Following the previous blog posting on the use of rhythmic isometric contractions in application of MET, there was a discussion on the topic on facebook.
In that thread of discussion the following postings occurred (Note: some of this selection of posts from that thread have been summarised reduced in length):
Before looking at some of these, and the remarkable insights they led to from Fred Mitchell Jr DO, I will draw attention to a variation on Pulsed MET (as previously described) – deriving from Karel Lewit (2010).
Lewits 1st rib method
Lewit describes the therapist as being active, with the patient resisting….the direct opposite of the way pulsed MET is employed.
In the illustration, above,the therapist stands behind seated patient, stabilizing neck/shoulder region of side to be treated, with one hand. The other hand is placed against side of the patient’s head.
The patient is asked to press her head against this hand, as the therapist rhythmically intensifies and slackens pressure.
Lewit suggests that 20 scalene isometric contractions of this sort (two per second) usually produces mobilization of the 1st (and sometimes 2nd) rib.
Ruddy’s model would require all efforts to be by patient – resisted by the practitioner.
The facebook thread
The facebook thread that led to Dr Mitchell’s explanations (see later in this posting) begins with my post:
‘Teaching in London this weekend, and I came across this quote from Fred Mitchell Jr. DO, son of the major developer of Muscle Energy Technique.’
“Treating a joint motion restriction as if the cause were tight muscle(s) is one approach that makes possible restoration of normal joint motion. Regardless of the cause of restriction, MET treatment, based on a ‘short muscle’ paradigm, is usually completely effective in eliminating blockage, and restoring normal range of motion, even when the blockage is due to non-muscular factors”
‘What do you think? This approach is usually, but not always successful, and when not – there’s always HVLA.’
There then followed a lively discussion between Ben Cormack, Rajam Roose, Zac Laraman and Vijay Gambhir, on the relative value of MET in treating joint dysfunction locally, to which I added:
“When a joint is restricted – particularly a spinal joint – of course it is a part of a chain of other functional and structural features, and seldom an isolated problem (unless the result of recent, direct, trauma).
So if we regard most spinal joint dysfunction as adaptive, we are not dealing with a local problem. The statement by Mitchell that I posted says (to me anyway) that MET is an efficient way of starting the normalisation process, instead of HVLA manipulation aimed at ‘correcting’ or ‘adjusting‘ that same dysfunction.
That reeducation in patterns of use, posture, breathing etc etc, are all part of what needs to be done is not the issue….only that MET is safer, more efficient (usually – in my experience) and involves more of the involved tissues beneficially, than HVLA. …..Kappler & Jones (2003) observed, relative to what’s preventing free motion in joints (commonly, but not always): “As the barrier is engaged, increasing amounts of force are necessary and the distance decreases. The term barrier may be misleading if it is interpreted as a wall or rigid obstacle to be overcome with a push.
As the joint reaches the barrier, restraints in the form of tight muscles and fascia, serve to inhibit further motion. We are pulling against restraints rather than pushing against some anatomic structure.”
It is these soft tissue barriers to free movement that MET addresses most effectively…..however…. I never said that this was all that needs to be done, only that it may be more effective than high velocity methods.”
Following some mild bickering from those engaged in this discussion, Christian Fossum DO entered the thread with this posting:
“I find MET an effective approach, but do chose other techniques when called for. One thought which I now frequently return to when my MET seems to be less effective is one given to me by Ed Stiles, D.O.: “When ineffective, are you treating the patient out of sequence?”. Sequencing the treatment added to my success, but didn’t exclude the use of other manipulative methods.”
More interchanges followed at which point Nathan Josephs brought in the names of Fred Mitchell (Sr and Jr) as well as Philip Greenman – referring us to his blog.
Hallie Robbins DO then added:
“MET is a blunt or sharp instrument depending on the practitioner’s precision. I use MET regularly, but I vary the amount of loading or activating force recruitment in order to address the discrete fiber bundles or larger muscle masses. I also have found that inviting a patient to move in specified directions in short arcs (or sometimes PNF-style larger movements) can help both provider and patient find and target the prime tissue restrictions quickly. This fits with Ed Stiles, DO, Sequencing approach”
“The version of MET I use (and teach mainly) is that of TJ Ruddy, who taught his methods to Mitchell (senior). It is what Rudy called “rapid resistive duction” and involved mini-isometric contractions (2 per second) usually towards the restriction barrier in Ruddy’s methodology, but in almost any direction in the way I use/teach it. In spinal regions this often involves coaching the patient into producing translation movements against a firm barrier (my hand as a rule) in order to produce mobilisation. I believe we are actually recruiting the intrinsic spinal muscles in this way. I don’t know if Drs Mitchell et al teach this marvellous version of MET?”
“Your and my interpretations of MET applications seem similar. Jay Sandweiss is the contact person and faculty with Fred’s son for Mitchell MET. In March at AAO Convo, Jay , Mickey and I were comparing treatment techniques; Jay calls mine “Flow” as I interweave functional and other modalities into the MET more than “only” setting up planes and working through barriers in the more classic MET version.”
Steve Goldstein offered these thoughts:
“I’ve found blending modified MET for joints with myofascial sensibility a fine combination. Clearing global restrictions along fascial lines and planes with modified MET for joints using low force extremely effective. Once I got over the hurdle of thing MET was just for muscles, and the load had to be 20%-30%, was when I started being extremely effective. I use low load resistive, as I call it, to free axial and peripheral joints quickly and efficiently. I use 5-10% force for intrinsic muscle and it also effected ligaments. Upon release a slight counter-force in the opposite direction is often enough to open a restricted direction. I agree the preciseness is a major component and contributor to the success of the application.”
