Back Clinic Chiropractic. This is a form of alternative treatment that focuses on the diagnosis and treatment of various musculoskeletal injuries and conditions, especially those associated with the spine. Dr. Alex Jimenez discusses how spinal adjustments and manual manipulations regularly can greatly help both improve and eliminate many symptoms that could be causing discomfort to the individual. Chiropractors believe among the main reasons for pain and disease are the vertebrae’s misalignment in the spinal column (this is known as a chiropractic subluxation).
Through the usage of manual detection (or palpation), carefully applied pressure, massage, and manual manipulation of the vertebrae and joints (called adjustments), chiropractors can alleviate pressure and irritation on the nerves, restore joint mobility, and help return the body’s homeostasis. From subluxations, or spinal misalignments, to sciatica, a set of symptoms along the sciatic nerve caused by nerve impingement, chiropractic care can gradually restore the individual’s natural state of being. Dr. Jimenez compiles a group of concepts on chiropractic to best educate individuals on the variety of injuries and conditions affecting the human body.
These assessment and treatment recommendations represent a synthesis of information derived from personal clinical experience and from the numerous sources which are cited, or are based on the work of researchers, clinicians and therapists who are named (Basmajian 1974, Cailliet 1962, Dvorak & Dvorak 1984, Fryette 1954, Greenman 1989, 1996, Janda 1983, Lewit 1992, 1999, Mennell 1964, Rolf 1977, Williams 1965).
Clinical Application of Neuromuscular Techniques: Quadratus Lumborum
Assessment of Shortness in Quadratus Lumborum (Figure 4.21)
Figure 4.21 Palpation assessment for quadratus lumborum overactivity. The muscle is palpated, as is gluteus medius, during abduction of the leg. The correct firing sequence should be gluteus, followed at around 25� elevation by quadratus. If there is an immediate �grabbing� action by quadratus it indicates overactivity, and therefore stress, so shortness can be assumed (see details of similar functional assessments in Ch. 5).
Review Lewit�s functional palpation test described under the heading assessment and treatment of tensor fascia lata.
When the leg of the side-lying patient is abducted, and the practitioner�s palpating hand senses that quadratus becomes involved in this process before the leg has reached at least 25� of elevation, then it is clear that quadratus is overactive. If it has been overactive for any length of time then it is almost certainly hypertonic and short, and a need for MET can be assumed.
Quadratus lumborum test (a) (See also Fig. 5.11A, B.) The patient is side-lying and is asked to take the upper arm over the head to grasp the top edge of the table, �opening out� the lumbar area. The practitioner stands facing the back of the patient, and has easy access for palpation of quadratus lumborum�s lateral border � a major trigger point site (Travell & Simons 1992) � with the cephalad hand.
Activity of quadratus is tested (palpated for) with the cephalad hand as the leg is abducted, while also palpating gluteus medius with the caudad hand. If the muscles act simultaneously, or if quadratus fires first, then it is stressed, probably short, and will benefit from stretching.
Quadratus lumborum test (b) The patient stands, back towards crouching practitioner. Any leg length disparity (based on pelvic crest height) is equalised by using a book or pad under the short leg side heel. With the patient�s feet shoulder-width apart, a pure sidebending is requested, so that the patient runs a hand down the lateral thigh/calf. (Normal level of sidebending excursion allows the fingertips to reach to just below the knee.) (See Fig. 3.2A, B, C.)
The side to which the fingertips travel furthest is assessed. If sidebending to one side is limited then quadratus on the opposite side is probably short. Combined evidence from palpation (test a) and this sidebending test indicate whether or not it is necessary to treat quadratus.
Box 4.8 Notes on Quadratus Lumborum
Norris (2000) describes the divided roles in which quadratus is involved: The quadratus lumborum has been shown to be significant as a stabiliser in lumbar spine movements (McGill et al 1996) while tightening has also been described (Janda 1983). It seems likely that the muscle may act functionally differently in its medial and lateral portions, with the medial portion being more active as a stabiliser of the lumbar spine, and the lateral more active as a mobiliser [see stabiliser/mobiliser discussion Ch. 2]. Such subdivision is seen in a number of other muscles for example the gluteus medius where the posterior fibres are more posturally involved (Jull 1994) the internal oblique where the posterior fibres attaching to the lateral raphe are considered stabilisers (Bergmark 1989) the external oblique where the lateral fibres work during flexion in parallel with the rectus abdominis (Kendall et al 1993).
Janda (1983) observes that, when the patient is sidebending (as in method (b)) �when the lumbar spine appears straight, with compensatory motion occurring only from the thoracolumbar region upwards, tightness of quadratus lumborum may be suspected�. This �whole lumbar spine� involvement differs from a segmental restriction which would probably involve only a part of the lumbar spine.
Quadratus fibres merge with the diaphragm (as do those of psoas), which makes involvement in respiratory dysfunction a possibility since it plays a role in exhalation, both via this merging and by its attachment to the 12th rib.
Shortness of quadratus, or the presence of trigger points, can result in pain in the lower ribs and along the iliac crest if the lateral fibres are affected. Shortness of the medial fibres, or the presence of trigger points, can produce pain in the sacroiliac joint and the buttock.
Bilateral contraction produces extension and unilateral contraction produces extension and sidebending to the same side.
The important transition region, the lumbodorsal junction (LDJ), is the only one in the spine in which two mobile structures meet, and dysfunction results in alteration of the quality of motion between these structures (upper and lower trunk/dorsal and lumbar spines). In dysfunction there is often a degree of spasm or tightness in the muscles which stabilise the region, notably: psoas and erector spinae of the thoracolumbar region, as well as quadratus lumborum and rectus abdominis.
Symptomatic differential diagnosis of muscle involvement at the LDJ is possible as follows: psoas involvement usually triggers abdominal pain if severe and produces flexion of the hip and the typical antalgesic posture of lumbago; erector spinae involvement produces low back pain at its caudad end of attachment and interscapular pain at its thoracic attachment (as far up as the mid-thoracic level); quadratus lumborum involvement causes lumbar pain and pain at the attachment of the iliac crest and lower ribs; and rectus abdominis contraction may mimic abdominal pain and result in pain at the attachments at the pubic symphysis and the xiphoid process, as well as forwardbending of the trunk and restricted ability to extend the spine.
There is seldom pain at the site of the lesion in LDJ dysfunction. Lewit (1992) points out that even if a number of these muscles are implicated, it is seldom necessary, using PIR methods, to treat them all since, as the muscles most involved (discovered by tests for shortness, overactivity, sensitivity and direct palpation) are stretched and normalised, so will others begin automatically to normalise.
MET for Shortness in Quadratus Lumborum (�banana�)
Quadratus lumborum MET method (a) (Fig. 4.22) The patient lies supine with the feet crossed (the side to be treated crossed under the non-treated side leg) at the ankle. The patient is arranged in a light sidebend, away from the side to be treated, so that the pelvis is towards that side, and the feet and head away from that side (�banana shaped�). As this sidebend is being achieved the affected quadratus can be palpated for bind so that the barrier is correctly identified.
Figure 4.22 MET treatment of quadratus lumborum utilising �banana� position.
The patient�s heels are placed just off the side of the table, anchoring the lower extremities and pelvis. The patient places the arm of the side to be treated behind her neck as the practitioner, standing on the side opposite that to be treated, slides his cephalad hand under the patient�s shoulders to grasp the treated side axilla. The patient grasps the practitioner�s cephalad arm at the elbow, with the treated side hand, making the contact more secure.
The patient�s treated side elbow should, at this stage, be pointing superiorly. The practitioner�s caudad hand is placed firmly but carefully on the anterior superior iliac spine, on the side to be treated. The patient is instructed to very lightly sidebend towards the treated side. This should produce an isometric contraction in quadratus lumborum on the side to be treated.
After 7 seconds the patient is asked to relax completely, and then to sidebend towards the nontreated side, as the practitioner simultaneously transfers his bodyweight from the cephalad leg to the caudad leg and leans backwards slightly, in order to sidebend the patient. This effectively stretches quadratus lumborum. The stretch is held for 15�20 seconds, allowing a lengthening of shortened musculature in the region. Repeat as necessary.
Quadratus lumborum MET method (b) (Fig 4.23) The practitioner stands behind the side-lying patient, at waist level. The patient has the uppermost arm extended over the head to firmly grasp the top end of the table and, on an inhalation, abducts the uppermost leg until the practitioner palpates strong quadratus activity (elevation of around 30� usually).
Figure 4.23 MET treatment of quadratus lumborum. Note that it is important after the isometric contraction (sustained raised/abducted leg) that the muscle be eased into stretch, avoiding any defensive or protective resistance which sudden movement might produce. For this reason, body weight rather than arm strength should be used to apply traction.
The patient holds the leg (and, if appropriate, the breath, see Box 4.2) isometrically in this manner, allowing gravity to provide resistance. After the 10-second (or so) contraction, the patient allows the leg to hang slightly behind him over the back of the table. The practitioner straddles this and, cradling the pelvis with both hands (fingers interlocked over crest of pelvis), leans back to take out all slack and to �ease the pelvis away from the lower ribs� during an exhalation.
The stretch should be held for between 10 and 30 seconds. (The method will only be successful if the patient is grasping the top edge of the table, so providing a fixed point from which the practitioner can induce stretch.)
Contraction followed by stretch is repeated once or twice more with raised leg in front of, and once or twice with raised leg behind the trunk in order to activate different fibres. The direction of stretch should be varied so that it is always in the same direction as the long axis of the abducted leg. This calls for the practitioner changing from the back to the front of the table for the best results. When the leg hangs to the back of the trunk the long fibres of the muscle are mainly affected; and when the leg hangs forward of the body the diagonal fibres are mainly involved.
Quadratus lumborum MET method (c) Gravity-induced postisometric relaxation of quadratus lumborum � self-treatment (See Fig. 3.2A�C and captions) The patient stands, legs apart, bending sideways. The patient inhales and slightly raises the trunk (a few centimetres) at the same time as looking (with the eyes only) away from the side to which side-flexion is taking place. On exhalation, the sidebend is allowed to slowly go further to its elastic limit, while the patient looks towards the floor, in the direction of the side-flexion. (Care is needed that very little, if any, forward or backward bending is taking place at this time.) This sequence is repeated a number of times.
