MUSCLE ENERGY

TECHNIQUES
(METS)
Senior Physiotherapist
Fared Alkordi
BSc (Physiotherapy)
MCSP
Outline
■ Introduction
■ How it works
■ Types
■ Technique
■ Practical
■ Contraindication and precautions
■ Common Errors
■ References
 Fernandez-de-las-Penas et al.
(2016) Chaitow
Manual Therapy for (2013)
Musculoskeletal Pain Syndromes Muscle Energy Techniques
 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
Physiological
Mechanisms
■ Old school / Traditionally
accepted mechanism
■ Produces muscle relaxation
via Golgi Tendon Organ
(GTO) and muscle spindle
reflexes (Mitchell jr and
Mitchell, 1995)
■ Resets the neurological
resting length of a muscle
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
 Responds to Inhibits muscle Autogenic
GTO
increased tension contraction Inhibition

Autogenic
Causes muscle
Responds to Inhibits Activation
contraction
Muscle Spindle muscle antagonist
(responsible for
lengthening
DTR)
muscle Reciprocal
inhibition

*In a static stretch: both sensory organs activate leading to initially increased muscle activation
(Muscle spindle) then muscle relaxation after 7-10 seconds (GTO)
(Page, 2012)

Types of
METs

Autogenic Reciprocal
inhibition MET Inhibition MET

Post facilitation
Post isometric stretching
Relaxation (PIR) (PFS)
■ Chaitow (2013);
■ Other muscle energy techniques
– Concentric isotonic MET
– Eccentric isotonic MET
– Pulsed MET
 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
Autogenic inhibition MET (PIR)

■ Stretch the involved muscle until you reach the

‘barrier’
■ Isometric contraction
■ Muscle relaxation
■ Re-engage ‘barrier’
■ Repeat
Tight Biceps
■ Re-examine Limiting elbow extension
Contract/resist Biceps
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
 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)
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
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
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
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
 How long you hold
the stretch for?
■ Duration of maintaining the stretch
(Chaitow, 2013)

At least 30 seconds Up to 60 seconds

• Neck • Chronically shortened

• Shoulder muscles
• Upper limb muscles • Large muscle groups
(lower limb muscles)
(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
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
Which Method should be used?

PIR

RI

PFS
■ Chaitow (2013); The presence of pain is frequently the
deciding factor

Acute Chronic

RI PIR PFS

• Does not involve • Progress from RI • Use for chronically

contraction of the when the affected shortened muscles
affected muscle muscle has become • Use if there is no pain
• Use in acute less sensitive and are • Good if
conditions where PIR able to tolerate strengthening is
and PFS might cause isometric contraction desired
adverse effect – • *Isotonic used for
pain/injury strength (not
covered)
 Upper Trapezius
(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
 Upper Trapezius 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
 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
 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
 Hip Flexor
Muscle Group
(PIR)
■ Shortness of iliosoas,
rectus femoris,
pectineus and TFL is
common
■ MTrPs in these
muscles refer pain to
the groin
■ When tight, they
restrict hip extension
and promote anterior Picture courtesy of Fernandez-de-las-Penas et al. 2016
pelvic tilt
Hip Flexor Muscle Group technique
■ Patient is treated in the Thomas 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 to TFL
– Knee flexion will localise the stretch to Rec Fem
– Hip abduction will localise the stretch to pectineus and short
adductors
 Hamstrings
Muscles (RI)
■ Normally overactive
tight muscles
■ Contribute to lower
crossed syndrome
(poor posture) and
related to lower
back pain
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
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.
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 and Tehan, 2006)
 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. The Journal 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. Indian Journal of Physical Therapy, 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 Physical Therapy of the Cervical and Thoracic Spine, ed. R.
Grand. New York: 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.
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