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ARTICLE IN PRESS

Journal of Bodywork and Movement Therapies (2008) 12, 312317

Journal of
Bodywork and
Movement Therapies
www.elsevier.com/jbmt

CLINICAL METHODS STUDY

A comparison of two muscle energy techniques for


increasing exibility of the hamstring muscle group
Madeleine Smith, B.Clin.Sc., M.H.Sc.(Osteo)a, Gary Fryer, Ph.D.,
B.App.Sc.(Osteo.), N.Da,b,c,
a

School of Biomedical and Clinical Sciences, Victoria University, Melbourne, Australia


Centre for Ageing, Rehabilitation & Exercise Science, Victoria University, Melbourne, Australia
c
A. T. Still Research Institute, A. T. Still University of Health Sciences, 800 W. Jefferson St.,
Kirksville, MO 63501, USA
b

Received 17 April 2008; received in revised form 15 June 2008; accepted 17 June 2008

KEYWORDS
Muscle;
Hamstring;
Stretching;
Isometric;
Osteopathic
medicine

Summary Variations in the application of muscle energy technique (MET) for


increasing the extensibility of muscles have been advocated, but little evidence
exists to support the relative merit of a particular approach. This study investigated
two types of muscle energy techniques that have been advocated in the osteopathic
literature that differ primarily in the duration of the post-contraction stretch phase.
Forty asymptomatic participants (mean age 22.173.5, male female 1:4) were
randomly allocated to one of two groups (Group 1: MET with 30-s post-isometric
stretch phase; Group 2: MET with 3-s post-isometric stretch phase). Hamstring length
was measured using active knee extension (AKE). Participants received an initial
application of the allocated intervention, and then a second application 1 week
later. Analysis with a split-plot ANOVA revealed a signicant effect of time
(F3,36 42.30;po0.01), but no signicant time*group interaction (F3,36 0.12;
p 0.95). Post-hoc analysis revealed that the signicant differences over time
occurred between pre- and post-measurements at both weeks, and between postWeek 1 and pre-Week 2 measurements.
Both techniques appeared to be equally effective in increasing hamstring
extensibility, and there appeared to be sustained improvement 1 week following
the initial treatment. The ndings suggest that altering the duration of the passive
stretch component does not have a signicant impact on the efcacy of MET for
short-term increases in muscle extensibility.
& 2008 Elsevier Ltd. All rights reserved.

Corresponding author at: A. T. Still Research Institute, A. T. Still University of Health Sciences, 800 W. Jefferson St., Kirksville, MO

63501, USA. Tel. +1 660 626 2530 Fax: +1 660 626 2099.
E-mail address: gfryer@atsu.edu (G. Fryer).
1360-8592/$ - see front matter & 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jbmt.2008.06.011

ARTICLE IN PRESS
A comparison of two muscle energy techniques for increasing exibility