Eye positions influence the tendency to flex and sidebend (eyes look down) and extend (eyes look up) (Lewit 1999). Gravity-induced stretches of this sort require holding the stretch position for at least as long as the contraction, and ideally longer. More repetitions may be needed with a large muscle such as quadratus, and home stretches should be advised several times daily. Quadratus lumborum MET method (d) The side-lying treatment of latissimus dorsi described below also provides an effective quadratus stretch when the stabilising hand rests on the pelvic crest (see Fig. 4.29).
Dr. Alex Jimenez offers an additional assessment and treatment of the hip flexors as a part of a referenced clinical application of neuromuscular techniques by Leon Chaitow and Judith Walker DeLany. The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
By Dr. Alex Jimenez
Additional Topics: Wellness
Overall health and wellness are essential towards maintaining the proper mental and physical balance in the body. From eating a balanced nutrition as well as exercising and participating in physical activities, to sleeping a healthy amount of time on a regular basis, following the best health and wellness tips can ultimately help maintain overall well-being. Eating plenty of fruits and vegetables can go a long way towards helping people become healthy.
These assessment and treatment recommendations represent a synthesis of information derived from personal clinical experience and from the numerous sources which are cited, or are based on the work of researchers, clinicians and therapists who are named (Basmajian 1974, Cailliet 1962, Dvorak & Dvorak 1984, Fryette 1954, Greenman 1989, 1996, Janda 1983, Lewit 1992, 1999, Mennell 1964, Rolf 1977, Williams 1965).
Clinical Application of Neuromuscular Techniques: Piriformis
Assessment of Shortened Piriformis
Test (a) Stretch test. When short, piriformis will cause the affected side leg of the supine patient to appear to be short and externally rotated. With the patient supine, the tested leg is placed into flexion at the hip and knee so that the foot rests on the table lateral to the contralateral knee (the tested leg is crossed over the straight non-tested leg, in other words as shown in Fig. 4.17). The angle of hip flexion should not exceed 60� (see notes on piriformis in Box 4.6).
Figure 4.17 MET treatment of piriformis muscle with patient supine. The pelvis must be maintained in a stable position as the knee (right in this example) is adducted to stretch piriformis following an isometric contraction.
The non-tested side ASIS is stabilised to prevent pelvic motion during the test and the knee of the tested side is pushed into adduction to place a stretch on piriformis. If there is a short piriformis the degree of adduction will be limited and the patient will report discomfort behind the trochanter.
Test (b) Palpation test (Fig. 4.18) The patient is side-lying, tested side uppermost. The practitioner stands at the level of the pelvis in front of and facing the patient, and, in order to contact the insertion of piriformis, draws imaginary lines between:
ASIS and ischial tuberosity, and
PSIS and the most prominent point of trochanter.
Where these reference lines cross, just posterior to the trochanter, is the insertion of the muscle, and pressure here will produce marked discomfort if the structure is short or irritated.
Figure 4.18 Using bony landmarks as coordinates the commonest tender areas are located in piriformis, in the belly and at the attachment of the muscle.
If the most common trigger point site in the belly of the muscle is sought, then the line from the ASIS should be taken to the tip of the coccyx rather than to the ischial tuberosity. Pressure where this line crosses the other will access the mid-point of the belly of piriformis where triggers are common. Light compression here which produces a painful response is indicative of a stressed muscle and possibly an active myofascial trigger point.
Piriformis Strength Test
The patient lies prone, both knees flexed to 90�, with practitioner at foot of table grasping lower legs at the limit of their separation (which internally rotates the hip and therefore allows comparison of range of movement permitted by shortened external rotators such as the piriformis).
The patient attempts to bring the ankles together as the practitioner assesses the relative strength of the two legs. Mitchell et al (1979) suggest that if there is relative shortness (as evidenced by the lower leg not being able to travel as far from the mid-line as its pair in this position), and if that same side also tests strong, then MET is called for. If there is shortness but also weakness then the reasons for the weakness need to be dealt with prior to stretching using MET.
Box 4.6 Notes on Piriformis
Piriformis paradox. The performance of external rotation of the hip by piriformis occurs when the angle of hip flexion is 60� or less. Once the angle of hip flexion is greater than 60� piriformis function changes, so that it becomes an internal rotator of the hip (Gluck & Liebenson 1997, Lehmkuhl & Smith 1983). The implications of this are illustrated in Figures 4.17 and 4.19.
This postural muscle, like all others which have a predominence of type l fibres, will shorten if stressed. In the case of piriformis, the effect of shortening is to increase its diameter and because of its location this allows for direct pressure to be exerted on the sciatic nerve, which passes under it in 80% of people. In the other 20% the nerve passes through the muscle so that contraction will produce veritable strangulation of the sciatic nerve.
In addition, the pudendal nerve and the blood vessels of the internal iliac artery, as well as common perineal nerves, posterior femoral cutaneous nerve and nerves of the hip rotators, can all be affected.
If there is sciatic pain associated with piriformis shortness, then on straight leg raising, which reproduces the pain, external rotation of the hip should relieve it, since this slackens piriformis. (This clue may, however, only apply to any degree if the individual is one of those in whom the nerve actually passes through the muscle.)
The effects can be circulatory, neurological and functional, inducing pain and paraesthesia of the affected limb as well as alterations to pelvic and lumbar function. Diagnosis usually hinges on the absence of spinal causative factors and the distributions of symptoms from the sacrum to the hip joint, over the gluteal region and down to the popliteal space. Palpation of the affected piriformis tendon, near the head of the trochanter, will elicit pain and the affected leg will probably be externally rotated.
The piriformis muscle syndrome is frequently characterised by such bizarre symptoms that they may seem unrelated. One characteristic complaint is a persistent, severe, radiating low back pain extending from the sacrum to the hip joint, over the gluteal region and the posterior portion of the upper leg, to the popliteal space. In the most severe cases the patient will be unable to lie or stand comfortably, and changes in position will not relieve the pain. Intense pain will occur when the patient sits or squats since this type of movement requires external rotation of the upper leg and flexion at the knee.
Compression of the pudendal nerve and blood vessels which pass through the greater sciatic foramen and re-enter the pelvis via the lesser sciatic foramen is possible because of piriformis contracture. Any compression would result in impaired circulation to the genitalia in both sexes. Since external rotation of the hips is required for coitus by women, pain noted during this act could relate to impaired circulation induced by piriformis dysfunction. This could also be a basis for impotency in men. (See also Box 4.7.)
Piriformis involvement often relates to a pattern of pain which includes: pain near the trochanter; pain in the inguinal area; local tenderness over the insertion behind trochanter; SI joint pain on the opposite side; externally rotated foot on the same side; pain unrelieved by most positions with standing and walking being the easiest; limitation of internal rotation of the leg which produces pain near the hip; and a short leg on the affected side.
The pain itself will be persistent and radiating, covering anywhere from the sacrum to the buttock, hip and leg including inguinal and perineal areas.
Bourdillon (1982) suggests that piriformis syndrome and SI joint dysfunction are intimately connected and that recurrent SI problems will not stabilise until hypertonic piriformis is corrected.
Janda (1996) points to the vast amount of pelvic organ dysfunction to which piriformis can contribute due to its relationship with circulation to the area.
Mitchell et al (1979) suggest that (as in psoas example above) piriformis shortness should only be treated if it is tested to be short and stronger than its pair. If it is short and weak (see p. 110 for strength test), then whatever is hypertonic and influencing it should be released and stretched first (Mitchell et al 1979). When it tests strong and short, piriformis should receive MET treatment.
Since piriformis is an external rotator of the hip it can be inhibited (made to test weak) if an internal rotator such as TFL is hypertonic or if its pair is hypertonic, since one piriformis will inhibit the other.
Box 4.7 Notes on Working and Resting Muscles
Richard (1978) reminds us that a working muscle will mobilise up to 10 times the quantity of blood mobilised by a resting muscle. He points out the link between pelvic circulation and lumbar, ischiatic and gluteal arteries and the chance this allows to engineer the involvement of 2400 square metres of capillaries by using repetitive pumping of these muscles (including piriformis).
The therapeutic use of this knowledge involves the patient being asked to repetitively contract both piriformis muscles against resistance. The patient is supine, knees bent, feet on the table; the practitioner resists their effort to abduct their flexed knees, using pulsed muscle energy approach (Ruddy�s method) in which two isometrically resisted pulsation/contractions per second are introduced for as long as possible (a minute seems a long time doing this).
Figure 4.19 MET treatment of piriformis with hip fully flexed and externally rotated (see Box 4.6, first bullet point).
Figure 4.20 A combined ischaemic compression (elbow pressure) and MET side-lying treatment of piriformis. The pressure is alternated with isometric contractions/stretching of the muscle until no further gain is achieved.
MET Treatment of Piriformis
Piriformis method (a) Side-lying The patient is side-lying, close to the edge of the table, affected side uppermost, both legs flexed at hip and knee. The practitioner stands facing the patient at hip level.
The practitioner places his cephalad elbow tip gently over the point behind trochanter, where piriformis inserts. The patient should be close enough to the edge of the table for the practitioner to stabilise the pelvis against his trunk (Fig. 4.20). At the same time, the practitioner�s caudad hand grasps the ankle and uses this to bring the upper leg/hip into internal rotation, taking out all the slack in piriformis.
A degree of inhibitory pressure (sufficient to cause discomfort but not pain) is applied via the elbow for 5�7 seconds while the muscle is kept at a reasonable but not excessive degree of stretch. The practitioner maintains contact on the point, but eases pressure, and asks the patient to introduce an isometric contraction (25% of strength for 5�7 seconds) to piriformis by bringing the lower leg towards the table against resistance. (The same acute and chronic rules as discussed previously are employed, together with cooperative breathing if appropriate, see Box 4.2.)
After the contraction ceases and the patient relaxes, the lower limb is taken to its new resistance barrier and elbow pressure is reapplied. This process is repeated until no further gain is achieved.
Piriformis method (b)1 This method is a variation on the method advocated by TePoorten (1960) which calls for longer and heavier compression, and no intermediate isometric contractions.
In the first stage of TePoorten�s method the patient lies on the non-affected side with knees flexed and hip joints flexed to 90�.The practitioner places his elbow on the piriformis musculotendinous junction and a steady pressure of 20�30 lb (9�13 kg) is applied. With his other hand he abducts the foot so that it will force an internal rotation of the upper leg.
