Osteopathic Manipulative Treatment: Muscle Energy Procedure - Lumbar Vertebrae

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 or Treatment

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 their 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 their 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 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 the conflicting efficacy of treatments.[4] Misalignment of the lumbar spine or loss of lumbar joint function are common causes 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 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 if the patient is experiencing worsening or new pain throughout the procedure. 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]