Esta é uma ferramenta adicional para o leque de recursos do Terapeuta Manual que ajuda a libertar e relaxar os músculos, favorecendo os mecanismos naturais de cura do corpo.
Esta é uma ferramenta adicional para o leque de recursos do Terapeuta Manual que ajuda a libertar e relaxar os músculos, favorecendo os mecanismos naturais de cura do corpo.
Esta é uma ferramenta adicional para o leque de recursos do Terapeuta Manual que ajuda a libertar e relaxar os músculos, favorecendo os mecanismos naturais de cura do corpo.
26 Issue 97 July 2011 INTERNATIONAL THERAPIST www.fht.org.uk
Muscle Energy Techniques A n additional tool for the physical therapists manual therapy toolbox, Muscle Energy Techniques (MET) can help to release and relax muscles, and promote the bodys own healing mechanisms. MET is unique in its application as the client provides the initial effort while the practitioner facilitates the process. The primary force originates from the contraction of soft tissue, which is then utilised to assist and correct the presenting musculoskeletal dysfunction. MET is generally classifed as a direct technique as opposed to indirect because the muscular effort is from a controlled position, in a specifc direction, against a distant counter force (usually the practitioner). One of the main uses of this method is to normalise joint range, rather than increase fexibility, and techniques can be used on any joints with restricted range of motion (ROM) identifed during the passive assessment. The benefts of MET may include: lRestoring normal tone in hypertonic muscles Physical therapists use MET to try to help relax the hypertonic shortened muscles. If a joint has limited ROM, then through the initial identifcation of the hypertonic structures, techniques can help to achieve normality in the tissues. MET applied in conjunction with massage therapy can be very benefcial in helping to achieve this relaxation effect. lStrengthening weak muscles MET can be used to help strengthen weak, or even faccid, muscles, with the client advised to contract the muscle classifed as weak against a resistance applied by the therapist (isometric contraction). Timing of techniques can be varied, for example, the client resists the movement to approximately 20 to 30 per cent of their capability for fve to 10 seconds, resting for 10 to 15 seconds, and then repeating the process fve to eight times. This can be improved over time. lPreparing muscle for subsequent stretching In some circumstances, the sport a client participates in may affect joint ROM. Most people can beneft from improved fexibility, and although the focus of MET is to reach normal ROM, a more intensive MET approach can be employed to improve fexibility beyond this. This might involve the client contracting beyond the standard 10 to 20 per cent of the muscles capability. Once MET has been incorporated into the treatment plan, a fexibility programme could follow. lImproved joint mobility A stiff joint can become a tight muscle and a tight muscle can become a stiff joint. When used correctly, MET can improve joint mobility, even when you are relaxing the muscles initially. A relaxation period follows the muscle contraction, which then helps to achieve the new ROM. The main effects of MET can be explained by two distinct physiological processes: post- isometric relaxation (PIR) and reciprocal inhibition (RI). Certain neurological infuences occur during MET, but before considering PIR/RI, it is useful to take into account the two types of receptors involved with the stretch refex (Diagram 1): lMuscle spindles sensitive to change in length and speed of change in muscle fbres. lGolgi tendon organs that detect prolonged change in tension. Stretching a muscle causes an increase in the impulses transmitted from the muscle spindle to the posterior horn cell (PHC) of the spinal cord. In turn, the anterior horn cell (AHC) transmits an increase in motor impulses to the muscle fbres, which creates a protective tension to resist the stretch. But increased tension maintained for a few seconds is sensed within the Golgi tendon organs, which transmit impulses to the PHC and has an inhibitory effect on the increased motor stimulus at the AHC. This inhibitory effect causes a reduction in motor impulses and consequent relaxation. This implies that the prolonged muscle stretch will increase overall stretching capability due to the protective relaxation of the Golgi tendon organs overriding the protective contraction. However, a fast stretch of the muscle spindles will cause immediate muscle contraction and if not sustained there will be no inhibitory action. When an isometric contraction is sustained, neurological feedback through the spinal cord to the muscle itself results in post-isometric relaxation (PIR), causing a reduction in tone of the contracted muscle. This lasts for approximately 20 to 25 seconds, during which the tissues can be more easily manipulated to a new resting length. During reciprocal inhibition (RI) (Diagram 2), the reduction in tone relies on the physiological inhibiting effect on antagonists during the contraction of a muscle. When the motor neurons of the contracting agonist muscle receive excitatory impulses from the afferent pathway, the motor neurons of the opposing antagonist muscle receive inhibitory impulses from their afferent pathway. It follows that contraction or an extended stretch of the agonist muscle must elicit relaxation or inhibit the antagonist, and that a fast stretch of the agonist will facilitate a contraction. The refractory period also lasts for approximately 20 seconds but, with RI, it is thought to be less powerful than PIR. In certain circumstances, use of the agonist may be inappropriate due to pain or injury. Method of treatment MET can be used with both acute and chronic conditions, but intensity and John Gibbons, sports osteopath, lecturer, and author, provides an introduction to Muscle Energy Techniques (MET) before looking at MET and the hamstrings in more detail Diagram 1: the stretch refex Case study James* is a 24-year-old male who plays rugby at a high standard. He has an ongoing right-sided hamstring injury that has not responded to conventional treatment. He has had some soft tissue work on his problematic