Introduction
Muscle energy technique (MET) is a manual procedure that uses controlled, voluntary isometric
contractions of a targeted muscle group and is
widely advocated by authors in the eld of
osteopathy. MET is claimed to be useful for
lengthening a shortened muscle, improving range
of motion at a joint and increasing drainage of uid
from peripheral regions (Greenman, 2003). Muscle
energy procedures, and related post-isometric
procedures such as proprioceptive neuromuscular
facilitation (PNF), have been demonstrated to be
more effective than static stretching for improving
the extensibility of shortened muscles (Handel
et al., 1997; Magnusson et al., 1996a; Sady et al.,
1982).
Passive stretching of various muscle groups,
particularly the hamstrings, has been reported to
improve the length and extensibility of muscles in
both short and long-term periods of stretching
(Bandy et al., 1997; Bandy et al., 1994; Feland
et al., 2001; Roberts and Wilson, 1999). Additionally, many researchers have reported that postisometric stretching techniques, such as MET and
PNF, produce greater changes in range of motion
and muscle extensibility than static or ballistic
stretching, immediately following treatment
(Cornelius et al., 1992; Moore and Hutton, 1980;
Tanigawa, 1992; Wallin et al., 1985) and in the
longer term (Handel et al., 1997; Magnusson et al.,
1996a; Sady et al., 1982; Wallin et al., 1985). The
exact mechanism by which increased muscle
extensibility occurs is still unclear, and probably
involves both neurophysiological (including changes
to stretch tolerance) and mechanical factors (such
as viscoelastic and plastic changes in the connective tissue elements of the muscle) (Fryer, 2006).
Although there are many variations of the
application of MET, with most authors in the eld
of osteopathy advocating a post-isometric stretch
for increasing muscle length, the recommended
duration for the passive stretch component varies.
A typical application of MET for the purpose of
lengthening a shortened muscles involves the
following steps: (1) stretch the muscle to a
palpated barrier or to the patients tolerance of
stretch, (2) the patient produces a voluntary
isometric contraction of the muscle under stretch
against the clinicians controlled and equal counterforce, (3) the muscle is allowed to relax, while
the clinician maintains a stretch for a dened
period, (4) the clinician takes up the slack
following relaxation so that the muscle has been
lengthened to a new barrier, (5) this process is
repeated several times. It is possible to alter the

313

application of MET by with variations to the


components of the technique: the force and
duration of the isometric contraction phase, the
duration of the post-contraction stretch phase, and
the number of repetitions. The literature currently
offers little guidance as to the most efcacious
application (Fryer, 2006).
In the osteopathic literature, two markedly
different applications of MET for increasing muscle
extensibility have been advocated by Greenman
(2003) and Chaitow (2006), with differences in the
number of repetitions (35 and 3, respectively),
and the period of passive stretching between the
isometric contractions. Chaitow suggests a stretch
duration following isometric contraction to be held
for at least 30 and up to 60 s for chronically
shortened muscles, whereas Greenman (2003) and
Mitchell et al. (1979) recommend only enough time
(several seconds) for patient relaxation and tension
to be taken up in the affected tissue. The relative
merit and efcacy of these different approaches
have not been investigated.
Ballantyne et al. (2003) and Lenehan et al.
(2003) used techniques similar to the Greenman
protocol, both following a 57 isometric contraction with a passive stretch lasting only several
seconds until the new barrier was engaged. Other
researchers have used PNF techniques similar to
the Chaitow method, such as Wallin et al. (1985)
and Handel et al. (1997), who used a maximal
isometric contraction with a 15 s rest period. While
these techniques were similar to the method
advocated by Chaitow, the duration of the stretch
(15 s) was shorter than the recommended minimum
of 30 s (Chaitow, 2006). The longer passive stretch
of the Chaitow approach may make the technique
more effective, given that passive stretching for a
30-s (Bandy and Irion 1994) or 60-s (Feland et al.,
2001) period have been reported to be more
efcacious for increasing muscle extensibility than
shorter durations.
The relative efcacy of the Greenman and
Chaitow approaches for increasing myofascial extensibility should be investigated. Most research
involving MET has focused on a single application of
treatment (Ballantyne et al., 2003; Mehta and
Hatton, 2002; Magnusson et al., 1996a), but
practitioners typically deliver more than one
treatment for a patient complaint, and anticipate
that there will be carry-over changes still present
from the previously delivered treatment. This study
aimed to determine the relative efcacy of the two
approaches for increasing the extensibility of the
hamstring muscles, and determine if there were
any carry-over changes in hamstring length, or
changes in responsiveness to treatment, when the

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314

M. Smith, G. Fryer

hamstrings were treated on a second occasion


1 week later.

