Continuing Education Activity

Muscle energy is a well-established osteopathic technique used to address a variety of somatic dysfunctions. Somatic dysfunctions are defined as changes to the structure and function of the somatic system, composed of muscle, fascia, nerves, and vasculature. In the cervical region, this typically presents as "increased muscle tension, sensitivity changes, asymmetry, and restriction of range of motion" This activity describes and explains the role of the Osteopathic Physician in evaluating and treating patients who undergo cervical muscle energy.

Objectives:

• Describe the steps to perform cervical muscle energy.
• Identify the common indications for cervical muscle energy.
• Review the absolute and relative contraindications for cervical muscle energy.
• Summarize the importance of collaboration and communication amongst the interprofessional team to improve outcomes for patients affected by chronic neck pain receiving cervical muscle energy.

Introduction

Muscle energy is a well-established osteopathic technique used to address a variety of somatic dysfunctions. Somatic dysfunctions are defined as changes to the structure and function of the somatic system, composed of muscle, fascia, nerves, and vasculature. In the cervical region, this typically presents as "increased muscle tension, sensitivity changes, asymmetry, and restriction of range of motion."[1] 

To alleviate dysfunction in a joint, muscle energy may be employed by utilizing intermittent patient force in opposition with a constant force applied by an osteopathic physician. Muscle energy has proven to effectively reduce many cervical dysfunctions, including pain, lordosis, decreased range of motion, and decreased muscle strength.[2] Muscle energy is considered a direct-technique, in that the dysfunctional muscle has active engagement during treatment.[3]

Anatomy and Physiology

The cervical spine consists of seven vertebrae, which are anatomically unique from the other four regions of the spine. The cervical bifid spinous processes, transverse foramina, and triangular vertebral foramen are key structural features that enable the functionality of this region.[4] The upper cervical spine (C1-C2), consists of the atlas (C1) and the axis (C2). The atlas, a ring-shaped vertebra lacking a body, articulates with the axis by encircling the dens below and the occiput above. The dens of C2 is a remnant of the body of the atlas (C1), ultimately fused with the body of C2.[5]

In contrast to C1-C2, the five vertebrae in the lower portion of the cervical spine (C3-C7), have a vertebral body and an uncinate process, a feature unique to the cervical spine that consists of a hook-shaped process on the superolateral margin designed to limit movement of the intervertebral discs during rotation. Furthermore, there are several ligaments connecting each level of the spine that include the anterior and posterior longitudinal ligaments, the ligamentum flavum, and the interspinous ligament. The nuchal ligament and the transverse ligament articulate at the level of the cervical spine only.[4] 

The structure of the cervical spine allows for a wide range of motion in all three planes (sagittal, transverse, and coronal). Flexion, forward bending of the neck in the sagittal plane. Extension, backward bending of the neck in the sagittal plane. Sidebending, flexion to the right or left in the coronal plane. And rotation, rotating to the left or right in the transverse plane.[6] The primary motion of the occipitoatlantal (C0-C1) joint is flexion and extension, the atlantoaxial joint (C1-C2) is rotation, C2-C4 is rotation, and C5-C7 is side-bending.

Indications

Indications for the use of muscle energy to address a cervical somatic dysfunction entails first diagnosing a dysfunction with palpatory findings and ensuring that the patient is a candidate for osteopathic manipulative treatment.[7]

Contraindications

Contraindications to muscle energy techniques divide into absolute and relative contraindications. Absolute contraindications include trauma, bone fractures, joint dislocation, infection, lack of patient consent, or muscle tears. Relative contraindications include cervical spine instability, internal bleeding, recent myocardial infarctions, or recent surgery.[3] Rheumatological conditions are also considered a relative contraindication and depend on disease severity and anatomical location of joints affected.[8]

Preparation

As preparation, the technique is explained to the patient and that in this approach, mutual collaboration between the operator and the patient is necessary.

Technique or Treatment

Several muscle energy techniques address dysfunction at the OA joint, AA joint, and within the remaining cervicals. 

