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Musc e Energy
Techniques
For Churchill Livingstone:

Senior Commissioning Editor: Sarena Wolfaard

Associate Editor: Claire Wilson
Project Manager: David Fleming
Design: Stewart Larking
Illustration Manager: Bruce Hogarth

Treatment table in the CD-Rom videoclips supplied

by Russell Medical Worcestershire UK.
Musc e Energy
Techniques
With accompanying DVD

Leon Chaitow NDDO

Registered Osteopathic Practitioner a n d Senior Lecturer, University o f Westminster, London, UK

With contributions by
Ken Crenshaw BS ATC CSCS
Sandy Fritz BS MS
Gary Fryer BSe ND DO
Craig Liebenson DC
Ron J Porterfield BS ATC
Nathan Shaw ATC CSCS
Erie Wilson PT DSe OCS SCS CSCS

Foreword by
Donald R Murphy DC DACAN

III ustrations by
Graeme Chambers BA(Hons)
Medical Artist

THIRD EDITION

CHURCHILL
LIVINGSTONE

ELSEVIER
EDINBURGH LONDON NEW YORK OXFORD PHILADELPHIA ST LOUIS SYDNEY TORONTO 2006
 CHURCHILL
LIVINGSTONE
ELSEVIER

An imprint of Elsevier Limited

© Pearson Professional Limited 1996

© Elsevier Limited 1999
© 2006, Elsevier Limited. All rights reserved.

The right of Leon Chaitow to be identified as author of this work has been asserted by him in
accordance with the Copyright, Designs and Patents Act 1988

No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form
or by any means, electronic, mechanical, photocopying, recording or otherwise, without either the prior
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permission of the publishers or a licence permitting restricted copying in the United Kingdom issued
by the Copyright licensing Agency, 90 Tottenham Court Road, London WIT 4LP. Permissions may be
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215 238 7869, fax: (+1) 215 238 2239, e-mail: [email protected]. You may also complete
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Support' and then 'Obtaining Permissions'.

First edition 1996

Second edition 1999
Third edition 2006

ISBN 10: 0443 101140

ISBN 13: 978 0443 101144

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library

Library of Congress Cataloging in Publication Data

A catalog record for this book is available from the Library of Congress

Notice

Neither the Publisher nor the Author assume any responsibility for any loss or injury and/or
damage to persons or property arising out of or related to any use of the material contained in this
book. It is the responsibility of the treating practitioner, relying on independent expertise and
knowledge of the patient, to determine the best treatment and method of application for the patient.
The Publisher

your source for books,

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 Contents
- -- --

The CD-ROM accompanying this text includes video sequences of all the techniques indicated in the text
by the icon. To look at the video for a given technique, click on the relevant icon in the contents list on
the CD-ROM. The CD-ROM is designed to be used in conjunction with the text and not as a stand-alone
product.

Contributors vii

Foreword ix

Preface xi

Acknowledgements xiii

1. An introduction to muscle energy techniques

2. Patterns of function and dysfunction 23

3. How to use MET 77

4. MET: efficacy and research 107

Gary Fryer

5. Sequential assessment and MET treatment of main postural muscles 131

6. MET and the treatment of joints 199

7. Integrated neuromuscular inhibition technique (I NIT) 247

8. Manual resistance techniques in rehabilitation 257

Craig Liebenson

9. MET in the physical therapy setting 27 3

Eric Wilson

10. MET in a massage therapy setting 299

Sandy Fritz

11. MET in treatment of athletic injuries 311

Ken Crenshaw, Nathan Shaw, Ron J Porterfield

Index 341
THIS PAGE INTENTIONALLY
LEFT BLANK
 Contributors

Ken Crenshaw BS ATC CSCS Ron J Porterfield BS ATC

Head Athletic Trainer, Arizona Diamondbacks Head Athletic Trainer, Tampa Bay Devil Rays
Baseball Team, Phoenix, AZ, USA Baseball Team, St Petersburg, FL, USA

Sandy Fritz BS MS Nathan Shaw ATC CSCS

Director, Health Enrichment Center, School of Strength and Conditioning Coordinator,
Therapeutic Massage, Lapeer, MI, USA Arizona Diamondbacks Baseball Team, Phoenix,
AZ, USA
Gary Fryer BSc NO DO
Senior Lecturer, School of Health Science, Eric Wilson PT DSc OCS SCS CSCS
Victoria University, Melbourne, Australia; Chief, Physical Therapy Element, 7th MDG,
Centre for Aging, Rehabilitation, Exercise and Dyess Air Force Base, TX, USA
Sport, Victoria University, Melbourne, Australia

Craig Liebenson DC
L.A. Sports and Spine, Los Angeles, CA, USA
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THIS PAGE INTENTIONALLY
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 Foreword