Materials and methods


Participants
Forty participants (mean age 22.173.5 years,
male: female 1.4) were recruited from students
enrolled at Victoria University, Melbourne, Australia. Twenty participants were required for each
group to achieve 80% power, based on a large effect
size, and analysis using a split-plot ANOVA (SPANOVA) (Aron and Aron, 1999). Volunteers under the
age of 18 and over the age of 65 were excluded, as
were those with lower extremity or lower back pain
at the time of the study. Participants were included
if they presented with shortened hamstrings,
determined as o751 of active knee extension
(AKE). Volunteers with 4751 of AKE were excluded
from the study, resulting in 15 volunteers (mean
age 22 years, SD 1.4, male: female ratio of
0.15) being excluded. Written, informed consent
was obtained from all participants and the study
was approved by the Victoria University Human
Research Ethics committee.
Participants were randomly assigned to Group 1
(MET with 30-s stretch) (N 20; mean age 21
years, SD 2.0; male: female ratio 1.2) or Group
2 (MET with 3-s stretch) (n 20; mean age 23.2
years, SD 4.7; male: female ratio 1.5).

Figure 1 Active knee extension measurement.

Pilot reliability study


An AKE pilot reliability study was conducted on 15
participants using 2 measurements of AKE, 10 min
apart, where the participant remained positioned
and attached to stabilsing bar in order to establish
an accurate measure of the reliability of the
measurement procedure. Repeatability was determined using an intra-class correlation (ICC) and
found to be highly correlated (ICC 0.99). The
standard error of mean (SEM) for the difference
scores between the two trials, which reects the
variability of measurements due to repetition and
random error and provides an indication of the
absolute reliability of the measurement procedure,
was calculated to be 0.79.

Measures
AKE was used to measure hamstring extensibility.
AKE has been commonly used by researchers for the
measurement of hamstring length (Handel et al.,
1997) and has been demonstrated to be a reliable
measure (Sullivan et al., 1992).
The participants were requested to lie supine
and the experimental hip exed to 901 and
strapped to a stabilizing bar. The thigh of the
opposite leg was rmly secured to minimize
rotation of the pelvis (Sullivan et al., 1992). Joint
markers were placed on the greater trochanter,
lateral femoral condyle, head of the bula and
lateral malleolus to provide a point of reference to
measure degree of knee extension (Figure 1). The
participants were asked to extend the knee as far
as possible, and a photograph was taken of this
position using a digital camera by Researcher 1.
This procedure was performed three times. The
digital images were analyzed using SiliconCOACH
Pro software to determine the angle of AKE, and
the mean of the three measures used for analysis.

Procedure
Researcher 1 measured the AKE of the investigated
leg and then left the room. Researcher 2 (GF; a
registered osteopath with 15 years clinical experience) entered the room and assigned participants
to treatment groups via lottery draw. Researcher 2
(MS; a nal-year osteopathic student) treated the
experimental leg of the participants according to
the group allocation (Figure 2), and then left the
room. Researcher 1, who was blinded to the
treatment allocations, re-entered the room and
performed the post-treatment AKE measurement
All participants returned 1 week later, receiving
the same measurement and treatment procedure
as previously described. There were no restrictions
to participant activity between treatments.
Intervention
Subjects allocated to Group 1 (n 20; mean
age 21, SD 2; male: female 1:2) received

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A comparison of two muscle energy techniques for increasing exibility

315

Statistical signicance was set at the po0.05 level.


Post-hoc analysis for signicant differences between the time periods were conducted with
paired t-tests.