Occipitoatlantal Dysfunction Muscle Energy

1. Diagnose dysfunction of the OA joint (i.e., OA flexed, rotated left, side bent right (F RlSr)). 
2. Using one hand to hold the patient's head, place the other hand at the OA junction to monitor articulation of the joint.
3. Place the patients head towards the barrier, or in opposition to the diagnosis. (i.e., If the patient is OA F RlSr,  Rotate the patient to the right, side bend to the left, and extend). 
4. Instruct the patient to attempt to move their head back into a neutral position and provide an isometric force for 3 to 5 seconds.
5. Reposition the patient further in the direction of the barrier, and repeat step 4. 
6. Repeat steps 4 through 5, three to five times, and reevaluate the dysfunction.[9]

Atlantoaxial Dysfunction Muscle Energy

1. Diagnose dysfunction of the AA joint (i.e., AA Rotated Left (Rl)). 
2. Holding the head of the patient with both hands, flex the neck to lock out the joints below the level of the AA joint. 
3. Rotate the patient's head toward the barrier (i.e., If AA Rl, rotate the patient to the right).
4. Instruct the patient to attempt to move their head back into a neutral position and provide an isometric force for 3 to 5 seconds. 
5. Reposition the patient further in the direction of the barrier, and repeat step 4. 
6. Repeat steps 4 through 5, three to five times, and reevaluate the dysfunction.[10]

C2-C7 Dysfunction Muscle Energy

1. Diagnose dysfunction of a vertebra (i.e., C4 Flexed, Rotated Right, Sidebent Right (C4 F RrSr)). 
2. While holding the patient's head with one hand, palpate the articular pillars with the other hand at the level of the dysfunctional vertebrae. 
3. Place the patients head towards the barrier, or in opposition to the diagnosis. (i.e., If the patient is C4 F RrSr, Rotate the patient to the left, side bend to the left, and extend). 
4. Instruct the patient to attempt to move their head back into a neutral position and provide an isometric force for 3-5 seconds.
5. Reposition the patient further in the direction of the barrier, and repeat step 4. 
6. Repeat steps 4 through 5, three to five times, and reevaluate the dysfunction.[11]

Complications

Adverse complications are rare; however, they may include stroke, disc herniation, fractures, or hematomas.[3] In a systematic review, the most frequently described major adverse event was cervical arterial dissection (CAD). However, there is currently not sufficient evidence to establish a risk profile for patients susceptible to this complication.[12]

Clinical Significance

This type of osteopathic approach is indicated not only for vertebral release but also for muscle relaxation. Very often, the deep muscles of the cervical tract can be a source of pain, not only local but also in the head, stimulating trigeminal pain. In fact, the sub-occipital muscles (3 out of 4) have a myodural bridge, the latter of which is innervated and rich in proprioceptors. A contracture of these muscles or the presence of triggers points can trigger migraines and headaches. In the acute phase, METs can be performed and relieve symptoms.

The technique stimulates correct intervention of the parasympathetic system and facilitates the restoration of the passage of fluids (blood and lymph).The MET approach can improve the function of the respiratory accessory muscles of the cervical tract, increasing the ventilatory capacity of patients with fibromyalgia.[13]

Chronic neck pain can result from previous trauma; in these cases, the contractile content of the muscles decreases, while the adipose tissue increases. In this clinical context, local inflammation (pain) increases, and the proprioceptive capacity of the muscular districts decreases with consequent deterioration of the neuromotor coordination (pain). MET can help restore not only proper spinal joint space but improve the ability of muscles to stretch and shorten comprehensively. This last point will allow the neck muscles to implement their function, reducing the causes of the pain.

MET can improve the morphology of the cervical tract (curvature); it could be a strategy for faster recovery from trauma such as whiplash.[2]

If the patient's cervical tract is very painful and not very mobile, it is possible to start using METs, using the eye muscles in conjunction with the small movements of C0-C2. Or, involve the lingual complex and movement of the cervical tract, up to C4.

Enhancing Healthcare Team Outcomes

Muscle energy of the cervical spine is a useful, non-invasive option for patients diagnosed with somatic dysfunctions. While an osteopathic clinician performs manipulative therapy in an office setting, overall patient outcomes can be improved by combining exercise with manipulative treatment and employing a multidisciplinary approach. In a systematic review by Hidalgo et al., multiple manipulative treatments combined with exercise, was more effective at reducing chronic neck pain, than manipulative therapies alone. [Level 1]

Chronic neck pain accounts for 25% of all outpatient visits for physiotherapy, and between 50 to 85% report recurrence.[14] Therefore, it is imperative to develop a treatment plan with maximum efficacy to reduce rates of recurrence and improve overall patient outcomes.

Nursing, Allied Health, and Interprofessional Team Interventions

The osteopath should always interact with other health figures, such as the physiotherapist, the speech therapist, and others. In the literature, it is clear that, very often, METs are used in combination with non-osteopathic treatments to improve the patient's clinical picture more quickly.

Nursing, Allied Health, and Interprofessional Team Monitoring

It is clear that, if osteopathic treatment (in this case, with the use of METs) is effective, the patient's health stands out in the daily or routine visits by other health professionals.