MET Flashcards
Stretching: Definition and Purpose
A general term used to describe any
therapeutic maneuver designed to increase
mobility of soft tissues and subsequently
improve ROM by elongating (lengthening)
structures that have adaptively shortened and
have become hypomobile over time
Contracture
adaptive shortening of the muscle-tendon
unit & other STs results in sig resistance to AROM, PROM
& limitation of ROM & may compromise ADL’s.
– Types of contracture
• Myostatic contracture – motor-tendon unit with ↓ROM
• Pseudomyostatic contracture – due to CNS lesion
• Arthrogenic and periarticular contractures -
• Fibrotic contracture and irreversible contractures
Interventions to Increase Mobility of Soft Tissues
Manual or Mechanical Stretching – Utilizes an external force
Passive Stretching
– No patient assistance
Assisted Stretching – Patient assistance
Self-Stretching
– Patient performs the stretch
Neuromuscular Facilitation and Inhibition Techniques
Muscle Energy Techniques (MET – that’s us!)
Joint Mobilization/Manipulation
Soft Tissue Mobilization and Manipulation
Neural Tissue Mobilization (Neuromeningeal Mobilization)
ndications for Stretching Exercises
Adhesions, Contractures, Scar Tissue Limit ROM
Potential for Structural Deformity d/t Limited ROM
Muscle Weakness, Shortening of Muscles
Part of a Total Fitness Program
Pre and Post Vigorous Exercise
Contraindications for Stretching Exercises
Bony Block Non-Union Fracture Acute Inflammation or Infection Sharp or Acute Pain With Elongation Hematoma or Tissue Trauma Hypermobility Hypomobility Provides Stability or Neuro- muscular Control
Potential Benefits and Outcomes for Stretching Exercises
Increased Flexibility and ROM
General Fitness
Other Potential Benefits – Injury prevention
– Reduced post-exercise soreness – Enhanced performance
Properties of Soft Tissue: Response to Immobilization and Stretch
Elasticity
Viscoelasticity
plasticity
Contractile and Non-Contractile Tissue Changes – Elasticity = ability to return to the pre-stretch state
– Viscoelasticity = initial stretch resistance, once sustained it allows the change in length & return back
• Only non-contractile connective tissue
– Plasticity = tendency to assume a new & greater
length after a stretch.
Mechanical Properties of Contractile Tissue
Contractile Elements of Muscle
Mechanical Response of the Contractile Unit to
Stretch and Immobilization
– Response to stretch
– Response to immobilization and remobilization • Morphological changes
• Immobilization in a shortened position - contracts
• Immobilization in a lengthened position- keeps new
length
Neurophysiological Properties of Contractile Tissue
Muscle Spindle -muscle sensory organ for tissue length and velocity changes
Golgi Tendon Organ –Neurophysiological to monitor tension
Procedural Guidelines for Application of Stretching Interventions
Examination and Evaluation of the Patient
– Test AROM & PROM for hypomobility
– Identify the involved tissues
– Evaluate the irritability of the tissues involved
– Assess strength of the tissues, do they have the capacity to control the new ROM’s safely ?
– Set outcome goals
Preparation for stretching
– Review goals, explain procedure & obtain consent
– Select techniques
– Warm up the tissues with local heat or active low- intensity exercises or ultrasound
– Patient is comfortable position
– No restrictive clothing
– Explain the need to be relaxed & geared to your tolerance
‘Barrier’ talk
Application of Manual Stretching Procedures – Move slowly to the point of tissue restriction
– Start with a low intensity in slow manner – Gradually release the stretch
– Review how patient tolerated the stretch.
- Physiologic barrier: end of voluntary or AROM
- elastic barrier: end of PROM
- Anatomic barrier: end of ROM due to bone or soft tissue.
- Restrictive barrier- due to injury?
Barrier= 1st sign of palpated or sensed resistance to free movements.
Restrictive barrier: when motion is lost within range, barrier that prevents movement in direction of motion loss.
-can be due to congestion, oedema, pain, chronic fibrosis
-MET works to move restrictive barrier as far into direction of motion loss as possible.
After stretch procedures:
– Apply cold to the stretched tissues & allow to cool in the lengthened position to minimize post- stretch soreness (10-15 minutes Hunting reflex of Lewis)
– Patient should perform AROM and strengthening exercises through the gained ROM immediately after stretching (can it be used at home functionally?)
– Are antagonists balanced with agonists in new ROM so adequate joint control & stability?
Precautions for stretching:
– Common errors and potential problems • Nonselective or poorly balanced stretching activities • Insufficient warm-up • Ineffective stabilization • Use of ballistic stretching • Excessive intensity • Abnormal biomechanics • Insufficient information about age-related difference
What is MET
“Muscle Energy Techniques (METs) is the terminology used for a broad class of manual therapy techniques directed at improving musculoskeletal function, and improving pain”.
“Historically, the concept emerged as a form of osteopathic manipulative diagnosis and treatment in which the patient’s muscles are actively used on request, from a precisely controlled position, in a specific direction, and against a distinctly executed physician counterforce”
Why do soft tissues change from their normal elastic, adequately toned functional status to become shortened, contracted, fibrosed, weakened, lengthened and / or painful?
• Biomechanical • Biochemical • Psychosocial OR • Abuse / overuse / misuse / disuse AND • Acute / subacute / chronic
Stress/strain/ creep
- Stress – force normalised over the area on which it acts
- Strain – change in shape as a result of the stress
Creep= slow reesponse to maintaining stretch with gradual elongation
Hysteresis= if load within elastic limits when the force is removed, tissues return to their initial state
Lengthening of the elongation related to the velocity of stretch:
- load quick, tissue behaves more stiffly.
- the slower the stretch the greater the lengthening.
What does the SAID principle stand for?
Specific Adaption to Imposed Demands is what happens as tissues adapt to imposed tasks and
demands
Integrins
Tensegrity
Integrins – a family of cell surface receptors that attach cells to the matrix and mediate mechanical and chemical signals from it. They direct cells to live, die, proliferate or differentiate
Tensegrity:
Designed cytoskeletons (fascia) of cells can become distorted.
• Results in modified cellular genetic behaviour and altered absorption and metabolism of nutrients.
• That’s why space travel (gravity free) results in osteoporosis!
• Same with us in daily life?
• Posture, overuse?
Questions to keep in mind while assessing / case Hx the patient?
• Which muscle groups have shortened and why?
• Which muscles have become weaker & is it
inhibition or through atrophy?
• Is it part of a mechanical chain reaction?
• Are joint restrictions associated?
• Motor control issues associated?
• Postural issues related?
Discuss NSLBP – deconditioned? Postural? Motor control ?
See the slight of the evolution of musculoskeletal dysfunction on slide 40 and 41
s
Postural and phasic muscles, how will each respond to stress
Muscles that have a predominately stabilising function will shorten when stressed
• Muscles that have a phasic (moving) function will weaken when stressed.
slide 44
Types of contractions in MET
Isometric contractions:
Isometric muscle energy techniques primarily reduce the tone in a hypertonic muscle and re-establish its normal resting length.
Types–PostIsometricRelaxation(PIR) - Reciprocal Inhibition (RI)
Duringanisometriccontraction,distancebetween origin and the insertion of muscle is maintained at a constant length.
• A fixed tension develops in muscle as patient contracts muscle against an equal counterforce applied by operator
• Preventing shortening of muscle from origin to insertion.
Isometric PIR method for acute:
• Taken to the point where resistance (barrier) is first perceived
• Patient asked to move away from the barrier while Dr’s
unyielding motion is toward the barrier
• Slowly increase to 20% of strength contraction and hold for 7-10 seconds on an inhaled breath then instructed to
“release your effort slowly and completely”
• Once completed Pt is instructed to breath in and out, and as they exhale move the limb to the new barrier without stretch.
• Repeat 3-5 times or until no further gain in ROM is made
• Subsequent contractions may gradually be increased in duration
or strength
If acute pain, there is NO stretch, the aim is to reduce hypertonicity
Isometric PIR method.
Chronic:
CHRONIC: for stretching chronic restricted, contracted soft tissues or tissues housing active
trigger points
• Taken to the point short of resistance (barrier)
• Patient asked to move away from the barrier while Dr’s unyielding motion is
toward the barrier
• Slowly increase to 30% (at most 40%) of strength contraction and hold for 7-10 seconds on an inhaled breath then instructed to “release your effort slowly and completely”
• Once completed Pt is instructed to breath in and out (5 seconds) so that completely relaxed.
• As they exhale move the limb to the new barrier and just beyond (preference for the patient to assist with the move to the new barrier)
• Hold for at least 30 seconds and up to 60 seconds.
• Repeat 3-5 times or until no further gain in ROM is made
If acute pain, there is NO stretch, the aim is to reducing hypertonicity
Explain Reciprocal Inhibition (R.I).
Acute and chronic
When one muscle is contracted, its antagonist is automatically inhibited. Ideal for when PIR causes pain OR if contracting the antagonist hurts.
Acute; for muscular contraction / mobilizing joints / pre- manip OR if PIR causes pain on antagonist contraction
• Taken to the point where resistance (barrier) is first perceived then moved slightly back to the midline (easy barrier)
• Patient asked to move toward the barrier while Dr’s unyielding motion resists this
• Slowly increase to 20% of strength contraction and hold for 7-10 seconds on an inhaled breath then instructed to “release and relax” as they exhale
• Once completed Pt is instructed to breath in and out, and as they exhale the Dr moves the limb to the new barrier
• Repeat 3-5 times or until no further ROM gain is made.
CHRONIC: for stretching chronic restricted, contracted soft tissues or tissues housing active trigger points and toning weakened muscles
• Taken to the point short of resistance (barrier)
• Patient asked to move away from the barrier while Dr’s yielding
motion is toward the barrier
• Slowly increase to 30% (at most 40%) of strength contraction and hold for 7-10 seconds on an inhaled breath then instructed to “release your effort slowly and completely”
• Once completed Pt is instructed to breath in and out (5 seconds).
• As they exhale move the limb to the new barrier and just beyond (preference for the patient to assist with the move to the new barrier)
• Hold for at least 30 seconds and up to 60 seconds
• Repeat 3-5 times or until no further gain in ROM is made
Isotonic contraction
What would you use it for?
Isotonic concentric occurs when?
How is it done?
For toning inhibited weakened muscles Types;
– Concentric contraction: mobilize a joint against its motion barriers
– Eccentric contraction (Isolytic): fibrosed muscle.
Isotonic Concentric Contraction occurs when muscle tension causes origin and insertion to approximate.
• The patient is allowed to overpower the practitioner.
Isotonic concentreic:
• Motion starts at the mid-range position.
• Patient attempts concentric contraction but an external force is applied by practitioner in opposite direction which initially matches the patient
• Patient gradually builds the force of contraction until 20% of the patients contractile strength is achieved
• Practitioner then allows the patient to overpower him / her until the shortest length of the muscle is reached
• The duration of the contraction should be 3 – 4 seconds
• Repeat 5 to 7 times
• Useful in toning weakened muscles.
Isotonic Eccentric aka isolytic:
CAUTION
USES
GUIDELINES
- Motionstartsattherestrictionbarrier
- Patient attempts concentric contraction but an external force is applied by practitioner in opposite direction which initially matches the patient
- Patient gradually builds the force of contraction until 20% of the patients contractile strength is achieved
- Practitionerthengraduallyoverpowerspatientuntilfull length of the muscle is reached
- The duration of the contraction should be 2 – 4 seconds
- Duration is 5 – 7 seconds if for strengthening
- Useful in cases with marked degree of fibrotic change. NOT for the frail or elderly pain-sensitive or osteoporotic
CAUTION:
CAUTION; Used cautiously to lengthen a severely contracted or hypertonic muscle as rupture of musculo-tendinous junction and insertion of tendon into bone or muscle fibers can occur.
USES:
Lengthen a shortened,contracted,or spastic muscle
• Strengthen a physiologically weakened muscle
• Reduce pain
• Stretchtight fascia
• Reducel ocalized oedema
• Mobilize an articulation with restricted mobility
GUIDLINES:
If there is any pain “STOP” and tell me***
• 3-5 repetitions for 7-10 seconds each
• 20% of muscle strength
• Isometric contraction should not be too hard
• After sustained but light contraction, a momentary pause should occur
Breathing during MET
Inhale slowly as isometric contraction builds up
• Hold the breath during 7-10 sec
• Release the breath as they slowly cease the
contraction
• Inhale and exhale fully once more following cessation of all efforts
Common errors by patient:
Contraction is too hard Contract in wrong direction
Contraction is not sustained for long enough Individual doesn’t relax completely after
contraction
Starting or finishing contraction too hastily
Errors by therapist:
Inaccurate control of joint position in relation to barrier to movement
Counterforce : incorrect direction
Inadequate patient: instructions
Moving to a new joint position too soon after contraction
Not waiting for refractory period following an isometric contraction before muscle can be stretched to a new resting length
Not maintaining stretch position for appropriate period of time
MET indications
Whenever somatic dysfunction is present and/or whenever
there is a need to
Normalize abnormal neuromuscular relationships
Improve local circulation and respiratory function
Lengthen and/or normalize restricted/hypertonic muscles and fascia
Mobilize restricted joint
Movement restriction due to muscle
Tightness
Muscle hyperactivity
Acute injuries
Myofascial restrictions, muscle imbalance
Or simply put . .. .
whenever there is Somatic Dysfunction present and this is considered present whenever objectively Asymmetry, Restricted or altered motion, or Tissue texture changes are present, and subjectively whenever pain or other sensorial changes are present.
MET contraindications
Fracture
Severe Sprain
Severe Strain
Open wounds
Metabolic bone or other disease eg. osteoporosis
Uncooperative, unresponsive, unconscious patients or those that cannot or will not follow directions
Caution if no clear diagnosis
Side Effects
Some muscle stiffness and soreness after treatment
• Increased likelihood if patient uses to much force with the contraction