The leg is held in this rotated position for periods of up to 2 minutes. This procedure is repeated two or three times. The patient is then placed in the supine position and the affected leg is tested for freedom of both external and internal rotation.
Piriformis method (b)2 The second stage of TePoorten�s treatment is performed with the patient supine with both legs extended. The foot of the affected leg is grasped and the leg is flexed at both the knee and the hip. As knee and hip flexion is performed the practitioner turns the foot inward, so inducing an external rotation of the upper leg. The practitioner then extends the knee, and simultaneously turns the foot outward, resulting in an internal rotation of the upper leg.
During these procedures the patient is instructed to partially resist the movements introduced by the practitioner (i.e. the procedure becomes an isokinetic activity). This treatment method, repeated two or three times, serves to relieve the contracture of the muscles of external and internal hip rotation.
Piriformis method (c) A series of MET isometric contractions and stretches can be applied with the patient prone and the affected side knee flexed. The hip is rotated internally by the practitioner using the foot as a lever to ease it laterally, so putting piriformis at stretch. Acute and chronic guidelines described earlier are used to determine the appropriate starting point for the contraction (at the barrier for acute and short of it for chronic).
The patient attempts to lightly bring the heel back towards the midline against resistance (avoiding strong contractions to avoid knee strain in this position) and this is held for 7�10 seconds. After release of the contraction the hip is rotated further to move piriformis to or through the barrier, as appropriate. Application of inhibitory pressure to the attachment or belly of piriformis is possible via thumb, if deemed necessary.
Piriformis method (d) A general approach which balances muscles of the region, as well as the pelvic diaphragm, is achieved by having the patient squat while the practitioner stands and stabilises both shoulders, preventing the patient from rising as this is attempted, while the breath is held. After 7�10 seconds the effort is released; a deeper squat is performed, and the procedure is repeated several times.
Piriformis method (e) This method is based on the test position (see Fig. 4.17) and is described by Lewit (1992). With the patient supine, the treated leg is placed into flexion at the hip and knee, so that the foot rests on the table lateral to the contralateral knee (the leg on the side to be treated is crossed over the other, straight, leg). The angle of hip flexion should not exceed 60� (see notes on piriformis, Box 4.6, for explanation).
The practitioner places one hand on the contralateral ASIS to prevent pelvic motion, while the other hand is placed against the lateral flexed knee as this is pushed into resisted abduction to contract piriformis for 7�10 seconds. Following the contraction the practitioner eases the treated side leg into adduction until a sense of resistance is noted; this is held for 10�30 seconds.
Piriformis method (f) Since contraction of one piriformis inhibits its pair, it is possible to self-treat an affected short piriformis by having the patient lie up against a wall with the non-affected side touching it, both knees flexed (modified from Retzlaff 1974). The patient monitors the affected side by palpating behind the trochanter, ensuring that no contraction takes place on that side.
After a contraction lasting 10 seconds or so of the non-affected side (the patient presses the knee against the wall), the patient moves away from the wall and the position described for piriformis test (see Fig. 4.17) above is adopted, and the patient pushes the affected side knee into adduction, stretching piriformis on that side. This is repeated several times.
Dr. Alex Jimenez offers an additional assessment and treatment of the hip flexors as a part of a referenced clinical application of neuromuscular techniques by Leon Chaitow and Judith Walker DeLany. The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
By Dr. Alex Jimenez
Additional Topics: Wellness
Overall health and wellness are essential towards maintaining the proper mental and physical balance in the body. From eating a balanced nutrition as well as exercising and participating in physical activities, to sleeping a healthy amount of time on a regular basis, following the best health and wellness tips can ultimately help maintain overall well-being. Eating plenty of fruits and vegetables can go a long way towards helping people become healthy.
These assessment and treatment recommendations represent a synthesis of information derived from personal clinical experience and from the numerous sources which are cited, or are based on the work of researchers, clinicians and therapists who are named (Basmajian 1974, Cailliet 1962, Dvorak & Dvorak 1984, Fryette 1954, Greenman 1989, 1996, Janda 1983, Lewit 1992, 1999, Mennell 1964, Rolf 1977, Williams 1965).
Clinical Application of Neuromuscular Techniques: Tensor Fascia Lata
�Assessment of shortness in tensor fascia lata (TFL)
The test recommended is a modified form of Ober�s test (see Fig. 4.14).
Figure 4.14 Assessment for shortness of TFL � modified Ober�s test. When the hand supporting the flexed knee is removed the thigh should fall to the table if TFL is not short.
Patient is side-lying with back close to the edge of the table. The practitioner stands behind the patient, whose lower leg is flexed at hip and knee and held in this position, by the patient, for stability. The tested leg is supported by the practitioner, who must ensure that there is no hip flexion, which would nullify the test.
The leg is extended only to the point where the iliotibial band lies over the greater trochanter. The tested leg is held by the practitioner at ankle and knee, with the whole leg in its anatomical position, neither abducted nor adducted and not forward or backward of the body.
Box 4.5 Notes on TFL
Mennell (1964) and Liebenson (1996) say that TFL shortness can produce all the symptoms of acute and chronic sacroiliac problems.
Pain from TFL shortness can be localised to the posterior superior iliac spine (PSIS), radiating to the groin or down any aspect of the thigh to the knee.
Although the pain may arise in the sacroiliac (SI) joint, dysfunction in the joint may be caused and maintained by taut TFL structures.
Pain from the band itself can be felt in the lateral thigh, with referral to hip or knee.
TFL can be �riddled� with sensitive fibrotic deposits and trigger point activity.
There is commonly a posteriority of the ilium associated with short TFL.
TFL�s prime phasic activity (all postural structures also have some phasic function) is to assist the gluteals in abduction of the thigh.
If TFL and psoas are short they may, according to Janda, �dominate� the gluteals on abduction of the thigh, so that a degree of lateral rotation and flexion of the hip will be produced, rotating the pelvis backwards.
Rolf (1977) points out that persistent exercise such as cycling will shorten and toughen the fascial iliotibial band �until it becomes reminiscent of a steel cable�. This band crosses both hip and knee, and spatial compression allows it to squeeze and compress cartilaginous elements such as the menisci. Ultimately, it will no longer be able to compress, and rotational displacement at knee and hip will take place.
The practitioner carefully introduces flexion at the knee to 90�, without allowing the hip to flex, and then, holding just the ankle, allows the knee to fall towards the table. If TFL is normal, the thigh and knee will fall easily, with the knee contacting the table surface (unless unusual hip width, or thigh length prevent this).
If the upper leg remains aloft, with little sign of �falling� towards the table, then either the patient is not letting go or the TFL is short and does not allow it to fall. As a rule the band will palpate as tender under such conditions.
Lewit�s TFL Palpation
(Lewit 1999; see also functional assessment method in Ch. 5)
Patient is side-lying and practitioner stands facing the patient�s front, at hip level. The practitioner�s cephalad hand rests over the anterior superior iliac spine (ASIS) so that it can also palpate over the trochanter. It should be placed so that the fingers rest on the TFL and trochanter with the thumb on gluteus medius. The caudad hand rests on the mid-thigh to apply slight resistance to the patient�s effort to abduct the leg.
The patient�s table-side leg is slightly flexed to provide stability, and there should be a vertical line to the table between one ASIS and the other (i.e. no forwards or backwards �roll� of the pelvis). The patient abducts the upper leg (which should be extended at the knee and slightly hyperextended at the hip) and the practitioner should feel the trochanter �slip away� as this is done.
If, however, the whole pelvis is felt to move rather than just the trochanter, there is inappropriate muscular imbalance. (In balanced abduction gluteus comes into action at the beginning of the movement, with TFL operating later in the pure abduction of the leg. If there is an overactivity (and therefore shortness) of TFL, then there will be pelvic movement on the abduction, and TFL will be felt to come into play before gluteus.)
The abduction of the thigh movement will then be modified to include external rotation and flexion of the thigh (Janda 1996). This confirms a stressed postural structure (TFL), which implies shortness.
It is possible to increase the number of palpation elements involved by having the cephalad hand also palpate (with an extended small finger) quadratus lumborum during leg abduction. In a balanced muscular effort to lift the leg sideways, quadratus should not become active until the leg has been abducted to around 25�30�. When quadratus is overactive it will often start the abduction along with TFL, thus producing a pelvic tilt.�(See also Fig. 5.11A and B)
Method (a) Supine MET treatment of shortened TFL (Fig. 4.15) The patient lies supine with the unaffected leg flexed at hip and knee. The affected side leg is adducted to its barrier which necessitates it being brought under the opposite leg/foot.
Figure 4.15 MET treatment of TFL (see Fig. 1.4 for description of isolytic variation). If a standard MET method is being used, the stretch will follow the isometric contraction in which the patient will attempt to move the right leg to the right against sustained resistance. It is important for the practitioner to maintain stability of the pelvis during the procedure. Note: the hand positions in this figure are a variation of those described in the text.
Using guidelines for acute and chronic problems, the structure will either be treated at, or short of, the barrier of resistance, using light or fairly strong isometric contractions for short (7 second) or long (up to 20 seconds) durations, using appropriate breathing patterns as described earlier in this chapter (Box 4.2).
The practitioner uses his trunk to stabilise the patient�s pelvis by leaning against the flexed (nonaffected side) knee. The practitioner�s caudad arm supports the affected leg so that the knee is stabilised by the hand. The other hand maintains a stabilising contact on the affected side ASIS.
The patient is asked to abduct the leg against resistance using minimal force. After the contraction ceases and the patient has relaxed using appropriate breathing patterns, the leg is taken to or through the new restriction barrier (into adduction past the barrier) to stretch the muscular fibres of TFL (the upper third of the structure).
Care should be taken to ensure that the pelvis is not tilted during the stretch. Stability is achieved by the practitioner increasing pressure against the flexed knee/thigh. This whole process is repeated until no further gain is possible.
Method (b) Alternative supine MET treatment of shortened TFL (Fig. 4.16) The patient adopts the same position as for psoas assessment, lying at the end of the table with non-tested side leg in full hip flexion and held by the patient, with the tested leg hanging freely, knee flexed.
