Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae

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Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae

Article Author:
Kathryn Lafans
Article Editor:
Victoria Troncoso
Updated:
10/28/2020 2:36:20 PM
For CME on this topic:
Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae CME
PubMed Link:
Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae

Introduction

Low back pain (LBP) is one of the most common ailments that affect people today. Ninety percent of individuals will experience acute back pain sometime in their lives, while 10 % will have chronic low back pain.[1] The cause of LBP is often multifactorial, and only 15 % of LBP is found to be due to a known etiology, while the remaining 85% have an unknown etiology for the pain.[2] LBP not only causes physical pain, but it also affects patients psychologically and is a source of depression and anxiety.[3] Spinal pain management continues to be an issue for healthcare providers on a global scale. Muscle Energy Technique (MET) is a treatment modality that has been researched and significantly decreases both acute and chronic low back pain by manipulating the spinal vertebra, intervertebral discs, spinal ligaments, and muscles connected to the spinal segments in question.[4][2][5] 

MET is an important tool that can be used by trained professionals to aid in the treatment of LBP, which is currently particularly crucial due to the marked potential abuse of opioid medications. Opioids do not address the underlying somatic dysfunction causing LBP and serve to only mask pain. MET provides a reduction of pain by addressing the root of the problem, which is the misalignment and inappropriate proprioception of the spine, surrounding musculature, and other associated soft tissues. MET is used to realign spinal segments and allow relaxation of musculature and other associated soft tissues. This is accomplished by gently placing spinal segments back into anatomic alignment using the body's own muscular system. Employing this procedure improves the flexibility of muscles, fascia, and joints, decreases pain, increases circulation, and augments lymphatic drainage of the region being treated.[5] 

Misalignment of the lumbar spine and the associated spinal tissues is a known cause of non-specific LBP.[6] MET is an osteopathic manipulative treatment that involves the patient contracting specific muscle groups after being placed in a very precise position against the gentle resistance of the clinician treating the patient.[7]

Anatomy and Physiology

Little is understood about the physiology behind MET and how it provides pain relief, but there are three mechanisms commonly thought to contribute. First, post-isometric relaxation appears to be implicated, defined as decreased muscle tonicity after an isometric muscle contraction. Reciprocal inhibition is also suspected in playing a role, via inhibition of the alpha motor neuron isometric contraction of an agonist muscle leads to decreased muscle tonicity of the antagonist muscle.

Post-isometric relaxation is used more frequently in the osteopathic community, but reciprocal inhibition is primarily used when a muscle is chronically fibrotic and has significant constraints.[5] Lastly, it is thought that the Golgi tendon reflex inhibition plays a role; when Golgi tendon organs in the muscles have stretched, a signal is sent to the spinal cord. Inhibitory interneurons in the spinal cord then send an inhibitory signal via the alpha motor neuron back to the muscle, causing it to relax reflexively.[8]

Indications

Indications for MET of the lumbar vertebrae include acute or chronic low back pain, lumbar muscle spasm, decreased range of motion, or stiffness of the lumbar spine.[2][6] By way of viscerosomatic reflexes, MET of the lumbar vertebrae is also indicated for pathologies of the prostate, descending colon, sigmoid colon, rectum, and lower extremities. 

Contraindications

Contraindications for MET of the lumbar spine include recent surgery of the lumbar region, significant injury of the lumbar spine including lumbar spinal fracture or acute cord compression, cauda equina syndrome, lumbar spinal malignancy, metastasis of primary malignancy to the lumbar spine, osteomyelitis of the lumbar spine, severe osteoporosis, connective tissue disease, and rheumatoid arthritis. Also, it is contraindicated to perform MET on intensive care unit patients due to exerting a muscle when the patient requires healing. Relative contraindications include mild osteoarthritis and patients with increased bleeding risk.[9][10]

Equipment

Padded treatment table or a comfortable place for the patient to sit or lie, at an appropriate height for the clinician. 

Personnel

Healthcare professionals trained in osteopathic manipulative medicine. 

Preparation

Depending on the patient’s functionality, the patient should be comfortably and safely seated and wearing comfortable clothing.

Technique

First, the physician will diagnose the lumbar vertebrae by noting the position of the vertebrae's transverse processes while the patient is in a neutral position, flexed and extended based on Fryette’s Principles.

The following steps will describe the treatment for a neutral, side bent left, and rotated right diagnosis (NSlRr).

Step 1: Have the patient sit straddling a treatment table near the end of the table such that the patient's back is to the physician, and the physician can stand beside/behind the patient. The patient should cross their arms across their chest.

Step 2: The physician will stand behind the patient and place his/her left axilla on top of the patient's left shoulder. The physician's left hand will then contact the patient's right shoulder. Resulting in the physician’s left arm crossing anteriorly to the patient’s chest.

Step 3: The physician palpates the dysfunctional lumbar segment with their right hand and maintains that position during the treatment to feel the restrictive barrier and monitor for release of the tissues in the lumbar spine.

Step 4: The physician will induce right side bending by applying downward pressure to the patient’s right shoulder.  Next, the physician will rotate the patient to the left down to the level of the lumbar spine segment by pulling the patient's right shoulder anteriorly until a restrictive barrier is palpated. Ultimately this will yield the patient's lumbar segment being addressed being placed in a rotated left and side bent right position, which is opposite of the patient’s lumbar spine diagnosis. This places the segment being treated at its restrictive barrier, and the segment is now positioned so that the segmental restriction can be corrected.  At this point, the physician can add a slight compressive force downwards through their axilla and left hand down into the segment in question, which assists tissue release.

Step 5: While maintaining the restrictive barrier, the physician asks the patient to  “attempt to sit in a neutral position,” or “turn your body to the right against my thumb that is placed on your back," or “push your left shoulder toward the ceiling.” These requests are intended to have the patient contract specific muscle groups and apply a gentle counterforce against the position being maintained by the physician.  In other words, the patient rotates right and side bends left against the physician’s isometric resistance created by maintaining the patient's treatment position. The patient should only utilize approximately 30 % of their force during this step. The physician asks the patient to maintain the contraction for 3-5 seconds.

Step 6: The physician repositions the patient to the new restrictive barrier as done before in Step 4 and asks the patient to attempt to sit in a neutral position, again, as described in Step 5.

Step 7: Repeat Steps 4 through 6 between 3 to 5 times.

Step 8: Lastly, the physician rechecks the dysfunctional lumbar segment for improvement.

The following steps will describe the treatment for a flexed, side bent left, and rotated left diagnosis (FSlRl).

Step 1: Have the patient sit straddling a treatment table near the edge of the table such that the patient's back is to the physician, and the physician can stand beside/behind the patient. The patient should cross their arms across their chest.

Step 2: The physician will stand behind the patient and place his/her right axilla on top of the patient's right shoulder. The physician's right hand will then contact the patient's left shoulder. This position results in the physician's right arm crossing anteriorly to the patient’s chest.

Step 3: The physician palpates the dysfunctional lumbar segment with their left hand and maintains that position during the treatment to feel the restrictive barrier and monitor for the release of the tissues in the lumbar spine.

Step 4: The physician will induce right side bending by applying downward pressure to the patient’s right shoulder through the contact with the physician's axilla. Next, the physician will rotate the patient to the right down to the level of the lumbar spine segment by pulling the patient's left shoulder anteriorly until a restrictive barrier is palpated. The physician then extends the patient’s lumbar spine by leaning the patient backward slightly until a restrictive barrier is palpated at the segment, and all three planes of motion are engaged to their restrictive barriers. Ultimately this will yield the patient's lumbar segment being addressed being placed in a rotated right, side bent right, and an extended position, opposite of the patient’s lumbar spine diagnosis. This places the segment being treated at its restrictive barrier, and the segment is now positioned so that the segmental restriction can be corrected.  At this point, the physician can add a slight compressive force downwards through their axilla and right hand down into the segment in question, which assists tissue release. 

Step 5: While maintaining the restrictive barrier, the physician asks the patient to “attempt to sit in a neutral position,” or “turn your body to the left against my thumb that is placed on your back,” or “push your right shoulder toward the ceiling.” These requests are intended to have the patient contract specific muscle groups and apply a gentle counterforce against the position being maintained by the physician. In other words, the patient side bends left, rotates left, and flexes the lumbar spine against the physician's isometric resistance created by maintaining the patient's treatment position. The patient should only utilize approximately 30 % of their force during this step.  The physician asks the patient to maintain the contraction for 3 to 5 seconds.

Step 6: The physician will reposition the patient to the new restrictive barrier as done before in Step 4 and ask the patient to attempt to sit in a neutral position again, as described in Step 5.

Step 7: Repeat Steps 4 through 6 between 3 to 5 times.

Step 8: Lastly, the physician will recheck the dysfunctional lumbar segment for improvement.[2]

Complications

Complications of Muscle Energy Technique of the lumbar spine include new or worsening low back pain, low back stiffness, radicular pain, increased muscle spasm, decreased range of motion. These complications are usually transient and will resolve within a day or two. Sometimes a patient can be “overcorrected” or “over treated,” which induces the opposite of their initial lumbar diagnosis; therefore, it is important to monitor the dysfunctional segment during the procedure and recheck it after the procedure is completed. 

Clinical Significance

There are multiple treatments for LBP, including massage, physical therapy, exercise programs, spinal injections, transcutaneous electric nerve stimulation (TENS) unit, patches, creams, medications, and counseling. Unfortunately, many of these treatments have inconclusive efficacy. Further research on the management of LBP is needed due to its high prevalence in patients, the large healthcare costs associated with it, and conflicting efficacy of treatments.[4] Misalignment of the lumbar spine is a common cause for non-specific LBP, and MET works to address the root of the problem.[6] 

A pilot study performed in 2003 showed that MET significantly improved acute LBP in which the patients underwent four contractions of MET held for 5 seconds each for a total of eight treatments. They were compared to a control group that received a sham treatment. Oswestry Disability Index (ODI) was recorded before and after MET. ODI statistically significantly improved with a decrease in ODI by 83 % in the MET group versus 65 % in the control group.[11] A systematic review of 26 studies consisting of symptomatic and asymptomatic patients found that MET effectively treats patients with acute and chronic low back pain. This review also found that MET is effective in treating other musculoskeletal pain, such as chronic neck and epicondylitis pain.[5] 

Overall, MET is a gentle method for treating LBP, it has been proven effective, and there is a low risk of harming patients when performing this procedure. However, more research is needed to continue exploring MET and its mechanism(s) of action.

Enhancing Healthcare Team Outcomes

The interprofessional team surrounding the practice of MET and Osteopathic Manipulative Medicine (OMM) includes the healthcare professionals trained in OMM and MET, the patient themselves, and likely nursing staff. When performing MET on a patient, it is important to keep the patient informed on what is involved before and during the treatment. The physician should be aware of how the patient experiences the procedure and should inquire throughout the procedure if the patient is experiencing worsening or new pain. If, at any point, the patient is uncomfortable, the procedure should be terminated. Therefore, communication between the physician and patient is paramount in the treatment process. [Level 2]


References

[1] Clark BC,Russ DW,Nakazawa M,France CR,Walkowski S,Law TD,Applegate M,Mahato N,Lietkam S,Odenthal J,Corcos D,Hain S,Sindelar B,Ploutz-Snyder RJ,Thomas JS, A randomized control trial to determine the effectiveness and physiological effects of spinal manipulation and spinal mobilization compared to each other and a sham condition in patients with chronic low back pain: Study protocol for The RELIEF Study. Contemporary clinical trials. 2018 Jul;     [PubMed PMID: 29792940]
[2] Patel VD,Eapen C,Ceepee Z,Kamath R, Effect of muscle energy technique with and without strain-counterstrain technique in acute low back pain - A randomized clinical trial. Hong Kong physiotherapy journal : official publication of the Hong Kong Physiotherapy Association Limited = Wu li chih liao. 2018 Jun;     [PubMed PMID: 30930578]
[3] Wendt M,Cieślik K,Lewandowski J,Waszak M, Effectiveness of Combined General Rehabilitation Gymnastics and Muscle Energy Techniques in Older Women with Chronic Low Back Pain. BioMed research international. 2019;     [PubMed PMID: 30809533]
[4] Szulc P,Wendt M,Waszak M,Tomczak M,Cieślik K,Trzaska T, Impact of McKenzie Method Therapy Enriched by Muscular Energy Techniques on Subjective and Objective Parameters Related to Spine Function in Patients with Chronic Low Back Pain. Medical science monitor : international medical journal of experimental and clinical research. 2015 Sep 29;     [PubMed PMID: 26418868]
[5] Thomas E,Cavallaro AR,Mani D,Bianco A,Palma A, The efficacy of muscle energy techniques in symptomatic and asymptomatic subjects: a systematic review. Chiropractic     [PubMed PMID: 31462989]
[6] Ghasemi C,Amiri A,Sarrafzadeh J,Dadgoo M,Jafari H, Comparative study of muscle energy technique, craniosacral therapy, and sensorimotor training effects on postural control in patients with nonspecific chronic low back pain. Journal of family medicine and primary care. 2020 Feb;     [PubMed PMID: 32318454]
[7] Selkow NM,Grindstaff TL,Cross KM,Pugh K,Hertel J,Saliba S, Short-term effect of muscle energy technique on pain in individuals with non-specific lumbopelvic pain: a pilot study. The Journal of manual     [PubMed PMID: 20046557]
[8] Contento VS,Dalton BH,Power GA, The Inhibitory Tendon-Evoked Reflex Is Increased in the Torque-Enhanced State Following Active Lengthening Compared to a Purely Isometric Contraction. Brain sciences. 2019 Dec 23;     [PubMed PMID: 31878094]
[9] Ingold CJ,Ratay S, Osteopathic Manipulative Treatment: HVLA Procedure - Inhaled Ribs 2020 Jan;     [PubMed PMID: 32965970]
[10] Roberge RJ,Roberge MR, Overcoming barriers to the use of osteopathic manipulation techniques in the emergency department. The western journal of emergency medicine. 2009 Aug;     [PubMed PMID: 19718381]
[11] Wilson E,Payton O,Donegan-Shoaf L,Dec K, Muscle energy technique in patients with acute low back pain: a pilot clinical trial. The Journal of orthopaedic and sports physical therapy. 2003 Sep;     [PubMed PMID: 14524509]