Results

an application of MET as advocated by Chaitow


(2006): the supine subjects hip was passively
exed and the leg extended until tension was
sensed by the researcher and the subject reported
a moderate stretching sensation. The participant
provided a moderate (approximately 40% of maximal contraction) knee exion isometric contraction, against the researchers shoulder for 710 s.
This was followed by 23 s of relaxation, and then
the leg was passively stretched to the palpated
barrier and/or tolerance to stretch and held for
30 s. The leg was then lowered to the table for a
short resting period (approximately 10 s). This
procedure was repeated two more times.
Those subjects allocated to Group 2 (n 20;
mean age 23.2, SD 4.7; male: female 1:5)
received an application of MET as advocated by
Greenman (2003): the supine subjects hip was
passively exed and the leg extended until tension
was sensed by the researcher and the subject
reported a moderate stretching sensation. The
participant then provided a moderate (approximately 40% of maximal contraction) knee exion
isometric contraction against the researchers
shoulder for 710 s. The subject was allowed to
relax for 23 s with the stretch maintained, and
then the leg was further extended to the palpated
barrier and/or tolerance to stretch. This procedure
was repeated three more times.

Analysis
All data were collated and analyzed using SPSS
professional version 16. Pre- and post-intervention
ROM measurements were analyzed for both groups
using a multi-variate (Hotellings T) SPANOVA.

Table 1

Mean AKE values (SD) for MET groups

Week Treatment PrePosttreatment treatment

Prepost

Group 1

154.00

8.484

Group 2

145.52
(8.64)
142.23

150.23

7.89

Group 1
Group 2

147.62
145.12

153.7
151.48

6.05
6.37

Treatment Allocation
Group 1

155.00

Group 2
152.50
Average AKE

Figure 2 Application of muscle energy technique.

The means and standard deviations for each


measurement
period
(pre-treatment,
posttreatment and prepost) are shown in Table 1 and
Figure 3. Prepost gains were similar for both
Groups 1 and 2 at Week 1 (8.48 and 7.89) and
Week 2 (6.05 and 6.37) (Table 2).
Analysis with the SPANOVA revealed a signicant
effect of time (F3,36 42.30; po0.01), but no
signicant time*group interaction (F3,36 0.12;
p 0.95). Further post-hoc analysis of the entire
group over each time interval using paired t tests
revealed signicant differences between Week 1
pre-measurement and all other measurement

150.00

147.50

145.00

142.50
Week 1
Pre PPT

Week 1
Post PPT

Week 2
Pre PPT

Week 2
Post PPT

Treatment Time

Figure 3 Comparative means of AKE (degrees) over time.

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M. Smith, G. Fryer

Table 2

Post-hoc analysis of changes over time

Treatment phase

Mean (SD)

Week
Week
Week
Week
Week
Week

8.24
2.49
8.70
5.75
.46
6.21

1
1
1
1
1
2

prepost
preWeek 2 pre
preWeek 2 post
postWeek 2 pre
postWeek 2 post
preWeek 2 post

(4.89)
(7.19)
(9.15)
(7.85)
(8.68)
(4.99)

p-value
0.00
0.04
0.00
0.00
0.74
0.00

periods, and between Week 1 post- and Week 2 pretreatment measurements, and between Week 2
pre- and post-measurements, suggesting both
short- and long-term signicant changes in AKE
(Table 2).

Discussion
Many variations of post-isometric stretching have
been advocated for the lengthening of shortened
muscles, but little research is available to help
clinicians choose the most efcacious method.
Although a few researchers have examined the
effect of varying the application of certain components in these techniques (Feland and Marin, 2004;
Mehta and Hatton, 2002; Rowlands et al., 2003),
little can yet be concluded concerning the most
efcacious application. A direct comparison between the methods advocated by Chaitow and
Greenman, two of the most commonly advocated
approaches to muscle stretching in the osteopathic
literature, had not previously been investigated.
The present study found that the immediate
prepost comparison of AKE at both treatment
periods were signicantly increased, demonstrating
an increase in the extensibility of the hamstring
muscle group. Although there was a signicant
within-group change over time, no signicant differences were evident between the two treatment
groups. Neither method in the present study was
found to produce signicantly greater gains in range
of motion on either treatment day or between
treatment days, suggesting that both treatment
techniques were equally effective for increasing
range of motion. This in itself is an important nding,
and implies that while MET may be more effective
than static stretching (Handel et al., 1997; Magnusson
et al., 1996a; Sady et al., 1982), variations in the
duration of post-isometric stretch do not signicantly
alter the efcacy for increasing muscle length.
However, it is worth noting that the Greenman
approach may be more time efcient because the
period between contractions is substantially shorter.

In the present study, the two treatments were


separated by a period of 1 week, and there was a
signicant difference between the initial preintervention values and both the pre- and postintervention values of the second week. While only
two treatments in 8 days is not representative of
typical clinical practice, the results suggest a carryover effect from the rst treatment. These results
also suggest that a longer period of treatment may
produce further gains in range of motion, and this is
worthy of investigation in the future.
Bandy and Irion (1994) explored the effect of
variations in the duration of each individual stretch
over a series of treatments, and found that a 30-s
duration of passive stretching produced increases in
range of motion greater than shorter durations, but
no different from longer ones. This suggests that
the longer passive stretch of the Chaitow approach
(3060 s) may make the technique more efcacious. This was not demonstrated, however, in the
present study. It may be that application over a
longer period of treatment, such as the 8 weeks
used by Bandy and Irion (1994), may be needed to
demonstrate differences in the efcacy of the two
techniques for increasing muscle extensibility, and
this is an area that should be further investigated.
The mechanism of action of isometric contraction or static stretching is still unclear, and
probably involves both neurophysiological and
mechanical factors (Fryer, 2006). AKE provides a
reliable measure of range of motion, but does not
measure the torque generated to produce the
stretch and does not give any evidence of a
biomechanical change to the muscle property.
The few studies that have measured torque applied
in pre- and post-passive knee extension (PKE)
following isometric stretching strongly suggest that
a change in tolerance to stretch, rather than
viscoelastic change, is the main mechanism for
increased extensibility (Magnusson et al., 1996b;
Ballantyne et al., 2003). It would be interesting to
examine the effect of a longer term of treatment
using torque-controlled PKE in order to determine
if changes to the viscoelastic property of the
muscle was affected over a longer time course.
It should be noted that while the subjects in the
present study displayed limited hamstring exibility, all were asymptomatic and likely to be younger
than a typical patient population. This is an
important limitation of the study, because it is
possible that differences in the efcacy of the two
MET approaches may be found when treating a
more representative patient population, such as an
older group, those with hamstring pain or healing
hamstring tears. It is feasible that these techniques
may help to prevent adhesion and cross-link

ARTICLE IN PRESS
A comparison of two muscle energy techniques for increasing exibility
formation in the repairing muscle (Lederman,
2005), and future study of these populations with
these stretching approaches may yield information
concerning relative treatment effectiveness that
proves valuable for clinicians.
Although the present study investigated MET
without comparison to either a control or static
stretching group, other researchers have reported
signicant differences between contractrelax
treatments and passive stretching (Tanigawa,
1992; Wallin et al., 1985; Moore and Hutton,
1980). While there were signicant differences
between pre-initial and post nal AKE measurements, a comparison to both a control and static
stretching would have added greater validity to the
results, and clearly demonstrated that both these
post-isometric techniques were superior to passive
stretching in this group of subjects.
The present study demonstrated that both the
Greenman and Chaitow approaches to MET resulted
in increased AKE, both immediately following the
treatments and 1 week after treatment. Further
study relating to the relative efcacy of the specic
components of MET techniques will be required to
determine most appropriate clinical application.

Conclusion
This study found that both Greenman and Chaitow
muscle energy approaches produced increased AKE
immediately after intervention, and demonstrated
a carryover effect 1 week later. There was a
signicant increase in range of motion of the knee
immediately following both treatments at both
weeks, and a signicant increase at the pretreatment measurement at Week 2. There was,
however, no signicant difference between the two
applications. This suggests that variations in the
elements of the techniques, such as the duration of
passive stretch, may not have a signicant inuence on the efcacy of the technique for increasing
hamstring extensibility.

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