Figure 4.16 MET treatment of psoas using Grieve�s method, in which there is placement of the patient�s foot, inverted, against the operator�s thigh. This allows a more precise focus of contraction into psoas when the hip is flexed against resistance.
The practitioner stands at the end of the table facing the patient so that his left lower leg (for a right-sided TFL treatment) can contact the patient�s foot. The practitioner�s left hand is placed on the patient�s distal femur and with this he introduces internal rotation of the thigh, and external rotation of the tibia (by means of light pressure on the distal foot from his lower leg).
During this process the practitioner senses for resistance (the movement should have an easy �springy� feel, not wooden or harsh) and observes for a characteristic depression or groove on the lateral thigh, indicating shortness of TFL.
This resistance barrier is identified and the leg held just short of it for a chronic problem, as the patient is asked to externally rotate the tibia, and to adduct the femur, against resistance, for 7�10 seconds. Following this the practitioner eases the leg into a greater degree of internal hip rotation and external tibial rotation, and holds this stretch for 10�30 seconds.
Method (c) Isolytic variation If an isolytic contraction is introduced in order to stretch actively the interface between elastic and non-elastic tissues, then there is a need to stabilise the pelvis more efficiently, either by use of wide straps or another pair of hands holding the ASIS downwards towards the table during the stretch.
The procedure consists of the patient attempting to abduct the leg as the practitioner overcomes the muscular effort, forcing the leg into adduction. The contraction/stretch should be rapid (2�3 seconds at most to complete). Repeat several times.
Method (d) Side-lying MET treatment of TFL The patient lies on the affected TFL side with the upper leg flexed at hip and knee and resting forward of the affected leg. The practitioner stands behind patient and uses caudad hand and arm to raise the affected leg (which is on the table) while stabilising the pelvis with the cephalad hand, or uses both hands to raise the affected leg into slight adduction (appropriate if strapping used to hold pelvis to table).
The patient contracts the muscle against resistance by trying to take the leg into abduction (towards the table) using breathing assistance as appropriate (see notes on breathing, Box 4.2). After the effort, on an exhalation, the practitioner lifts the leg into adduction beyond the barrier to stretch the interface between elastic and non-elastic tissues. Repeat as appropriate or modify to use as an isolytic contraction by stretching the structure past the barrier during the contraction.
Additional TFL Methods
Mennell has described superb soft tissue stretching techniques for releasing TFL. These involve a series of snapping actions applied by thumbs to the anterior fibres with patient side-lying, followed by a series of heel of hand thrusts across the long axis of the posterior TFL fibres.
Additional release of TFL contractions is possible by use of elbow or heel of hand �stripping� of the structure, neuromuscular deep tissue approaches (using thumb or a rubber-tipped T-bar) applied to the upper fibres and those around the knee, and specific deep tissue release methods. Most of these are distinctly uncomfortable and all require expert tuition.
Self-Treatment and Maintenance
The patient lies on her side, on a bed or table, with the affected leg uppermost and hanging over the edge (lower leg comfortably flexed). The patient may then introduce an isometric contraction by slightly lifting the hanging leg a few centimeters, and holding this position for 10 seconds, before slowly releasing and allowing gravity to take the leg towards the floor, so introducing a greater degree of stretch.
This is held for up to 30 seconds and the process is then repeated several times in order to achieve the maximum available stretch in the tight soft tissues. The counterforce in this isometric exercise is gravity.
Dr. Alex Jimenez offers an additional assessment and treatment of the hip flexors as a part of a referenced clinical application of neuromuscular techniques by Leon Chaitow and Judith Walker DeLany. The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
By Dr. Alex Jimenez
Additional Topics: Wellness
Overall health and wellness are essential towards maintaining the proper mental and physical balance in the body. From eating a balanced nutrition as well as exercising and participating in physical activities, to sleeping a healthy amount of time on a regular basis, following the best health and wellness tips can ultimately help maintain overall well-being. Eating plenty of fruits and vegetables can go a long way towards helping people become healthy.
Suffer Sciatica: Are you experiencing pain along one side of your body from your lower back down through your hip and the back of your leg? If so, you could be suffering from a condition called sciatica.
According to the Mayo Clinic, sciatica can best be described as “most commonly occurring when a herniated disk or a bone spur on the spine compresses part of the nerve. This causes inflammation, pain and often some numbness in the affected leg.”
A variety of issues weigh in on an individual’s likelihood of ending up with sciatica. Most of them deal with increased pressure on the spine.
Suffer Sciatica: Causes
Obesity: carrying too much weight is instrumental in bringing on a number of health related issues. Extra pounds overload the spine, causing damage that results in sciatica.
Improper Lifting: Individuals who frequently twist the bodies and lift heavy loads are more likely to suffer from sciatica. Certain jobs that require these movements are a key cause of the condition.
Sedentary Lifestyle. A person’s job does not have to involve lifting to be responsible for this condition. Sitting for extended periods without stretching or standing puts excess pressure on the spine and can cause sciatica.
Too Many Birthdays. Getting older can affect all of our body’s joints and bones in a negative manner, especially if we never committed to an exercise routing. An individual’s back often deteriorates with age, causing bone spurs and herniated disks that sometimes result in sciatica.
Treatment options for sciatica are varied, and the choice depends on the severity of the condition.
Pain Medication: A common and easy way to treat sciatica is with drug therapy. Anti-inflammatory drugs are frequently used to reduce�the inflammation around the nerve, which is a big contributor of the pain. Over-the-counter pain medicines, as well as codeine, may also help with pain management.
Acupuncture. Alternative therapies like acupuncture have shown positive results in the treatment of sciatica. If a drug-free treatment option appeals to you, find an experienced acupuncturist in your area and talk to them about treatment options.
Strengthening Exercises. A consistent exercise program strengthens your muscles and helps the body function effectively. Ask your doctor which exercises assist the body with bouncing back from sciatica.
Supplements. Supplying the body with vital vitamins and minerals assists in overall health in general, including improvement from sciatica. Daily doses of supplements such as calcium, magnesium, St. John’s Wort, and Vitamin B12 have shown to treat sciatica effectively.
Chiropractic Care. Chiropractors understand all things spine-related, and work with the body as a whole to help it heal itself. Chiropractic treatment for sciatica works to align the spine and reduce the stress to the lower back. Treatment helps alleviate the underlying causes of the condition, and shows positive results in a short amount of time.
Cortisone Injections. Most of the time, sciatica can be treated by the less invasive measures mentioned above. However, severe bouts of sciatica may require a shot of cortisone directly into the inflamed area. Individuals generally choose this option when other treatments have garnered no relief.
Dealing with sciatica is painful and irritating, as the condition often sidelines the sufferer from daily activities. By knowing the treatment options that are effective in combating both the underlying causes and the pain of sciatica, sufferers can begin a regimen that will help them get back on their feet, pain-free in the shortest period of time possible and no longer have to suffer.
If you are suffering from sciatica and would like to talk to an experienced chiropractor about how to treat the condition, contact us today.
Sciatica
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Expectant Mothers: Pregnancy is an exciting, precious time in a woman’s life, full of new experiences. Unfortunately, the baby’s development brings about bodily changes that often wreak havoc on the back and joints, and end up causing pain. These issues also frequently cause issues during delivery, and increase the time it takes for the body to recover post-pregnancy.
Expectant moms benefit from chiropractic care in a number of ways. Here are five key ways chiropractic care helps alleviate the toll pregnancy takes on a woman’s body.
#1: Expectant Mothers: Chiropractic Keeps The Spine In Alignment.
Pregnancy adds significant additional weight to a woman’s body in a short amount of time. This change bears on the spine, frequently pulling it out of alignment.
When this happens, the pain can be quite severe. Chiropractic care during pregnancy works to keep the spine in alignment and all supporting tendons working optimally, to be better prepared and able to adequately support the extra weight.
#2: Chiropractic Reduces Need For Pain Relievers.
Most times, individuals experiencing moderate pain pop a couple of over the counter pain relievers and think nothing of it. However, pregnant women strive to avoid medications when possible.
Chiropractic adjustments decrease the underlying issues that cause pain, so the patient relies less on medications. Experiencing less pain as well as eliminating the need for pain killers is a win-win situation for expectant mothers.
#3: Chiropractic Strengthens And Repairs Joints.
Pregnancy really beats up an expectant mothers joints. Chiropractic care for expectant mothers is a productive way to minimize the effect the large, protruding abdomen has on her hips, legs, and ankles.
Treating the body as a whole, chiropractic treatment works to strengthen the body and promotes healing of injured or strained areas.
#4: Chiropractic Helps Achieve Pelvic Alignment.
An aligned pelvis is critical to the birthing process, and increases the chances of being able to give birth naturally. According to the American Pregnancy Association,
“When the pelvis is misaligned it may reduce the amount of room available for the developing baby. This restriction is called intrauterine constraint. A misaligned pelvis may also make it difficult for the baby to get into the best possible position for delivery. This can affect the mother�s ability to have a natural, non-invasive birth.”
An experienced chiropractor can effectively align the pelvis before delivery, so the mother is able to deliver with little incident.
#5: Chiropractic Increases The Body’s Ability To Bounce Back.
Let’s face it, every pregnant woman thinks “will I ever fit in the clingy red dress again?” The healthier and stronger a woman’s body is before and during pregnancy, the easier it is to get back into shape once the baby is born. Eating right and safely exercising are effective ways to accomplish this.
Chiropractic care is also a valuable component to fitness. Expectant mothers who choose chiropractic enjoy better posture, less pain, and increased mobility, especially late in the third trimester.
This allows them to maintain exercise routines and be active longer than those suffering from back pain and achy joints. After the delivery, it’s easier to get back into a fitness routine, and into that red dress, if the new mother’s joints, back, and hips are aligned and functioning properly.
Chiropractic care can serve to reduce pain and increase the overall heath of expectant mothers, letting her relax and focus on the more pleasant aspects of pregnancy. Expecting women who commit to chiropractic care can look forward to a stronger body, the chances of a smoother delivery, and an easier recovery after the baby comes.
Pregnancy & Chiropractic Care
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Parents of children suffering from ear infections are all too familiar with this cry. Tugging at their ears, crying, and trouble sleeping are all signs of an ear infection in your little one.
Children are more susceptible to ear infections than adults because of their smaller Eustachian tubes, and their less effective immune systems. Unfortunately, chronic ear infections can quickly become a painful, ongoing problem.