I suggested that it might be useful to~: “Try adding mini-pulses instead of even brief, light sustained contractions. Ruddy’s magic injunction was to “avoid wobble and bounce” – so a mere pulsing is called for, and 5 to 10% of strength sounds to be at the upper end of what I think is needed. I’d love to know why Ruddy’s approach is not more widely taught…perhaps someone can ask Jay to ask Fred….?
To which Hallie responded: “I can check with Jay and Fred Jr-“
What follows in this posting are the words of Fred Mitchell Jr, one of the primary developers and teachers of MET, and the son of the main developer of MET as we know it….with clear reference to the foundational influence of the work of TJ Ruddy DO, on the evolution of this most useful approach.
Thomas Jefferson (T.J.) Ruddy never used the expression “muscle energy,” to my knowledge. His alliterative name for one of his many techniques was “Ruddy’s Rapid Rhythmic Resistive Duction Technique,” (RRRRD)
It is worth noting that Ruddy was already an ophthalmologist (in his day they were called Eye, Ear, Nose, and Throat –EENT – specialists), MD, before he went to Kirksville to study [osteopathy] with Andrew Taylor Still.
When my father, Fred L. Mitchell, Sr., met Ruddy (approximately 1958), he was demonstrating one of his many (actually, over 100 patented) inventions, the “eye finger” – a soft appliance molded to the ovoid contour of the eyeball used on the eyelid for resisting extraocular muscle actions, which were being used to pump
edema from the orbit. The idea of using a patient’s voluntary precisely controlled muscle actions for a focused local therapeutic effect was an epiphany for my father.
Later, Ruddy applied the principle of using striated muscles as venous/lymphatic pumps in the context of the long-lever techniques he had learned from Still for treating osteopathic lesions of the axial skeleton or limbs. I have seen the photograph taken of Ruddy while he is watching A. T. Still demonstrating thoracic spine long lever technique using the arm.
When I saw Ruddy demonstrate a RRRRD procedure for treating an upper thoracic segmental dysfunction, it looked very much like that old photograph. With one hand he palpated the vertebra, with the other he held the patient’s wrist while taking his pulse (to time his oscillating resistance to the (sustained) muscle contraction) and holding the arm in an abducted position, and using the arm lever to control and localize myofascial tension. His instruction to the patient would be the equivalent of, “Try to keep your arm in this position.”
Resist vs. Think
Herein lies a significant difference between RRRRD and MET. Many practitioners who say they are employing Muscle Energy Technique are in the habit of saying to patients the equivalent of “Resist me when I push against you.”
The few who better understand the MET paradigm give their patient instructions that include a target for the patient’s effort. The patient may be instructed to “Make an eight ounce push with your forehead toward your left hip.” These detailed instructions are addressed (through imagery) to the global reflex systems which impact the somatic dysfunction being treated, with the goal of using imagery to re-program spinal cord internuncial neurons involved in the spinal effector mechanisms of core muscle and synergist participants.
Ruddy had taken to heart Still’s lectures about the importance of microcirculation. He was among the many students who heard Still state his intension to transform all of them into philosophers, and certainly not the only one who understood Still’s goal. He knew that Still was not quoting a bumper sticker when he said, “The rule of the artery is supreme.” He understood the reference to microcirculation. It is possible that Ruddy understood osteopathic lesions to be importantly, if not primarily, abnormal disturbances of circulatory dynamics. Restoring mobility to a joint was accomplished, mainly, by decongesting the tissues around it.
Most people understand the fluid pumping effect of a muscle contraction. Many understand in a general way its stretching effect on fascia and that muscle proprioceptive afferents are stimulated when a muscle contracts. Since its original formulation by my father, MET has evolved for me as biochemistry and neurophysiology have shed more light on the quantitative details of these phenomena.
My father’s earliest concept of what we now call MET placed heavy emphasis on Sherrington’s Second “law” (describing how antagonist muscles inhibit each other).
Consequently, his treatments for dysfunctions of the axial skeletal joints called for very forceful patient contractions “to inhibit the tight muscle.”
Such forceful contractions are still commonly used throughout Europe by practitioners of Post-Isometric Relaxation (PIR), especially those trained by Vlad Janda. Janda’s principal mentor, Karel Lewit, after he visited me at MSU, changed his approach to using grams of isometric force instead of kilograms. He confirmed that in a letter to me, and expressed his gratitude to me for my guidance in MET. We had extensive correspondence regarding MET and PIR. The sub-maximal
recruitment idea probably originated with me. At least, I was thinking in terms of precisely controlling which motor units fire for maximum therapeutic effects by how I instructed the patient.
Old MET vs. Modern MET
The current modern MET applications taught in my courses have departed significantly from what my father taught, mostly from my own research. Being a teacher means being frequently confronted with things you know for sure that turn out to be wrong. (Apologies to either Will Rogers or Mark Twain, whose wisdom I may have paraphrased).
Dr Mitchell has offered many other insights in his generous response to Hallie’s query about ‘pulsed MET’, and I hope to post these in a future blog.
For now though it may be time to digest the essence of the information we have been offered….that Ruddy learned from Still, that Fred Mitchell Sr learned from Ruddy….and that we can all learn from these pioneers, and the insightful commentary from Fred Mitchell Jr DO who continues that legacy.
Kappler & Jones 2003 in Foundations of Osteopathic Medicine 2nd edition pp852-880
Lewit K Manipulative Therapy Elsevier 2010 p217
Mitchell F Jr. 1998 Muscle Energy Manual Vol.2: MET Press, East Lansing p1
Ruddy T 1962 Osteopathic rapid rhythmic resistive technic. Academy of Applied Osteopathy Yearbook, Carmel, California