hamstring with advice on a stretching programme. Having initially carried out a thorough assessment to consider other differential diagnoses for the cause, rather than purely treating the presenting pain, I found no dysfunction present in the lumbar spine, pelvis, hip or lower limb. James presented with pain in his right hamstring, located more on the lateral, central aspect, and he identifed the aggravating factor as the movement of rotation when he played rugby. He was relatively pain free when running in a straight line, but if he rotated, changed direction or passed a ball, then symptoms would worsen. General assessment of the hamstrings The hip fexion test helps to provide the practitioner with an overall impression of the general length of the hamstring muscles. The client lies in a supine position with both legs extended. The therapist passively guides the clients left leg into fexion until a point of bind is felt. The normal range is between 80 and 90 degrees; less than 80 degrees determines that the length of the hamstrings is held in a shortened position. However, neural tension of the sciatic nerve and specifc hamstring injury will also restrict the movement. The client had 60 degrees of motion in his right leg, but the symptoms were not reproduced with the normal hip fexion test. Assessment of the lateral hamstrings Pictures 1 and 2 demonstrate a specifc test that I used to determine whether the clients (not pictured) lateral hamstrings were tight, and involved a technique that individually isolated and tested the lateral (biceps femoris) and medial hamstrings (semitendinosus and semimembranosus). The therapist applies an internal rotation and adduction, while the clients leg is taken into passive fexion, which isolates the biceps femoris. If the motion feels restrictive, the therapist needs to determine whether the range of motion is less than the original hip fexion test, and if it is, then the lateral hamstring can be identifed as short. When this test was carried out on James, it had the effect of reproducing his symptoms, which indicated that the biceps femoris is the muscle that is responsible for his specifc symptoms. MET | Sport INTERNATIONAL THERAPIST www.fht.org.uk www.fht.org.uk INTERNATIONAL THERAPIST Issue 97 July 2011 27 Muscle Energy Techniques duration of symptoms will determine which variation of MET is suitable. lTherapist guides muscle to point of resistance (point of bind) before releasing slightly from that position (especially if the tissue is tender). lClient isometrically contracts affected muscle (PIR) or the antagonist (RI) to approximately 10 to 20 per cent of its strength capabilities against resistance. lClient holds contraction for 10 to 12 seconds. lClient relaxes fully by taking a deep breath in and, as they breathe out, the therapist passively guides the specifc joint that lengthens the hypertonic muscle into a new position, effectively normalising joint ROM. lProcess repeated until no further progress is made (normally three to four times) and fnal stretch held for approximately 20 to 30 seconds. MET is quite a mild form of stretching when compared to other techniques, such as proprioceptive neuromuscular facilitation (PNF), and MET is therefore more appropriate for rehabilitation. Most conditions involving muscle shortening will occur in postural muscles, since these are composed predominantly of slow twitch fbres, therefore a milder form of stretching is perhaps more suitable. 2 1 (All pictures are a reconstruction using a model) Diagram 2: reciprocal inhibition (RI) Sport | MET 28 Issue 97 July 2011 INTERNATIONAL THERAPIST www.fht.org.uk P I C T U R E S :
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P U B L I S H I N G Assessment of the medial hamstrings Although I was able to determine that it was the right lateral hamstring, the biceps femoris, that was causing James problem, to isolate the medial hamstrings in order to investigate whether they were the restrictive tissue, the clients leg is externally rotated and abducted, while the hip is being passively fexed (Pictures 3 and 4). For many athletes who present with hamstring injuries, it is important to differentiate between the lateral and medial hamstrings for a successful rehabilitation programme to be achieved. A combination of corrective treatment and rest will help to improve physiological function and sport performance with a reduced risk of recurrent injury. John Gibbons, sports osteopath, lecturer, author, and regular speaker/contributor to FHT, owns Peak Sporting Performance at Oxford University Sports. His new book, Muscle Energy Techniques, a Practical Guide for Physical Therapists, will be available in September 2011 from Lotus Publishing (www.lotuspublishing.co.uk), Physique and Amazon. T. 07850 176600 www.peaksport.co.uk 5 6 4 MET PIR treatment of the hamstrings (non-specifc) James needs his right biceps femoris lengthened to the normal ROM, and to achieve this, the hip needs to be taken into a rotation (as above), and from this position an MET for the specifc muscle can be performed. It is important that the hamstrings are treated in a position that is related to the clients sport and the position that may have caused the initial trauma. James injured his right hamstring while rotating his trunk to the left to pass the ball. The following technique is very good for lengthening the hamstrings as a group. The therapist adopts a standing posture and passively guides the clients right leg into hip fexion until a bind is felt in the hamstrings. From this position, the clients lower leg is placed onto the therapists right shoulder (Picture 5). The client pushes down against the shoulder of the therapist for 10 seconds. After the contraction of the hamstrings and during the relaxation phase, the therapist passively takes the right leg into further fexion (Picture 6). To apply a RI method at this point, the client would fex their hip while the therapist encourages passive hip fexion. This involves the client contracting the hip fexors, which causes a reciprocal inhibition in the hamstrings and promotes relaxation, thereby helping achieve an increased ROM and new position. *The clients name has been changed. 3
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