Parents have a variety of options at their disposal to treat their child’s ear infections. Drops, antibiotics, and ventilation tubes placed by surgical procedure are all commonly used treatments for chronic infections. Chiropractic care is another option available and is rapidly gaining acceptance and popularity for the effective treatment of ear infections.
According to HealthyChild.com, ear infections are the reason for 35% of pediatrician visits, and ear pain is the number one reason a child visits a chiropractor. Children who suffer from recurring ear infections benefit from chiropractic care in several ways that are not available through other, more traditional forms of treatment.
Here are a few of the benefits chiropractic care offer for ear infections are:
Ear Infections: It Is Non-Invasive
Unlike the surgical procedure that is often used to combat ear infections by inserting tubes in the child’s ears, chiropractic adjustments provide a non-invasive form of treatment.
This treatment option works well because a little one’s spine may be moved out of alignment from the birthing process, or from any number of spills he or she makes learning to walk, run, or navigate stairs. An experienced chiropractor can map out a treatment plan that includes gentle adjustments of the child’s neck and spine. The goal is to decrease fluid build up within the ear canals that bring on ear infections and pain.
It Is A Painless Option Of Treatment
The last thing parents want in any medical treatment is to cause their child more pain. A negative experience at a doctor’s office can create a fear that lasts for years to come.
Children with ear infections have nothing to fear from visiting a chiropractor. During a chiropractic visit, the child will participate in adjustments that are pain free. The treatments will be able to reduce the pain in a short amount of time in many instances, and reduce the chance of dealing with another ear infection down the road.
It Treats The Underlying Cause
Other options of treatment may decrease the symptoms of an ear infection, but never get to the actual root issue. Chiropractic care strives to return the body in its entirety to its normal function.
This is the main building block concept for chiropractic in general. By re-aligning the spine, the body as a whole can be healthier and more resistant to infection and disease. Chiropractic care helps adjust the child’s body back to a normal state, thus providing a way for it to heal itself and fight off future ear (and other) infections better than simply using drops and antibiotics.
If your child is susceptible to ear infections, there are steps you can take to minimize the chances of an occurrence in the first place. Frequent hand washing to prevent the spread of germs and avoiding cigarette smoke are two simple ways to combat ear infections.
Chiropractic treatment continues to show promise in treating the underlying issues that cause a child to suffer from ear infections. If you are looking for a treatment that is pain free, not intimidating to the child, and an alternative to invasive surgery, enlisting the help of a chiropractor is a fantastic option.
So if your child is experiencing chronic ear infections, give us a call. Our Doctor of Chiropractic is here to help!
Doctors Of Chiropractic Ensure Patients Have Strong Posture
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Muscle Energy Techniques: A revolution has taken place in manipulative therapy involving a movement away from high velocity/low amplitude thrusts (HVT � now commonly known as �mobilization with impulse� and characteristic of most chiropractic and, until recently, much osteopathic manipulation) towards gentler methods which take far more account of the soft tissue component (DiGiovanna 1991, Lewit 1999, Travell & Simons 1992).
Greenman (1996) states that: �Early [osteopathic] techniques did speak of muscle relaxation with soft tissue procedures, but specific manipulative approaches to muscle appear to be 20th century phenomena.� One such approach � which targets the soft tissues primarily, although it also makes a major contribution towards joint mobilization � has been termed muscle energy technique (MET) in osteopathic medicine. There are a variety of other terms used to describe this approach, the most general (and descriptively accurate) of which was that used by chiropractor Craig Liebenson (1989, 1990) when he described muscle energy techniques as �active muscular relaxation techniques�. Muscle energy techniques evolved out of osteopathic procedures developed by pioneer practitioners such as T. J. Ruddy (1961), who termed his approach �resistive duction�, and Fred Mitchell Snr (1967). As will become clear in this chapter, there also exists a commonality between Muscle energy techniques and various procedures used in orthopaedic and physiotherapy methodology, such as proprioceptive neuromuscular facilitation (PNF). Largely due to the work of experts in physical medicine such as Karel Lewit (1999), MET has evolved and been refined, and now crosses all interdisciplinary boundaries.
MET has as one of its objectives the induced relaxation of hypertonic musculature and, where�appropriate (see below), the subsequent stretching of the muscle. This objective is shared with a number of �stretching� systems, and it is necessary to examine and to compare the potential benefits and drawbacks of these various methods (see Box 1.1).
MET, as presented in this book, owes most of its development to osteopathic clinicians such as T. J. Ruddy (1961) and Fred Mitchell Snr (1967), with more recent refinements deriving from the work of people such as Karel Lewit (1986, 1999) and Vladimir Janda (1989) of the former Czechoslovakia, both of whose work will be referred to many times in this text.
T. J. Ruddy (1961)
In the 1940s and 50s, osteopathic physician T. J. Ruddy developed a treatment method involving patient-induced, rapid, pulsating contractions against resistance which he termed �rapid resistive duction�. It was in part this work which Fred Mitchell Snr used as the basis for the evolution of MET (along with PNF methodology, see Box 1.1). Ruddy�s method called for a series of rapid, low amplitude muscle contractions against resistance, at a rate a little faster than the pulse rate. This approach is now known as pulsed MET, rather than the tongue-twisting �Ruddy�s rapid resistive duction�.
As a rule, at least initially, these patient-directed pulsating contractions involve an effort towards the barrier, using antagonists to shortened structures. This approach can be applied in all areas where sustained contraction muscle energy technique procedures are appropriate, and is particularly useful for self-treatment, following instruction from a skilled practitioner. Ruddy suggests that the effects include improved local oxygenation, venous and lymphatic circulation, as well as a positive influence on both static and kinetic posture, because of the effects on proprioceptive and interoceptive afferent pathways.
Ruddy�s work formed part of the base on which Mitchell Snr and others constructed MET and aspects of its clinical application are described in Chapter 3.
Fred Mitchell Snr
No single individual was alone responsible for MET, but its inception into osteopathic work must be credited to F. L. Mitchell Snr, in 1958. Since then his son F. Mitchell Jnr (Mitchell et al 1979) and many others have evolved a highly sophisticated system of manipulative methods (F. Mitchell Jnr, tutorial on biomechanical procedures, American Academy of Osteopathy, 1976) in which the patient �uses his/her muscles, on request, from a precisely controlled position in a specific direction, against a distinctly executed counterforce�.
Philip Greenman
Professor of biomechanics Philip Greenman (1996) states that:
The function of any articulation of the body which can be moved by voluntary muscle action, either directly or indirectly, can be influenced by muscle energy procedures … . Muscle energy techniques can be used to lengthen a shortened, contractured or spastic muscle; to strengthen a physiologically weakened muscle or group of muscles; to reduce localized edema, to relieve passive congestion, and to mobilize an articulation with restricted mobility.
Sandra Yale
Osteopathic physician Sandra Yale (in DiGiovanna 1991) extols MET�s potential in even fragile and severely ill patients:
Muscle energy techniques are particularly effective in patients who have severe pain from acute somatic dysfunction, such as those with a whiplash injury from a car accident, or a patient with severe muscle spasm from a fall. MET methods are also an excellent treatment modality for hospitalized or bedridden patients. They can be used in older patients who may have severely restricted motion from arthritis, or who have brittle osteoporotic bones.
Edward Stiles
Among the key MET clinicians is Edward Stiles, who elaborates on the theme of the wide range of MET application (Stiles 1984a, 1984b). He states that:
Basic science data suggests the musculoskeletal system plays an important role in the function of other systems. Research indicates that segmentally related somatic and visceral structures may affect one another directly, via viscerosomatic and somaticovisceral reflex pathways. Somatic dysfunction may increase energy demands, and it can affect a wide variety of bodily processes; vasomotor control, nerve impulse patterns (in facilitation), axionic flow of neurotrophic proteins, venous and lymphatic circulation and ventilation. The impact of somatic dysfunction on various combinations of these functions may be associated with myriad symptoms and signs. A possibility which could account for some of the observed clinical effects of manipulation.
As to the methods of manipulation he now uses clinically, Stiles states that he employs muscle energy methods on about 80% of his patients, and functional techniques (such as strain/counterstrain) on 15�20%. He uses high velocity thrusts on very few cases. The most useful manipulative tool available is, he maintains, muscle energy techniques.
J. Goodridge and W. Kuchera
Modern osteopathic refinements of MET � for example the emphasis on very light contractions which has strongly influenced this text � owe much to physicians such as John Goodridge and William Kuchera, who consider that (Goodridge & Kuchera 1997):
Localization of force is more important than intensity. Localization depends on palpatory proprioceptive perception of movement (or resistance to movement) at or about a specific articulation … . Monitoring and confining forces to the muscle group or level of somatic dysfunction involved are important for achieving desirable changes. Poor results are most often due to improperly localized forces, often with excessive patient effort.
Early Sources Of Muscle Energy Techniques
MET emerged squarely out of osteopathic tradition, although a synchronous evolution of treatment methods, involving isometric contraction and stretching, was taking place independently in physical therapy, called PNF (see Box 1.1).
Fred Mitchell Snr (1958) quoted the words of the developer of osteopathy, Andrew Taylor Still: �The attempt to restore joint integrity before soothingly restoring muscle and ligamentous normality was putting the cart before the horse.� As stated earlier, Mitchell�s work drew on the methods developed by Ruddy; however, it is unclear whether Mitchell Snr, when he was refining MET methodology in the early 1950s, had any awareness of proprioceptive neuromuscular facilitation (PNF), a method which had been developed a few years earlier, in the late 1940s, in a physical therapy context (Knott & Voss 1968).
PNF method tended to stress the importance of rotational components in the function of joints and muscles, and employed these using resisted (isometric) forces, usually involving extremely strong contractions. Initially, the focus of PNF related to the strengthening of neurologically weakened muscles, with attention to the release of muscle spasticity following on from this, as well as to improving range of motion at intervertebral levels (Kabat 1959, Levine et al 1954) (see Box 1.1).
Postisometric Relaxation & Reciprocal Inhibition: Two Forms Of MET (Box 1.2)
A term much used in more recent developments of muscle energy techniques is postisometric relaxation (PIR), especially in relation to the work of Karel Lewit (1999). The term postisometric relaxation refers to the effect of the subsequent reduction in tone experienced by a muscle, or group of muscles, after brief periods during which an isometric contraction has been performed.
