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EDUCATIONAL COUNCIL ON OSTEOPATHIC PRINCIPLES Muscle Energy Model I.

Definition A form of osteopathic manipulative diagnosis and treatment in which the patients muscles are actively used on request, from a precisely controlled position, in a specific direction, and against a distinctly executed physician counterforce. History Fred Mitchell, Sr., D.O. is recognized as the original developer of muscle energy technique. He credited T.J. Ruddy, D.O. and Carl Kettler, D.O. as primary sources for the concept. He published his first description of the model in the Academy of Applied Osteopathy Yearbook in 1948 as The Balanced Pelvis in Relation to Chapmans Reflexes and later, in 1958, with more detail in Structural Pelvic Function. Mitchell taught the first muscle energy tutorial in 1970 in Fort Dodge, Iowa, attended by the following osteopathic physicians: John Goodridge, Philip Greenman, Rolland Miller, Devota Nowland, Edward Stiles, and Sara Sutton. (see The Muscle Energy Manual by Fred L. Mitchell, Jr. for more detail. Proposed Mechanism(s) A system of practice which uses physician-guided, voluntary muscle contraction to treat a specific mechanical diagnosis. The technique can be used to restore normal muscle tone and/or improve joint mechanics. Anatomic/Physiologic Principles POST-ISOMETRIC RELAXATION Goal: To accomplish muscle relaxation Physiologic Basis: Mitchell Jr. postulated that immediately after an isometric contraction, the neuromuscular apparatus is in a refractory state during which passive stretching may be performed without encountering strong myotatic reflex opposition. All the physician needs to do is resist the contraction, and then take up the soft tissue slack during the refractory period. Force of Contraction: Sustained gentle pressure JOINT MOBILIZATION USING MUSCLE FORCE Goal: To accomplish restoration of joint motion in an articular dysfunction Physiologic Basis: Distortion of articular relationships and motion loss results in a reflex hypertonicity of the musculature crossing the dysfunctional joint, similar to thrust (HVLA) technique. This increase in muscle tone tends to compress the joint surfaces and results in thinning of the intervening layer of synovial fluid and adherence of joint surfaces. Restoration of motion to the articulation results in a gapping, or reseating of the distorted joint with reflex relaxation of the previously hypertonic musculature. Force of Contraction: Maximal muscle contraction that can be comfortably resisted by the physician RESPIRATORY ASSISTANCE Goal: To produce improved body physiology using the patients voluntary respiratory motion. Physiologic Basis: The muscular forces involved in these techniques are generated by the simple act of breathing. This may involve the direct use of the respiratory muscles themselves, or motion transmitted to the spine, pelvis, and extremities in response to ventilation motions. The physician usually applies a fulcrum against which the respiratory forces can work. Force of Contraction: Exaggerated respiratory motion

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OCULOCEPHALOGYRIC REFLEX Goal: To effect reflex muscle contractions using eye motion. Physiologic Basis: Functional muscle groups are contracted in response to voluntary eye motion on the part of the patient. These eye movements reflexively affect the cervical and truncal musculature as the body attempts to follow the lead provided by eye motion. It can be used to produce very gentle post-isometric relaxation or reciprocal inhibition. Force of Contraction: Exceptionally gentle RECIPROCAL INHIBITION Goal: To lengthen a muscle shortened by cramp or acute spasm. Physiologic Basis: When a gentle contraction is initiated in the agonist muscle, there is a reflex relaxation of that muscles antagonistic group. Force of Contraction: Very gentle CROSSED EXTENSOR REFLEX Goal: Used in the extremities where the muscle that requires treatment is in an area so severely injured (e.g., fractures or burns) such that manual contact with the affected limb is inadvisable. Physiologic Basis: This form of muscle energy technique uses the learned cross pattern locomotion reflexes engrammed into the central nervous system. When the flexor muscle in one extremity is contracted voluntarily, the flexor muscle in the contralateral extremity relaxes and the extensor contracts. Force of Contraction: Very gentle Types of Muscle Contraction Used in Muscle Energy Technique ISOMETRIC MUSCLE CONTRACTION Most common form of contraction used in muscle energy technique. The origin and insertion of the muscle are maintained in a stationary position while the muscle is contracted against resistance. ISOTONIC MUSCLE CONTRACTION This basic principle is applied to joint restriction by activating a specific muscle while fixing only one end of the muscular attachment, with the goal of restoring normal mechanics. Hypotonic, reflexively inhibited muscles are frequently treated with isotonic contractions. ISOLYTIC MUSCLE CONTRACTION Used for the treatment of fibrotic or chronically shortened myofascial tissues. The applied counterforce is greater than the patient force, resulting in lengthening of the myofascial tissues. Types of Joint Restrictors MONOARTICULAR MUSCLES Also referred to as short restrictors, considered key in maintaining Type II, segmental dysfunctions POLYARTICULAR MUSCLES Also referred to as long restrictors, considered to maintain Type I, group dysfunctions IV. V. Indications Clinically relevant somatic dysfunction Contraindications Absolute Absence of somatic dysfunction

Lack of patient consent and/or cooperation Relative Infection, hematoma, or tear in involved muscle Fracture or dislocation of involved joint Rheumatologic conditions causing instability of the cervical spine Undiagnosed joint swelling of involved joint Positioning that compromises vasculature VI. Safety and Efficacy Muscle energy techniques have inherent safety due to the corrective force being applied by the patient. Too vigorous a contraction on the part of the patient can render the technique less effective and result in post treatment soreness or muscle spasm. Principles of Diagnosis Identification of a specific motion restriction is critical. Specific findings of somatic dysfunction (tenderness, asymmetry, restriction of motion, tissue texture abnormalities) are utilized in the muscle energy model.. Principles of Treatment Key steps for successful direct muscle energy techniques: 1. Accurate specific diagnosis of somatic dysfunction 2. Position the patient at the point of initial resistance (feathers edge) of the barrier 3. Physician must establish an appropriate counterforce 4. Patient introduces appropriate muscle energy effort a. Direction b. Duration c. Amount of force 5. The patient must completely relax following muscle effort 6. A pause of 1-2 seconds is necessary for neuromuscular adaptation (post-relaxation phase) 7. Physician must reposition the patient at the new restrictive barrier 8. Repeat steps 3-6 until no further change is obtained 9. Reassess for appropriate change Special Considerations Muscle energy technique is the prototypical active, direct osteopathic manipulative technique. Muscle energy technique can be used to treat any joint that is crossed by voluntary muscles. Muscle contraction is a principle mechanism for promoting lymphatic and venous circulation, thereby making muscle energy technique important in the treatment of edema/congestion. This in turn may result in secondary reduction of inflammation. References 1. DiGiovanna EL, Schiowitz S, Dowling DJ. An Osteopathic Approach to Diagnosis and Treatment, 3rd edition. Lippincott Williams & Williams, 2005. 2. Educational Council on Osteopathic Principles. Glossary of Osteopathic Terminology. Chevy Chase, MD: American Association of Colleges of Osteopathic Medicine, 2006. 3. Ehrenfeuchter WC and Sandhouse M. Muscle Energy Techniques. In: Ward R, ed. Foundations for Osteopathic Medicine, 2nd edition. Lippincott, Williams & Wilkins 2003 4. Greenman, DO, P.E. Principles of Manual Medicine, 3rd edition. Lippincott Williams & Wilkins, 2003. 5. Kimberly, PE. Outline of Osteopathic Manipulative Procedures: The Kimberly Manual 2006.

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6. Mitchell, Jr. DO, F.L., The Muscle Energy Manuals Volumes 1: Concepts and Mechanisms The Musculoskeletal Screen, Cervical Region Evaluation and Treatment, MET Press, 1999. 7. Mitchell, Jr. DO, F.L., The Muscle Energy Manuals Volumes 2: Evaluation and Treatment of the Thoracic Spine, Lumbar Spine, and Rib Cage, MET Press, 1999. 8. Mitchell, Jr. DO, F.L., The Muscle Energy Manuals Volumes 3: Evaluation and Treatment of the Pelvis and Sacrum, MET Press, 1999. 9. Mitchell Sr. FL. Structural Pelvic Dysfunction. In: Barnes MW, ed. Yearbook of the Academy of Applied Osteopathy. Indianapolis, IN: American Academy of Osteopathy; 1958:79 10. Mitchell Jr FL, Moran PS, Pruzzo NA. An Evaluation and Treatment Manual of Osteopathic Muscle Energy Procedure. 2nd Ed. Kansas City, MO: Institute for Continuing Education in Osteopathic Principles, Inc; 1973 11. Ward RC. Foundations For Osteopathic Medicine 2nd Ed., Lippincott Williams & Wilkins, Philadelphia 2003.

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