The use of Muscle Energy Techniques (METs) to reduce muscle pain and improve muscle length. Types, physiological mechanisms and practical techniques in clinical settings.

1. Senior Physiotherapist
Fared Alkordi
BSc (Physiotherapy)
MCSP
MUSCLE ENERGY
TECHNIQUES
(METS)

2. Outline
■ Introduction
■ How it works
■ Types
■ Technique
■ Practical
■ Contraindication and precautions
■ Common Errors
■ References

3. Fernandez-de-las-Penas et al.
(2016)
ManualTherapy for
Musculoskeletal PainSyndromes
Chaitow
(2013)
Muscle EnergyTechniques

4. Definition
■ MET: A system of manual procedures that utilises active muscle
contraction effort from the patient, usually against a controlled matching
counterforce from the physiotherapist (Fernandez-de-las-Penas et al.
2016)
■ You can use METs to:
– Lengthen shortened muscles and promote relaxation
– Mobilise articulations with restricted movement
– Strengthen weakened muscles
– Reduced localised oedema and passive congestion in the tissues
– Enhance proprioception and motor control in patients with pain

5. Physiological
Mechanisms
■ Old school /Traditionally
accepted mechanism
■ Produces muscle relaxation
via GolgiTendon Organ
(GTO) and muscle spindle
reflexes (Mitchell jr and
Mitchell, 1995)
■ Resets the neurological
resting length of a muscle

6. Suggested Physiological Mechanisms
■ Chaitow (2013); increased flexibility of the muscles is largely
attributed to an increase in individual’s tolerance to stretch
■ METs reduce pain perception (hypoalgesia) through the activation
of muscles’ and joints’ mechanoreceptors (Fryer and Fossum,
2010)
■ METs induce hypoalgesia via peripheral mechanisms associated
with increasing fluid drainage. Rhythmic muscle contractions
increase blood and lymph flow rates (Havaz et al. 1997) which may
lead to decreased sensitisation to peripheral nociceptors
■ METs improve proprioception and motor control because they
involve active and precise recruitment of muscle activity
■ Malmstrom et al (2010); prolonged unilateral neck muscle
contraction task increased the accuracy of head repositioning

7. *In a static stretch: both sensory organs activate leading to initially increased muscle activation
(Muscle spindle) then muscle relaxation after 7-10 seconds (GTO)
GTO
Responds to
increased tension
Inhibits muscle
contraction
Muscle Spindle
Responds to
muscle
lengthening
Causes muscle
contraction
(responsible for
DTR)
Inhibits
antagonist
muscle
Autogenic
Inhibition
Autogenic
Activation
Reciprocal
inhibition

8. Types of
METs
Reciprocal
Inhibition MET
Autogenic
inhibition MET
Post isometric
Relaxation (PIR)
Post facilitation
stretching
(PFS)
(Page, 2012)

9. ■ Chaitow (2013);
■ Other muscle energy techniques
– Concentric isotonic MET
– Eccentric isotonic MET
– Pulsed MET

10. MET for myofascial tissues
METs can be used to Lengthen
and desensitise myofascial
tissues;
• Myofascial trigger points
• Acute myofascial pain
• Fibrotic shortened muscles
• Tight muscles affecting
posture

11. Autogenic inhibition MET (PIR)
■ Stretch the involved muscle until you reach the
‘barrier’
■ Isometric contraction
■ Muscle relaxation
■ Re-engage ‘barrier’
■ Repeat
■ Re-examine
Tight Biceps
Limiting elbow extension
Contract/resist Biceps

12. 1. Stretch the involved muscle
The muscle should be stretched to its ‘barrier’ (Sense of
palpated resistance or possible end range)
– A) Light stretching force to the initial or first barrier
if the muscle is acutely painful
– B) Moderate stretching force to a comfortable
sensation of stretch experienced by the patient if the
muscle is mildly painful or not-painful

13. 2. Isometric Contraction
■ Request the patient to contract the targeted muscle
■ Advise the patient to inhale before they contract the
muscles
*Push away from the barrier* against your controlled
unyielding resistance for 3-5 seconds
A. Light contraction if the muscle is painful or contains
active MTrPs (10-30% of Maximum possible contraction)
B. Moderate contraction force for pain-free, fibrotic muscles
(50% of maximum possible contraction)