The terms proprioceptive neuromuscular facilitation (PNF) and postisometric relaxation (PIR) (the latent hypotonic state of a muscle following isometric activity) therefore represent variations on the same theme. A further variation involves the physiological response of the antagonists of a muscle which has been isometrically contracted � reciprocal inhibition (RI).
When a muscle is isometrically contracted, its antagonist will be inhibited, and will demonstrate reduced tone immediately following this. Thus the antagonist of a shortened muscle, or group of muscles, may be isometrically contracted in order to achieve a degree of ease and additional movement potential in the shortened tissues.
Sandra Yale (in DiGiovanna 1991) acknowledges that, apart from the well understood processes of reciprocal inhibition, the precise reasons for the effectiveness of MET remain unclear � although in achieving PIR the effect of a sustained contraction on the Golgi tendon organs seems pivotal, since their response to such a contraction seems to be to set the tendon and the muscle to a new length by inhibiting it (Moritan 1987). Other variations on this same theme include �hold�relax� and �contract�relax� techniques (see Box 1.1).
Lewit & Simons (1984) agree that while reciprocal inhibition is a factor in some forms of therapy related to postisometric relaxation techniques, it is not a factor in PIR itself, which is a phenomenon resulting from a neurological loop, probably involving the Golgi tendon organs (see Figs 1.1 and 1.2).
Liebenson (1996) discusses both the benefits of, and the mechanisms involved in, use of muscle energy techniques (which he terms �manual resistance techniques�, or MRT):
Two aspects to MRT [i.e. MET by another name] are their ability to relax an overactive muscle … and their ability to enhance stretch of a shortened muscle or its associated fascia when connective tissue or viscoelastic changes have occurred.
Two fundamental neurophysiological principles account for the neuromuscular inhibition that occurs during application of these techniques. The first is postcontraction inhibition [also known as postisometric relaxation, or PIR], which states that after a muscle is contracted, it is automatically in a relaxed state for a brief, latent, period. The second is reciprocal inhibition (RI) which states that when one muscle is contracted, its antagonist is automatically inhibited.
Liebenson suggests that there is evidence that the receptors responsible for PIR lie within the muscle and not in the skin or associated joints (Robinson 1982).
Where pain of an acute or chronic nature makes controlled contraction of the muscles involved difficult, the therapeutic use of the antagonists can patently be of value. Thus modern MET incorporates both postisometric relaxation and reciprocal inhibition methods, as well as aspects unique to itself, such as isokinetic techniques, described later.
A number of researchers, including Karel Lewit of Prague (Lewit 1999), have reported on the usefulness of aspects of MET in the treatment of trigger points, and this is seen by many to be an excellent method of treating these myofascial states, and of achieving the restoration of a situation where the muscle in which the trigger lies is once more capable of achieving its full resting length, with no evidence of shortening.
Travell & Simons (1992) mistakenly credited Lewit with developing MET, stating that �The concept of applying post-isometric relaxation in the treatment of myofascial pain was presented for the first time in a North American journal in 1984 [by Lewit]�. In fact Mitchell Snr had described the method some 25 years previously, a fact acknowledged by Lewit (Lewit & Simons 1984).
Key Points About Modern Muscle Energy Techniques
MET methods all employ variations on a basic theme. This primarily involves the use of the patient�s own muscular efforts in one of a number of ways, usually in association with the efforts of the therapist:
1. The operator�s force may exactly match the effort of the patient (so producing an isometric contraction) allowing no movement to occur � and producing as a result a physiological neurological response (via the Golgi tendon organs) involving a combination of:
� reciprocal inhibition of the antagonist(s) of the muscle(s) being contracted, as well as
� postisometric relaxation of the muscle(s) which are being contracted.
The operator�s force may overcome the effort of the patient, thus moving the area or joint in the direction opposite to that in which the patient is attempting to move it (this is an isotonic eccentric contraction, also known as an isolytic contraction).
The operator may partially match the effort of the patient, thus allowing, although slightly retarding, the patient�s effort (and so producing an isotonic concentric, isokinetic, contraction).
Other variables may be also introduced, for example involving:
l Whether the contraction should commence with the muscle or joint held at the resistance barrier or short of it � a factor decided largely on the basis of the degree of chronicity or acuteness of the tissues involved
How much effort the patient uses � say, 20% of strength, or more, or less
The length of time the effort is held � 7�10 seconds, or more, or less (Lewit (1999) favours 7� 10 seconds; Greenman (1989), Goodridge & Kuchera (1997) all favour 3�5 seconds)
Whether, instead of a single maintained contraction, to use a series of rapid, low amplitude contractions (Ruddy�s rhythmic resisted duction method, also known as pulsed muscle energy techniques)
The number of times the isometric contraction (or its variant) is repeated � three repetitions are thought to be optimal (Goodridge & Kuchera 1997)
The direction in which the effort is made � towards the resistance barrier or away from it, thus involving either the antagonists to the muscles or the actual muscles (agonists) which require �release� and subsequent stretching (these variations are also known as �direct� and �indirect� approaches, see p. 8)
Whether to incorporate a held breath and/or specific eye movements to enhance the effects of the contraction � desirable if possible, it is suggested (Goodridge & Kuchera 1997, Lewit 1999)
What sort of resistance is offered (for example by the operator, by gravity, by the patient, or by an immovable object)
Whether the patient�s effort is matched, overcome or not quite matched � a decision based on the precise needs of the tissues � to achieve relaxation, reduction in fibrosis or tonifying/ reeducation
Whether to take the muscle or joint to its new barrier following the contraction, or whether or not to stretch the area/muscle(s) beyond the barrier � this decision is based on the nature of�the problem being addressed (does it involve shortening? fibrosis?) and its degree of chronicity
Whether any subsequent (to a contraction) stretch is totally passive, or whether the patient should participate in the movement, the latter being thought by many to be desirable in order to reduce danger of stretch reflex activation (Mattes 1995)
Whether to utilize Muscle energy techniques alone, or in a sequence with other modalities such as the positional release methods of strain/counterstrain, or the ischaemic compression/inhibitory pressure techniques of neuromuscular technique (NMT) � such decisions will depend upon the type of problem being addressed, with myofascial trigger point treatment frequently benefiting from such combinations (see description of integrated neuromuscular inhibition (INIT), p. 197 (Chaitow 1993)).
Greenman summarises the requirements for the successful use of MET in osteopathic situations as �control, balance and localisation�. His suggested basic elements of MET include the following:
A patient/active muscle contraction, which
� commences from a controlled position
� is in a specific direction (towards or away from a restriction barrier)
The operator applies distinct counterforce (to meet, not meet, or to overcome the patient�s force)
The degree of effort is controlled (sufficient to obtain an effect but not great enough to induce trauma or difficulty in controlling the effort).
What is done subsequent to the contraction may involve any of a number of variables, as will be explained.
The essence of MET then is that it uses the energy of the patient, and that it may be employed in one or other of the manners described above with any combination of variables depending upon the particular needs of the case. Goodridge (one of the first osteopaths to train with Mitchell Snr in 1970) summarises as follows: �Good results [with MET] depend on accurate diagnosis, appropriate levels of force, and sufficient localization. Poor results are most often caused by inaccurate diagnosis, improperly localized forces, or forces that are too strong� (Goodridge & Kuchera 1997) (see also Box 1.3).
Using agonist or antagonist? (Box 1.4)
As mentioned, a critical consideration in MET, apart from degree of effort, duration and frequency of use, involves the direction in which the effort is made. This may be varied, so that the operator�s�force is directed towards overcoming the restrictive barrier (created by a shortened muscle, restricted joint, etc.); or indeed opposite forces may be used, in which the operator�s counter-effort is directed away from the barrier.
There is general consensus among the various osteopathic experts already quoted that the use of postisometric relaxation is more useful than reciprocal inhibition in normalizing hypertonic musculature. This, however, is not generally held to be the case by experts such as Lewit and Janda, who see specific roles for the reciprocal inhibition variation.
Osteopathic clinicians such as Stiles and Greenman believe that the muscle which requires stretching (the agonist) should be the main source of �energy� for the isometric contraction, and suggest that this achieves a more significant degree of relaxation, and so a more useful ability to subsequently stretch the muscle, than would be the case were the relaxation effect being achieved via use of the antagonist (i.e. using reciprocal inhibition).
Following on from an isometric contraction � whether agonist or antagonist is being used � there is a refractory, or latency, period of approximately 15 seconds during which there can be an easier (due to reduced tone) movement towards the new position (new resistance barrier) of a joint or muscle.
Variations On The Muscle Energy Techniques Theme
Liebenson (1989, 1990) describes three basic variations which are used by Lewit and Janda as well as by himself in a chiropractic rehabilitation setting.
Lewit�s (1999) modification of MET, which he calls postisometric relaxation, is directed towards relaxation of hypertonic muscle, especially if this relates to reflex contraction or the involvement of myofascial trigger points. Liebenson (1996) notes that �this is also a suitable method for joint mobilisation when a thrust is not desirable�.
Lewit�s postisometric relaxation method
(Lewit 1999)
The hypertonic muscle is taken, without force or �bounce�, to a length just short of pain, or to the point where resistance to movement is first noted (Fig. 1.3).
The patient gently contracts the affected hypertonic muscle away from the barrier (i.e. the agonist is used) for between 5 and 10 seconds, while the effort is resisted with an exactly equal counterforce. Lewit usually has the patient inhale during this effort.
This resistance involves the operator holding the contracting muscle in a direction which would stretch it, were resistance not being offered.
The degree of effort, in Lewit�s method, is minimal. The patient may be instructed to think in terms of using only 10 or 20% of his available strength, so that the manoeuvre is never allowed to develop into a contest of strength between the operator and the patient.
After the effort, the patient is asked to exhale and to let go completely, and only when this is achieved is the muscle taken to a new barrier with all slack removed but no stretch � to the extent that the relaxation of the hypertonic muscles will now allow.
Starting from this new barrier, the procedure is repeated two or three times.
In order to facilitate the process, especially where trunk and spinal muscles are involved, Lewit usually asks the patient to assist by looking with his eyes in the direction of the contraction during the contracting phase, and in the direction of stretch during the stretching phase of the procedure.