As the art and science of neuromusculoskeletal specific treatment approaches that are most likely
care evolve, it is becoming increasingly clear that to correct the identified dysfunctions. Muscle energy
manual techniques are essential in the proper techniques (METs) are among the most valuable
management of patients with problems in this area. tools that any manual clinician can have in his or
What is less easily measured, however, is the impact her tool box. There are many reasons for this.
of the degree of skill with which these techniques First, METs have a wide application. This is
are applied on the outcome of management. Most exemplified by the presence in this edition of chapters
clinicians who use manual techniques in the treat­ specific to massage therapy, physical therapy and
ment of dysfunction in the locomotor system would athletic training. METs can be applied to muscle
agree, however, that the level of skill with which a hypertonicity and muscle tightness, but can be
practitioner applies a certain technique is of the equally effectively applied to joint dysfunction and
utmost importance in the success of any management joint capsule adhesions. They can be applied to
strategy. Intuition would tell us that a clinician little old ladies or high level athletes, and anyone
with limited skill and a limited variety of methods in between. Important modifications must be made
in his or her armamentarium would be less effective, for each application and each individual, as is
especially for a difficult case, than one who demonstrated in this book. But because the method
possesses wide-ranging knowledge and ability. is as flexible as it is, the clinician is provided with
It has been said that "you can't learn manual a tool that he or she can modify for a variety of types
skills from a book". However, you can build upon of dysfunction, and a variety of types of patients.
an existing body of knowledge, skill and expe­ Second, METs can be applied in a gentle manner.
rience with a written source that introduces new In manual therapy, we always want to be as gentle
methodology and instructs in the scientific basis as possible, in a way that still provides effective
and proper application of one's current methodology. correction of dysfunction. MET, particularly when
In addition, a written source of high-quality, applied to muscle hypertonicity and to joint
clinically applicable information can be an excellent dysfunction, is both gentle and effective. For those
source of support material when one is taking an of us who use thrust techniques, METs also represent
undergraduate or postgraduate course in manual a different method of applying joint manipulation
therapy. Dr. Chaitow has produced such a book. that is well tolerated by the apprehensive patient,
One of the unique aspects of manual therapy or the acute situation. And, MET has been shown
that one discovers early on in practice is that no to be equally effective as thrust techniques.
two patients are alike and no two locomotor systems Third, METs actively involve the patient in the
are alike. As a result, each patient requires a process. One of the essential ingredients in a
highly individualized approach that addresses his successful management strategy involves empower­
or her unique circumstances. This means that one ing the patient to take charge of his or her own
must be meticulous about identifying those specific recovery. This means that the patient must not be
dysfunctions, be they joint, muscle or otherwise, a passive recipient of treatment, but rather and
that are most important in producing the disorder active participant. Unlike many manual procedures,
from which the patient suffers, and choosing those with METs the patient must be involved in every
step, contracting at the appropriate time, relaxing techniques can be incorporated into the overall
at the appropriate time, engaging in eye move­ rehabilitation strategy. I can say for myself that I
ments, breathing, etc. METs allow the clinician to could not imagine how I would attempt to manage
apply corrective measures while at the same time the majority of patients that I see without METs at
beginning the process of transferring responsibility my disposal.
to the patient. But, for all these benefits of METs to be realized,
Finally, METs are effective. As Dr. Fryer demon­ one must apply them with skill and precision. And
strates in his chapter, the research into the clinical they must be applied in the context of a manage­
efficacy of METs is in it's infancy. And he also ment strategy that takes into consideration the
points out the interesting challenges to effective entire person. This book represents an important
research in this area. However, Dr. Fryer also step in this direction.
reveals that those studies that have begun to assess
whether METs have an impact on clinical outcome Donald R. Murphy, DC, DACAN
have suggested that, when an overall management Clinical Director, Rhode Island Spine Center
strategy includes the use of skilled METs, patients Clinical Assistant Professor,
benefit to a greater degree than when these methods Brown University School of Medicine
are not included. In this book, not only is this Adjunct Associate Professor of Research,
research presented, but also, in Dr. Liebenson's New York Chiropractic College
chapter, the reader is instructed as to how these Providence, RI USA
 Preface

What has surprised and excited me most about Captain Eric Wilson PT Dsc, author of that chapter,
the content of this third edition is the speed with gained his MET knowledge from impeccable
which research and new methods of using MET sources at Michigan State University's School of
have made the previous edition relatively out of Osteopathic Medicine.
date. It's not that the methods described in previous There are fascinating descriptions in Chapter 11
editions are inaccurate, but rather that the theo­ of MET as used by athletic trainers Ken Crenshaw,
retical explanations as to how MET 'works' may Nate Shaw and Ron Porterfield in the context of
have been over-simplistic. The diligent research, a professional baseball team's (Tampa Bay Devil
much of it from Australia, that is outlined by Gary Rays) need to help their athletes to remain func­
Fryer DO in Chapter 4, reveals mechanisms tional, despite overuse patterns that would not be
previously unsuspected, and this may well change easily tolerated by normal mortals.
the way muscle energy methods are used clinically. Chapter 10 provides a respite from extremes
In addition, increasingly refined and focused of pain and overuse and illustrates the efficiency
ways of using the variety of MET methods are with which MET can be incorporated into normal
emerging, and excitingly many of these are from therapeutic massage settings. Here Sandy Fritz
professions other than the usual osteopathic MS describes incorporation of these safe and effec­
backgrounds. tive approaches in ways that avoid breaking the
MET emerged initially from osteopathic tradi­ natural flow of a traditional bodywork setting.
tion, but what has become clear is just how well it From my own perspective I am increasingly
has travelled into other disciplines, with chapters exploring the dual benefits gained by use of slow
in this book variously describing MET usage in eccentric isotonic contraction/ stretches (see Chapters
chiropractic rehabilitation, physical therapy, athletic 3 and 5), and of the remarkably efficient 'pulsed'
training and massage contexts. For example: MET methods devised by Ruddy (1962) over half
In Chapter 8 a chiropractic perspective is offered a century ago and described in Chapters 3 and 6.
by Craig Liebenson DC, in which MET is seen to In short, the expanded content of this third
offer major benefits in rehabilitation. The evolution edition highlights the growing potential of MET in
of the methods outlined in that chapter also cross­ multidisciplinary and integrated settings and, by
fertilize with the pioneering manual medicine offering an updated evidence base, takes us closer
approaches as taught by Vladimir Janda MD and to understanding the mechanisms involved in its
Karel Lewit MD, with both of whom Liebenson multiple variations.
trained. These East European giants collaborated
and worked with some of the osteopathic Leon Chaitow NO DO
developers of MET. Corfu, Greece 2005
The clinical use of MET in treating acute low­
back pain in physical therapy settings, as described REFERENCES
in detail in Chapter 9, has identified very precise Ruddy T J 1962 Ost�opathic rhythmic resistive
MET applications in which acutely distressed spinal technic. Academy of Applied Osteopathy Yearbook
joints have been successfully treated and rehabilitated. 1962, pp 23-31
THIS PAGE INTENTIONALLY
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 Acknowledgements

As in previous editions, my respect and appre­ commonly has to be carved out of non-existent
ciation go to the osteopathic and manual medicine spare time. I truly cannot thank any of you
pioneers who developed MET, and to those who enough!
continue its expanding use in different professional I wish to thank the editorial staff at Elsevier
settings. in Edinburgh, in particular Sarena Wolfaard and
My profound thanks also go to the remarkable Claire Wilson, who continue to help me to solve
group of health care professionals who have con­ the inevitable problems associated with compila­
tributed their time and efforts to the chapters they tion of a new edition, not least those linked to the
have authored in this new edition: Ken Crenshaw, filming of new material for the CD-ROM.
Sandy Fritz, Gary Fryer, Craig Liebenson, Ron And, for creating and maintaining the tranquil
Porterfield, Nate Shaw and Eric Wilson. and supportive environment in Corfu that allowed
Only those who have undertaken the writing me to work on this text, my unqualified thanks
of a chapter for someone else's book will know the and love go to my wife Alkmini.
effort it requires, and the space to accomplish this
THIS PAGE INTENTIONALLY
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 An
introduction to
muscle energy
1
techniques
---- - ---

CHAPTER CONTENTS Muscle energy techniques (MET)

Muscle energy techniques (MET) Muscle energy techniques are a class of soft tissue
The route of dysfunction osteopathic (originally) manipulation methods
Revolution or evolution 3 that incorporate precisely directed and controlled,
MET by any other name 3 patient initiated, isometric and/or isotonic con­
History 3 tractions, designed to improve musculoskeletal
Early sources of MET 7 function and reduce pain.
Postisometric relaxation and reciprocal inhibition: As will be seen in later chapters, MET methods
two forms of MET 8 have transferred to almost all other manual thera­
Key points about modern MET 9 peutic settings. Liebenson (chiropractic, Ch. 8),
Variations on the MET theme 12 Wilson (physical therapy, Ch. 9), Fritz (massage
Lewit's postisometric relaxation method therapy, Ch. 10) and Crenshaw and colleagues
(Lewit 1999a) 13 (athletic training, Ch. 1 1 ) have all described the
What may be happening? 14 usefulness, in their professional work, of incor­
Why fibrosis occurs naturally 16 porating MET methodology, while in Ch. 4 Fryer
Putting it together 17 evaluates the evidence base for MET.
Why MET might be ineffective at times 18
To stretch or to strengthen 18