14. 3. Muscle Relaxation
■ The patient should fully relax for several
seconds with the stretch maintained (10
seconds)
■ Advise the patient to take a deep exhalation to
assess relaxation

15. 4. Re-engage barrier
■ The slack that has developed in the tissues
following the contraction and relaxation phase
is taken up
■ The muscle then can be stretches to a new
barrier without using increased force

16. 5. Repeat
■ Repeat the process 2-4 times OR until a change
in tissue texture is noted
6. Re-examine
■ To determine weather the tissues have changed

17. Post Facilitation Stretching (PFS)
(The differences)
■ PFS is a technique developed by Dr.Vladimir Janda (1988) that involves a
maximal contraction of the muscle at mid-range with a rapid movement to
maximal length followed by a static stretch
■ The muscle is placed between a fully stretched and a fully relaxed state
■ A maximum degree of effort is used in the isometric contraction for 5-10
seconds
■ The patient is then asked to relax and a RAPID stretch is applied by the
physio to a new barrier and is held for few seconds
■ The patients then relaxes for 20 seconds
■ Repeat from 3-5 times

18. How long you hold
the stretch for?
■ Duration of maintaining the stretch
(Chaitow, 2013)
At least 30 seconds Up to 60 seconds
• Neck
• Shoulder
• Upper limb muscles
• Chronically shortened
muscles
• Large muscle groups
(lower limb muscles)

19. (Jadav and Patel, 2015): Comparison
between the effect of PIR and PFS on tight
hamstrings
■ 5 stretches per day, 5 days a week for 6 weeks
■ Measurement of knee extension with hip at 90° flexion
■ Both groups (N=25 each) showed a significant increased in knee ROM
– PIR mean of 7° improvement
– PFS mean of 15° improvement
■ Conclusion: PFS is a better and should be used in clinical settings
■ Limitation:
– Age (18 – 30)
– Subjects with pathological hip or knee conditions were excluded

20. Reciprocal inhibition MET
■ The affected muscle is placed in a mid-range
position
■ The patient pushes towards the
restriction/barrier whereas the therapist
completely resists this effort (isometric)
■ This is followed by relaxation of the patient
along with exhalation, and the therapist
applies a passive stretch to the new barrier
■ The procedure is repeated between 3 – 5
times
■ 10-20% of maximum muscle contraction Tight Biceps
Limiting elbow extension
Contract/resist triceps

21. Which Method should be used?
PIR
RI
PFS

22. ■ Chaitow (2013);The presence of pain is frequently the
deciding factor
RI PIR PFS
• Does not involve
contraction of the
affected muscle
• Use in acute
conditions where PIR
and PFS might cause
adverse effect –
pain/injury
• Progress from RI
when the affected
muscle has become
less sensitive and are
able to tolerate
isometric contraction
• Use for chronically
shortened muscles
• Use if there is no pain
• Good if
strengthening is
desired
• *Isotonic used for
strength (not
covered)
ChronicAcute

24. UpperTrapezius
(PIR)
■ Common source of
MTrPs related to neck
pain and headaches
■ Levator scapulae is
normally stretched when
applying MET to upper
trapezius
■ Subtle fine tuning of neck
rotation using palpation
and patient feedback to
determine the most
effective position
Picture courtesy of Fernandez-de-las-Penas et al. 2016

25. UpperTrapezius technique
1. The shoulder is firmly depressed and stabilised
2. Neck is flexed and side-bent away from the involved side,
with rotation of the neck dependant on the fibre direction
and sense of stretch
3. The patient isometric effort is either:
A. Neck extension with side bending towards the involved
side
B. Elevation of the shoulder
* Can be done in sitting

26. Pectoralis
Minor (PIR)
■ Pec minor referral
pattern is to anterior
deltoid region, ulnar
side of the arm, hand
and fingers (Simons et
al 1999)
■ Shortened pec minor
affects posture
producing rounded
shoulder and forward
head posture in upper
crossed syndrome Picture courtesy of Fernandez-de-las-Penas et al. 2016

27. Pectoralis Minor technique
1. The tissues over the sternum are firmly stabilised by the
physio’s forearm
2. Posterior and lateral force is applied to the anterior shoulder
3. The patient attempts to lift the shoulder against the physio’s
unyielding counterforce
4. Note that the physio’s arm is straight and the isometric force is
easily resisted by the physio’s body weight
* Use a small towel for padding if the contact on the shoulder is
uncomfortable

28. Hip Flexor
Muscle Group
(PIR)
■ Shortness of iliosoas,
rectus femoris,
pectineus andTFL is
common
■ MTrPs in these
muscles refer pain to
the groin
■ When tight, they
restrict hip extension
and promote anterior
pelvic tilt
Picture courtesy of Fernandez-de-las-Penas et al. 2016

29. Hip Flexor Muscle Group technique
■ Patient is treated in theThomas test position
■ Unaffected leg is fully flexed, held by the patient and stabilised by the
physio’s body to ensure stability of the lumbar spine
■ An extension force is applied to the thigh until a ‘barrier’ is felt
■ The patient pushes the thigh up against the physio’s unyielding
counterforce
■ Addition of:
– Hip adduction will localise the stretch toTFL
– Knee flexion will localise the stretch to Rec Fem
– Hip abduction will localise the stretch to pectineus and short
adductors

30. Hamstrings
Muscles (RI)
■ Normally overactive
tight muscles
■ Contribute to lower
crossed syndrome
(poor posture) and
related to lower
back pain

31. Hamstrings MET technique
■ The patient’s straight leg is flexed until a mild stretch in the hamstrings
is experienced by the patient
■ The leg is supported on the physio’s shoulder
■ Brace the patient knee using a cross arm formation around the distal
aspect of the quads
■ The patients produces isometric contraction as in active straight leg
motion resisted by the physio’s body weight

33. Common errors in muscle energy
application
■ Joint barrier is overlocked
■ Patients pushes too hard
■ Patient’s contraction duration is too short
■ Too few repetitions to make a change
■ Patient does not relax
■ Physio does not offer stable support of limb or region
■ Physio allows movement during contraction phase
■ Physio is uncomfortable, awkward, poorly positioned, unbalanced or
tense.

34. Contraindications and precautions
■ METs are generally Safe
■ Contraindications
– Fractures
– Acute sprains
– Acute strains
■ Caution
– Osteoporosis
– Hypermobility
■ Be aware of use of force and leverage with patient with acute pain
■ Listen to the patient's feedback
■ Stop! If there are any signs of vertebrobasilar insufficiency such as vertigo, visual
disturbances, dysphasia, dysarthria, hoarseness, facial numbness, paraesthesia, confusion or
drop attacks (Gibbons andTehan, 2006)

35. References
■ Chaitow, L. (2013). Muscle energy techniques. Elsevier Health Sciences.
■ Fernández-de-las-Peñas,C., Cleland, J., & Dommerholt, J. (2016). Manual therapy for musculoskeletal pain syndromes.
[Erscheinungsort nicht ermittelbar]: Elsevier.
■ Fryer, G & Fossum (2010).Therapeutic mechanisms underlying muscle energy approaches. Cephalalgia. 28. 264-275.
■ Havas, E., Parviainen,T.,Vuorela, J.,Toivanen, J., Nikula,T., &Vihko,V. (1997). Lymph flow dynamics in exercising human
skeletal muscle as detected by scintography. TheJournal of physiology, 504(1), 233-239.
■ Jadav, M., & Patel, D. (2015). Comparison of effectiveness of post facilitation stretching and agonist contract-relax technique
on tight hamstrings. IndianJournal of PhysicalTherapy, 2(2), 70-75. [Online]
http://indianjournalofphysicaltherapy.in/ojs/index.php/IJPT/article/viewFile/56/59
■ Janda,V. (1988). Muscles and Cervicogenic Pain Syndromes. In PhysicalTherapy of theCervical andThoracic Spine, ed. R.
Grand. NewYork: Churchill Livingstone.
■ Malmström, E. M., Karlberg, M., Holmström, E., Fransson, P.A., Hansson, G. Å., & Magnusson, M. (2010). Influence of
prolonged unilateral cervical muscle contraction on head repositioning–decreased overshoot after a 5-min static muscle
contraction task. Manual therapy, 15(3), 229-234. [Online]
https://www.sciencedirect.com/science/article/pii/S1356689X09002082
■ Page, P. (2012). Current concepts in muscle stretching for exercise and rehabilitation. International journal of sports physical
therapy, 7(1), 109. [Online] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3273886/
■ Page, P., Frank, C., & Lardner, R. (2010). Assessment and treatment of muscle imbalance: the Janda approach. Human kinetics.

36. THANKYOU