The key elements in this approach, as in most MET, involve precise positioning, as well as taking out slack and using the barrier as the starting and ending points of each contraction.
What Is Happening?
Karel Lewit, discussing MET methods (Lewit 1999), states that medullary inhibition is not capable of explaining their effectiveness. He considers that the predictable results obtained may relate to the following facts:
During resistance using minimal force (isometric contraction) only a very few fibers are active, the others being inhibited
During relaxation (in which the shortened musculature is taken gently to its new limit without stretching) the stretch reflex is avoided � a reflex which may be brought about even by passive and non-painful stretch (see Mattes� views p. 3).
He concludes that this method demonstrates the close connection between tension and pain, and between relaxation and analgesia.
The use of eye movements as part of the methodology is based on research by Gaymans (1980) which indicates, for example, that flexion is enhanced by the patient looking downwards, and extension by the patient looking upwards. Similarly, sidebending is facilitated by looking towards the side involved. These ideas are easily proved by self-experiment: an attempt to flex the spine while maintaining the eyes in an upwards (towards the forehead) looking direction will be found to be less successful than an attempt made to flex while looking downwards. These eye-direction aids are also useful in manipulation of the joints.
Effects of Muscle energy techniques
Lewit (1999) discusses the element of passive muscular stretch in MET and maintains that this factor does not always seem to be essential. In some areas, self-treatment, using gravity as the resistance factor, is effective, and such cases sometimes involve no element of stretch of the muscles in question. Stretching of muscles during MET, according to Lewit (1999), is only required when contracture due to fibrotic change has occurred, and is not necessary if there is simply a disturbance in function. He quotes results in one series of patients in his own clinic in which 351 painful muscle groups, or muscle attachments, were treated by MET (using postisometric�relaxation) in 244 patients. Analgesia was immediately achieved in 330 cases and there was no effect in only 21 cases. These are remarkable results by any standards.
Lewit suggests, as do many others, that trigger points and �fibrositic� changes in muscle will often disappear after MET contraction methods. He further suggests that referred local pain points, resulting from problems elsewhere, will also disappear more effectively than where local anaesthesia or needling (acupuncture) methods are employed.
Janda�s postfacilitation stretch method
Janda�s variation on this approach (Janda 1993), known as �postfacilitation stretch�, uses a different starting position for the contraction and also a far stronger isometric contraction than that suggested by Lewit and most osteopathic users of Muscle energy techniques:
The shortened muscle is placed in a mid-range position about halfway between a fully stretched and a fully relaxed state.
The patient contracts the muscle isometrically, using a maximum degree of effort for 5�10 seconds while the effort is resisted completely.
On release of the effort, a rapid stretch is made to a new barrier, without any �bounce�, and this is held for at least 10 seconds.
The patient relaxes for approximately 20 seconds and the procedure is repeated between three and five times more.
Some sensations of warmth and weakness may be anticipated for a short while following this more vigorous approach.
Reciprocal inhibition variation
This method, which forms a component of PNF methodology (see Box 1.1) and Muscle energy techniques, is mainly used in acute settings, where tissue damage or pain precludes the use of the more usual agonist contraction, and also commonly as an addition to such methods, often to conclude a series of stretches whatever other forms of MET have been used (Evjenth & Hamberg 1984):
The affected muscle is placed in a mid-range position.
The patient is asked to push firmly towards the restriction barrier and the operator either completely resists this effort (isometric) or allows a movement towards it (isotonic). Some degree of rotational or diagonal movement may be incorporated into the procedure.
On ceasing the effort, the patient inhales and exhales fully, at which time the muscle is passively lengthened.
Liebenson notes that �a resisted isotonic effort towards the barrier is an excellent way in which to facilitate afferent pathways at the conclusion of treatment with active muscular relaxation techniques or an adjustment (joint). This can help reprogram muscle and joint proprioceptors and thus re-educate movement patterns.� (See Box 1.2.)
Strengthening variation
Another major muscle energy variation is to use what has been called isokinetic contraction (also known as progressive resisted exercise). In this the patient starts with a weak effort but rapidly progresses to a maximal contraction of the affected muscle(s), introducing a degree of resistance to the operator�s effort to put the joint, or area, through a full range of motion. The use of isokinetic contraction is reported to be a most effective method of building strength, and to be superior to high repetition, lower resistance exercises (Blood 1980). It is also felt that a limited range of motion, with good muscle tone, is preferable (to the patient) to having a normal range with limited power. Thus the strengthening of weak musculature in areas of permanent limitation of mobility is seen as�an important contribution in which isokinetic contractions may assist.
Isokinetic contractions not only strengthen the fibres which are involved, but also have a training effect which enables them to operate in a more coordinated manner. There is often a very rapid increase in strength. Because of neuromuscular recruitment, there is a progressively stronger muscular effort as this method is repeated. Isokinetic contractions, and accompanying mobilisation of the region, should take no more than 4 seconds at each contraction in order to achieve maximum benefit with as little fatiguing as possible, either of the patient or the operator. Prolonged contractions should be avoided. The simplest, safest, and easiest-to-handle use of isokinetic methods involves small joints, such as those in the extremities. Spinal joints may be more difficult to mobilise while muscular resistance is being fully applied.
The options available in achieving increased strength via these methods therefore involve a choice between either a partially resisted isotonic contraction, or the overcoming of such a contraction, at the same time as the full range of movement is being introduced (note that both isotonic concentric and eccentric contractions will take place during the isokinetic movement of a joint). Both of these options should involve maximum contraction of the muscles by the patient. Home treatment of such conditions is possible, via self-treatment, as in other MET methods.
Isolytic Muscle Energy Techniques
Another application of the use of isotonic contraction occurs when a direct contraction is resisted and overcome by the operator (Fig. 1.4). This has been termed isolytic contraction, in that it involves the stretching, and sometimes the breaking down, of fibrotic tissue present in the affected muscles. Adhesions of this type are reduced by the application of force by the operator which is just greater than that being exerted by the patient. This procedure can be uncomfortable, and the patient should be advised of this. Limited degrees of effort are therefore called for at the outset of isolytic contractions. This is an isotonic eccentric contraction, in that the origins and insertions of the muscles involved will become further separated, despite the patient�s effort to approximate them. In order to achieve the greatest degree of stretch (in the condition of myofascial fibrosis, for example), it is necessary for the largest number of fibers possible to be involved in the isotonic contraction. Thus there is a contradiction in that, in order to achieve this large involvement, the degree of contraction should be a maximal one, and yet this is likely to produce pain, which is contraindicated. It may also, in many instances, be impossible for the operator to overcome.
This stretches the muscles which are contracting (TFL shown in example) thereby inducing a degree of controlled microtrauma, with the aim of increasing the elastic potential of shortened or fibrosed tissues.
The patient should be instructed to use about 20% of possible strength on the first contraction, which is resisted and overcome by the operator, in a contraction lasting 3�4 seconds. This is then repeated, but with an increased degree of effort on the part of the patient (assuming the first effort was relatively painless). This continuing increase in the amount of force employed in the contracting musculature may be continued until, hopefully, a maximum contraction effort is possible, again to be overcome by the operator. In some muscles, of course, this may require a heroic degree of effort on the part of the operator, and alternative methods are therefore desirable. Deep tissue techniques, such as neuromuscular technique, would seem to offer such an alternative. The isolytic manoeuvre should have as its ultimate aim a fully relaxed muscle, although this will not always be possible.
Why Fibrosis Occurs Naturally
An article in the Journal of the Royal Society of Medicine (Royal Society of Medicine 1983) discusses connective tissue changes:
Aging affects the function of connective tissue more obviously than almost any organ system. Collagen fibrils thicken, and the amounts of soluble polymer decrease. The connective tissue cells tend to decline in number, and die off. Cartilages become less elastic, and their complement of proteoglycans changes both quantitatively and qualitatively. The interesting question is how many of these processes are normal, that contribute blindly and automatically, beyond the point at which they are useful? Does prevention of aging, in connective tissues, simply imply inhibition of cross linking in collagen fibrils, and a slight stimulation of the production of chondroitin sulphate proteoglycan?
The effects of various soft tissue approaches such as NMT and Muscle energy techniques will impact directly on these tissues as well as on the circulation and drainage of the affected structures, which suggests that the ageing process can be influenced. Destruction of collagen fibrils, however, is a serious matter (for example when using isolytic stretches), and although the fibrous tissue may be replaced in the process of healing, scar-tissue formation is possible, and this makes repair inferior to the original tissues, both in functional and structural terms. An isolytic contraction has the ability to break down tight, shortened tissues and the replacement of these with superior material will depend, to a large extent, on the subsequent use of the area (exercise, etc.), as well as the nutritive status of the individual. Collagen formation is dependent on adequate vitamin C, and a plentiful supply of amino acids such as proline, hydroxyproline and arginine. Manipulation, aimed at the restoration of a degree of normality in connective tissues, should therefore take careful account of nutritional requirements.
The range of choices in stretching, irrespective of the form of prelude to this � strong or mild isometric contraction, starting at or short of the barrier � therefore covers the spectrum from all- passive to all-active, with many variables in between.
Putting It Together
Many may prefer to use the variations, as described above, within individual settings. The recommendation of this text, however, is that they should be �mixed and matched� so that elements of all of them may be used in any given setting, as appropriate. Lewit�s (1999) approach seems ideal for more acute and less chronic conditions, while Janda�s (1989) more vigorous methods seem�ideal for hardy patients with chronic muscle shortening.
Muscle energy techniques offers a spectrum of approaches which range from those involving hardly any active contraction at all, relying on the extreme gentleness of mild isometric contractions induced by breath-holding and eye movements only, all the way to the other extreme of full-blooded, total- strength contractions. Subsequent to isometric contractions � whether strong or mild � there is an equally sensitive range of choices, involving either energetic stretching or very gentle movement to a new restriction. We can see why Sandra Yale (in DiGiovanna 1991) speaks of the usefulness of MET in treating extremely ill patients.
Many patients present with a combination of recent dysfunction (acute in terms of time, if not in degree of pain or dysfunction) overlaid on chronic changes which have set the scene for their acute current problems. It seems perfectly appropriate to use methods which will deal gently with hypertonicity, and more vigorous methods which will help to resolve fibrotic change, in the same patient, at the same time, using different variations on the theme of MET. Other variables can be used which focus on joint restriction, or which utilise RI should conditions be too sensitive to allow PIR methods, or variations on Janda�s more vigorous stretch methods (see Box 1.1).