Tendons 18 The route to dysfunction

_....
_--...
Joints and M ET 20

References ' 21 Why and how we lose functional balance, flexi­

bility, stability and strength differs from person to
person, although the basic formula leading to
altered functionality inevitably contains similar
ingredients.
Ignoring for the moment psychosocial (anxiety,
fear, depression, etc.) and biochemical (nutritional
status, hormonal balance, etc.) issues, we might
consider the decline into dysfunction from a
largely biomechanical perspective. It should be
possible to agree that the nature and degree of the
demands of our active, or inactive, daily life, work
and leisure activities, as well as our individual
relationships with the close environment (shoes,
 CHAPTER ONE
2 An introduction to muscle energy techniques
L

chairs, cars, etc.), define the adaptive changes that In truth, however, structure and function are
are superimposed on our unique inherited and so intertwined that one cannot be considered
acquired characteristics. Leaving aside the effects without the other. The structure of a unit, or area,
of trauma, how our structures respond to the determines what function it is capable of. Seen in
repetitive demands of living, and habits of use reverse, it is function that imposes demands on
(posture, gait, breathing patterns, etc.), determines the very structures that allow them to operate, and
the dysfunctional configurations that emerge. which, over time, can modify that structure
Liebenson (2000) has observed that to prevent - just think of the gross structural changes that
musculoskeletal injury and dysfunction the indi­ occur in response to the functions involved in
vidual needs to avoid undue mechanical stress lifting weights or running marathons! Quite
(excessive adaptive demands), while at the same different changes emerge compared with those
time improving flexibility and stability in order to that would result from playing cards or chess.
acquire greater tolerance to strain. The lead author On 'a cellular level this has been expressed
of this book has expressed Liebenson's observation succinctly by Hall & Brody (1 999), who stated:
differently, as follows (Chaitow & DeLany 2005):
The number of sarcomeres in theory deter­
Benefit will usually emerge if any treatment mines the distance through which a muscle
reduces the overall stress load to which the person can shorten and the length at which it
is adapting (whether this be chemical, psycho­ produces maximum force. Sarcomere num­
logical, physical, or a combination of these), or if ber is not fixed and in adult muscle the
the person's mind-body can be helped to copel number can increase or decrease. The stimulus
adapt more efficiently to that load. for sarcomere length changes may be the amount
of tension along the myofibril or the myotendon
Liebenson (2000) suggests that there is evidence
(musculotendenous) junction, with high tension
that too little (or infrequent) tissue stress can be
leading to an addition of sarcomeres and low
just as damaging as too much (or too frequent, or
tension causing a decrease [italics added].
too prolonged) exposure to biomechanical stress.
In other words, deconditioning through inactivity So, at its simplest, the load on tissue, which
provokes dysfunction just as efficiently as does makes functional demands, leads to structural
excessive, repetitive and inappropriate bio­ change. It is therefore essential, when considering
mechanical stress. dysfunction, to identify, as far as possible through
If, over time, as a result of too little or too much observation, assessment, palpation, testing, imag­
in the way of adaptive demand, pathological ing, and questioning, just what structural modifi­
changes occur in soft tissues and joints, the conse­ cations coexist with the reported functional
quences are likely to include altered (commonly changes and /or pain, in order to construct a
reduced) functional efficiency, often with painful rational plan of therapeutic action. Conversely, in
consequences. attempting to restore normal function, or to
It was Karr ( 1 976) who described the musculo­ reduce the degree of dysfunction and/or pain, at
skeletal system as 'the primary machinery of least some of the focus needs to be towards
life.' It is, after all, largely through that system modifying the identified structural changes that
that we express our uniqueness, by means of have evolved.
which we walk, and move, dance, run, paint, lift Fortunately a variety of methods exist that can
and play, and generally interact with the world. encourage more normal function, modify structure,
But it was Lewit (1999a) who used the term and r.educe ar eliminate pain, depending on the
'locomotor system', and it is this descriptor that nature and chronicity of the problem. Among the
seems closer to reality than the phrase 'musculo­ most effective of such clinical tools - capable of
skeletal system'. The word 'locomotor' embraces assisting in both structural and functional change
a sense of activity and movement, whereas - are the range of methods that have been labelled
musculoskeletal sounds passive and structural, muscle energy techniques (MET) (Mitchell 1967,
rather than functional. Lewit & Simons 1 984, Janda 1 990, Lewit 1999a).
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