, we attempt to understand the principles that underlie the use of indirect osteopathic methods, that is, how indirect technique harnesses autonomic response, along with the global nature of myofascial continuity, and the effect joint and ligament dysfunction has upon muscular tension, incorporating all of this in a method and application for technique.
Erik Dalton’s Activators & Enhancers
Let’s return to Dalton as I attempt to weave these disparate concepts together. Dalton realized that active and passive elements of client participation were needed to facilitate change to soft-tissue.
He dubbed these Activators, Co-activators and Enhancers. (12)
Activators: Application of fast-paced, muscle-stimulating maneuvers using fingers, fists and forearms to activate (turn on) weak muscles.
Co-activators: Application of sustained pressure to tendon GTOs, spinal ligaments and joint capsule mechanoreceptors to calm hypertonicity and to restore elasticity.
Enhancers: Combining active and passive client movements while deep GTO
You can continue to read his article in greater depth to understand how he was applying his manual therapy application utilizing AMP Active Movement Participation, as it is common within direct myofascial release and direct deep-tissue applications. Essentially Dalton is utilizing Janda’s theory with specifically targeted technique. For my purpose, I mused on how to achieve change utilizing indirect methods with specifically the enhancers Dalton discusses. One method is to utilize modified MET in the form of low force or ‘load’ resistance.
Enhancers & Patient Effort-Modifying MET
Combining patient effort as modified MET in this instance is modifying the effort patients resist a counter-force of 1-5%, to no more than 10% of maximum effort in resistance to facilitate or ‘enhance’ an autonomic effect. In this instance the effect will be to target the thoracic spine, ‘asking’ the articular receptors to facilitate an inhibiting effect on spinal joints, ligaments, fascia and intrinsic musculature. This can be used at all joint structures. I have dubbed this along the lines of Dalton’s concept as Articular Receptor Enh9ancement.
Articular Receptor Enhancement
This concept is applied to stimulate joint receptors activity which can in turn ‘open the door’ to changing chronically held axial spine erector spinae musculature. It can be utilized on all joints of the upper and lower extremities. If you already utilize ‘joint play’, then articular receptor enhancement will augment this nicely.
The ‘enhancement’ is the triggering of afferent activity by using low force patient effort. The key to using these techniques are understanding ‘cardinal motions’ of any given joint. In the axial spine the primary motion is sagittal plane flexion-extension, then rotation and side-bending or lateral flexion.
By intending the spine to relax in the direction of these restriction(s), such as using lower force patient resistance in flexion and extension, the catch is not using effort or the spine directly, although you can, it is instead by resisting levering force of the upper extremity for the thoracic spine and the lower extremity force as levers for the lumber spine. The levering can be applied both as long and short as humeral or femoral levers. Resistance can be used for both directions.
Autonomic Manipulation: Thoracic Spine Leverage Technique
This is an autonomic joint receptor activation release. It is meant to ‘activate’ sensory receptors, so that the receptors of the mid-thoracic region are activated to inhibit the current sustained tonal settings from nocioceptor (pain) activation, or mechanoreceptors activated by sustained compression or tension. This is indicative of chronic habitual postural distortion to myofascial, ligament, musculature and joints structures of the spine.
Place the client in sidelying position with arms bent or arms straight. You will be learning the bent arm technique or humeral short lever technique. When assessing this position, if external rotators of the shoulder are hypertonic, the elbows won’t meet. They will be ‘splayed apart’. Roll your client forward to approximate the arms as comfortable as possible. Once in position, ask your client to isometrically contract against a force no greater than what you judge to be 5%.
Critical to the success of the technique is the concept of low loading. The force is usually between 5-10%. But can be lower. The key is this in NOT a muscle technique, it is an AUTONOMIC technique.
Low loading through autonomic rersponse targets intrinsic thoracic musculature and joint or articular receptors.
Ask your client to resist at 5-10% against the following directions:
Both hands pushing cranially or superiorly for extensionBoth hands pushing caudally or inferior for flexion Both hands pushing down into the table for SB/Rotation Both hands pushing the opposite direction towards the ceiling for SB/Rotation Both elbows ‘pulling apart’ scapular adduction Hands between elbows ‘pushing’ together scapular abduction
Since the thoracic spine behaves in a ‘coupled motion’ manner, these levers with resistance, target thoracic flexion, extension, rotation and side bending. This is a very efficient ‘shotgun’ technique.
The results you will achieve will quick, painless and effectively softening sufficient axial soft-tissue.
Robert Schleip, Fascial Plasticity: A New Neurobiological Explanation Part 2 Journal of Movement & Bodywork Therapies, April 2003, p.1. Michael Shea, Myofascial Release Textbook: Expression of the Autonomic Nervous System pp 45-56, 1995 Shea Educational Group, Juno, Florida. Erik Dalton, Article: Receptor Techniques, AMTA Journal Winter 2004 p.84 Wikipedia http://en.wikipedia.org/wiki/Hans_Selye) Michael Shea, Myofascial Release Textbook: Expression of the Autonomic Nervous System pp 45-56, 1995 Shea Educational Group, Juno, Florida. Erik Dalton, Article: Receptor Techniques, AMTA Journal Winter 2004 p.87 Robert Schleip, Fascial Plasticity: A New Neurobiological Explanation Part 1 p11, Journal of Movement & Bodywork Therapies, January 2003 Philip Page, Clare C. Frank, and Robert Lardner, Assessment & Treatment of Muscular Imbalance-The Janda Approach. 2010 by Benchmark Physical Therapy Inc., p.1 Ibid p.27 Grubb ER, Hagedorn EM, Inoue N, Leake MJ, Lounsberry NL, Love SD, Matus JR, Morris LM, Stafford KM, Staton GS, Waters CM Muscle Energy Project, University of Kentucky, AT 690, Spring 2010 p.1 Chaitow’s Chat-http://chaitowschat-leon.blogspot.com/) Erik Dalton, Article: Receptor Techniques, AMTA Journal Winter 2004 p.81