Discussion of common errors in application of Muscle energy techniques will help to clarify these thoughts.
Why Muscle Energy Techniques Might Be Ineffective At Times
Poor results from use of Muscle energy techniques may relate to an inability to localize muscular effort sufficiently, since unless local muscle tension is produced in the precise region of the soft tissue dysfunction, the method is likely to fail to achieve its objectives. Also, of course, underlying pathological changes may have taken place, in joints or elsewhere, which make such an approach of short-term value only, since such changes will ensure recurrence of muscular spasms, sometimes almost immediately.
MET will be ineffective, or cause irritation, if excessive force is used in either the contraction phase or the stretching phase.
The keys to successful application of Muscle energy techniques therefore lie in a precise focusing of muscular activity, with an appropriate degree of effort used in the isometric contraction, for an adequate length of time, followed by a safe movement through the previous restriction barrier, usually with patient assistance.
Use of variations such as stretching chronic fibrotic conditions following an isometric contraction and use of the integrated approach (INIT) mentioned earlier in this chapter represent two examples of further adaptations of Lewit�s basic approach which, as described above, is ideal for acute situations of spasm and pain.
To Stretch Or To Strengthen?
Marvin Solit (1963), a former pupil of Ida Rolf, describes a common error in application of Muscle energy techniques � treating the �wrong� muscles the �wrong� way:
As one looks at a patient�s protruding abdomen, one might think that the abdominal muscles are weak, and that treatment should be geared towards strengthening them. By palpating the abdomen, however, one would not feel flabby, atonic muscles which would be the evidence of weakness; rather, the muscles are tight, bunched and shortened. This should not be surprising because here is an example of muscle working overtime maintaining body equilibrium. In addition these muscles are supporting the sagging viscera, which normally would be supported by their individual ligaments. As�the abdominal muscles are freed and lengthened, there is a general elevation of the rib cage, which in turn elevates the head and neck.
Attention to tightening and hardening these supposedly weak muscles via exercise, observes Solit, results in no improvement in posture, and no reduction in the �pot-bellied� appearance. Rather, the effect is to further depress the thoracic structures, since the attachments of the abdominal muscles, superiorly, are largely onto the relatively mobile, and unstable, bones of the rib cage. Shortening these muscles simply achieves a degree of pull on these structures towards the stable pelvic attachments below.
The approach to this problem adopted by Rolfers is to free and loosen these overworked and only apparently weakened tissues. This allows for a return to some degree of normality, freeing the tethered thoracic structures, and thus correcting the postural imbalance. Attention to the shortened, tight musculature, which will also be inhibiting their antagonist muscles, should be the primary aim. Exercise is not suitable at the outset, before this primary goal is achieved.
The common tendency in some schools of therapy to encourage the strengthening of weakened muscle groups in order to normalise postural and functional problems is also discussed by Vladimir Janda (1978). He expresses the reasons why this approach is �putting the cart before the horse�: �In pathogenesis, as well as in treatment of muscle imbalance and back problems, tight muscles play a more important, and perhaps even primary, role in comparison to weak muscles� (Fig. 1.5). He continues with the following observation:
Clinical experience, and especially therapeutic results, support the assumption that (according to Sherrington�s law of reciprocal innervation) tight muscles act in an inhibitory way on their antagonists. Therefore, it does not seem reasonable to start with strengthening of the weakened muscles, as most exercise programmes do. It has been clinically proved that it is better to stretch tight muscles first. It is not exceptional that, after stretching of the tight muscles, the strength of the weakened antagonists improves spontaneously, sometimes immediately, sometimes within a few days, without any additional treatment.
This sound, well-reasoned, clinical and scientific observation, which directs our attention and efforts towards the stretching and normalizing of those tissues which have shortened and tightened, seems irrefutable, and this theme will be pursued further in Chapter 2.
Muscle energy techniques are designed to assist in this endeavor and, as discussed above, also provides an excellent method for assisting in the toning of weak musculature, should this still be required, after the stretching of the shortened antagonists, by use of isotonic methods.
Tendons
Aspects of the physiology of muscles and tendons are worthy of a degree of review, in so far as Muscle energy techniques and its effects are concerned (see also Box 1.5). The tone of muscle is largely the job of the Golgi tendon organs. These detect the load applied to the tendon, via muscular contraction. Reflex effects, in the appropriate muscles, are the result of this information being passed from the Golgi tendon organ back along the cord. The reflex is an inhibitory one, and thus differs from the muscle spindle stretch reflex. Sandler (1983) describes some of the processes involved:
When the tension on the muscles, and hence the tendon, becomes extreme, the inhibitory effect from the tendon organ can be so great that there is sudden relaxation of the entire muscle under stretch. This effect is called the lengthening reaction, and is probably a protective reaction to the force which, if unprotected, can tear the tendon from its bony attachments. Since the Golgi tendon organs, unlike the [muscle] spindles, are in series with the muscle fibres, they are stimulated by both passive and active contractions of the muscles.
Pointing out that muscles can either contract with constant length and varied tone (isometrically), or with constant tone and varied length (isotonically), he continues: �In the same way as the gamma efferent system operates as a feedback to control the length of muscle fibers, the tendon reflex serves as a reflex to control the muscle tone�.
The relevance of this to soft tissue techniques is explained as follows:
In terms of longitudinal soft tissue massage, these organs are very interesting indeed, and it is perhaps the reason why articulation of a joint, passively, to stretch the tendons that pass over the joint, is often as effective in relaxing the soft tissues as direct massage of the muscles themselves. Indeed, in some cases, where the muscle is actively in spasm, and is likely to object to being pummelled directly, articulation, muscle energy techniques, or functional balance techniques, that make use of the tendon organ reflexes, can be most effective.
The use of this knowledge in therapy is obvious and Sandler explains part of the effect of massage on muscle: �The [muscle] spindle and its reflex connections constitute a feedback device which can�operate to maintain constant muscle length, as in posture; if the muscle is stretched the spindle discharges increase, but if the muscle is shortened, without a change in the rate of gamma discharge, then the spindle discharge will decrease, and the muscle will relax.�
Sandler believes that massage techniques cause a decrease in the sensitivity of the gamma efferent, and thus increase the length of the muscle fibers rather than a further shortening of them; this produces the desired relaxation of the muscle. Muscle energy techniques provides for the ability to influence both the muscle spindles and also the Golgi tendon organs.
Joints & Muscle Energy Techniques
Bourdillon (1982) tells us that shortening of muscle seems to be a self-perpetuating phenomenon which results from an over-reaction of the gamma-neuron system. It seems that the muscle is incapable of returning to a normal resting length as long as this continues. While the effective length of the muscle is thus shortened, it is nevertheless capable of shortening further. The pain factor seems related to the muscle�s inability thereafter to be restored to its anatomically desirable length. The conclusion is that much joint restriction is a result of muscular tightness and shortening. The opposite may also apply where damage to the soft or hard tissues of a joint is a factor. In such cases the periarticular and osteophytic changes, all too apparent in degenerative conditions, are the major limiting factor in joint restrictions. In both situations, however, Muscle energy techniques may be useful, although more useful where muscle shortening is the primary factor.
The restriction which takes place as a result of tight, shortened muscles is usually accompanied by some degree of lengthening and weakening of the antagonists. A wide variety of possible permutations exists in any given condition involving muscular shortening which may be initiating, or be secondary to, joint dysfunction combined with weakness of antagonists. A combination of isometric and isotonic methods can effectively be employed to lengthen and stretch the shortened groups, and to strengthen and shorten the weak, overlong muscles.
Paul Williams (1965) stated a basic truth which is often neglected by the professions which deal with musculoskeletal dysfunction:
The health of any joint is dependent upon a balance in the strength of its opposing muscles. If for any reason a flexor group loses part, or all of its function, its opposing tensor group will draw the joint into a hyperextended position, with abnormal stress on the joint margins. This situation exists in the lumbar spine of modern man.
Lack of attention to the muscular component of joints in general, and spinal joints in particular, results in frequent inappropriate treatment of the joints thus affected. Correct understanding of the role of the supporting musculature would frequently lead to normalisation of these tissues, without the need for heroic manipulative efforts. Muscle energy techniques and other soft tissue approaches focus attention on these structures and offer the opportunity to correct both the weakened musculature and the shortened, often fibrotic, antagonists.
More recently, Norris (1999) has pointed out that:
The mixture of tightness and weakness seen in the muscle imbalance process alters body segment alignment and changes the equilibrium point of a joint. Normally the equal resting tone of the agonist and antagonist muscles allows the joint to take up a balanced position where the joint surfaces are evenly loaded and the inert tissues of the joint are not excessively stressed. However if the muscles on one side of a joint are tight and the opposing muscles relax, the joint will be pulled out of alignment towards the tight muscle(s).
Such alignment changes produce weight-bearing stresses on joint surfaces, and result also in shortened soft tissues chronically contracting over time. Additionally such imbalances result in reduced segmental control with chain reactions of compensation emerging (see Ch. 2).
Several studies will be detailed (Chs 5 and 8) showing the effectiveness of Muscle energy techniques application in diverse population groups, including a Polish study on the benefits of Muscle energy techniques in joints damaged by haemophilia, and a Swedish study on the effects of Muscle energy techniques in treating lumbar spine dysfunction, as well as an American/Czech study involving myofascial pain problems. In the main, the results indicate a universal role in providing resolution or relief of such problems by means of the application of safe and effective muscle energy techniques.
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#3: Chiropractic Strengthens And Repairs Joints.
It Treats The Underlying Cause
Edward Stiles
Liebenson (1996) discusses both the benefits of, and the mechanisms involved in, use of muscle energy techniques (which he terms �manual resistance techniques�, or MRT):
Using agonist or antagonist? (Box 1.4)
What Is Happening?
This stretches the muscles which are contracting (TFL shown in example) thereby inducing a degree of controlled microtrauma, with the aim of increasing the elastic potential of shortened or fibrosed tissues.
Muscle energy techniques are designed to assist in this endeavor and, as discussed above, also provides an excellent method for assisting in the toning of weak musculature, should this still be required, after the 
The relevance of this to soft tissue techniques is explained as follows:
