We have a new President in Dr Paul Lambden. At Paul’s first board meeting with the council, he asked open and honest questions about what sets the LCSP apart from other organisations. These were challenging and thought provoking questions. It generated reflection on my part, of my years since becoming a council member, invited because of my interest in trying to produce worthwhile CPD workshops. Over the years, I have seen a shift in the members’ skill base, I would now describe us as a professional body that specialise in ‘bodywork’ based on sound knowledge of Anatomy and Physiology whether their emphasis is Remedial Massage or Sports Massage Therapy.

When I started in Remedial Massage, I was fortunate to catch Ken Woodward at the tail end of his teaching career, and I gained so much from his wise words and thoughts. The main message that always stays with me is about being curious, investigating, in what is presented before us, because if we aren’t we will never help anyone. This thought process is often with me, when assessing someone who has acute pain on top of a long term chronic, postural issue that could cause that low dull ache. Our basic training is a platform from which to start, and as therapists we have to be in charge of our own development and how and who we treat. Often when we work on our own we have to be conscientious not to allow stagnation to occur. Ken’s wise words have continually prompted me to reflect on my practice, a recent result of this thought process took me to the NLSSM. I attended a Postural Assessment workshop with Jason Anderson. It was a great day and reassuring to hear another therapist talk about a subject to confirm my own knowledge. He brought his own energy and insights to Postural Assessment, and opened my mind to new ways of explaining the role of muscle action and function. I had a really enjoyable day reflecting, consolidating and developing my confidence in assessment.

Should you wish to build upon your skillset, we have details of the upcoming CPD courses on the back page, including the date for the next regional meeting.

The meeting is taking place in the Palm Court Hotel in Scarborough, I will be presenting a talk on how MET’s can enhance and refine our assessments, and how they can be integrated into our treatment.

Nick Dinsdale has a selection of one day courses, we have had excellent feedback from members who have already attended his workshops.

After a therapist, Mary McConnell attended the Introduction to the Hendrickson Method workshop this spring, she asked me if I would come up to Scotland with Tom’s work. Whilst Mary is organising the workshop (details on the back page), it is open for LCSP members who are most welcome to attend, so if you are interested contact Mary.

After much consideration, Giles Gamble and myself are going ahead with the Hendrickson Method Practitioner Programme. Tom is really delighted we are going ahead, as we have re-organised his original format. We have tried to make it far more accessable in this financial climate. You can now complete each part of the programme as and when you would like to. The only prerequisite to attending the course is that you must have attended the ‘Introduction to the Hendrickson Method’ 3 day course. Further details are on my website www.flexible-healing.com.

Just a reminder there will be a selection of CPD records requested this coming October.

We all have our ‘box’ of skills, I believe what is so wonderful about bodywork is that each therapist connects with different skills, and applies them in their own unique way; however the science behind it is the same.

One of my most useful tools is Muscle Energy Technique, so I thought I would use these pages as a beneficial review. Whilst there is lots of debate in literature about how MET works. Some focus on the Golgi tendon organs, whereas some authors focus on the muscle spindle. It is best to have a clear understanding of the essential neurologic role of the muscle spindle MET works the conscious, voluntary contraction of isolated muscles. Creating an isolated voluntary contraction is different from the muscle contraction we use in everyday life. Because the higher brain centres are used to isolate muscle contraction, this is a unique neurologic effect, compared to those accomplished in everyday functional activities.

• Extrafusal fibres, these provide the force of muscle contraction and are innovated by alpha motor nerves.
• Intrafusal fibres, also called muscle spindles. These are activated by the gamma nerves, which act as sensory receptors to help control the tone and length of the muscle.

– If a muscle contraction is sustained over a length of time, this can either be unconsciously or involuntary tightened. It is thought that the gamma motor neuron activity has set itself an abnormally high firing rate. This then keeps the muscles tone too high (hypertonic), so when it is resting, it is too short.

– Voluntary isometric contraction makes the fibres at the belly of the muscle shorten, loosening the intramural fibres and unloading the muscle spindle, switching it off temporarily. As isolated voluntary isometric contraction requires only alpha motor nerve activity, the gamma motor nerve is not firing to the muscle spindle.

– When muscles relax after voluntary isometric contraction, the alpha motor nerve switches off and the belly of the muscle lengthens. As this relaxation takes place, the gamma motor nerve switches on to re-set the muscles resting tone. In theory, because gamma motor nerves have just been turned off, the new rate at which they are firing has been reduced, decreasing the resting tone of the muscle.

Mechanical Basis of Muscle Relaxation Using MET

Muscles that are in an adaptive, shortened position or held in a sustained contraction have an increased stiffness. Relaxation after isometric contraction increases muscle temperature and reduces this stiffness because of the thixotropic (solidifies when cold or still / more fluid when warmed or stirred) property of the muscle.

How Muscle Energy Technique can lengthen muscle and reduce trigger points.

• Muscle contraction increases muscle temperature because the stored energy from the contraction is released as heat, as the muscle relaxes. The heat increases the elasticity and extensibility of the connective tissue (the fascia of the muscle tendon unit) and decreases the viscosity within the muscle.
• When a muscle contracts isometrically, the muscle fibres shorten and the connective tissue lengthens to keep the muscle at the same length. This lengthening dissolves abnormal crosslinks in the collagen, allowing more normal gliding of the fibres and permitting the muscles to be stretched to a new length.
• The muscle spindles are allowed to be set to a new length-tension relation after an isometric contraction.
• The pain and dysfunction associated with trigger points is relieved when the muscle is restored to its full length.

Therapeutic Principles of Muscle Energy Technique.

There are many styles of MET. The style listed below has proved most effective clinically.

• One of the most important things to remember with the MET is that it should never be painful. Should it be even mildly painful, STOP. Less pressure should then be used until a comfortable resistance is found.
• If it is still painful, use RI (reciprocal inhibition). If you find the contraction still elicits pain, work with any muscle related to the associated joint that is not too painful.
• Perform MET on the hypertonic or shortened muscles first, as those tissues inhibit their antagonists. After you have released the hypertonic muscles use MET to strengthen the weaker ones.
• Take the muscle to its mid-range position half way between its fully stretched and fully relaxed position. In this position it is the most accurate measure of its strength, and is usually the most comfortable. If a muscle cannot be placed in its midrange position, it is placed at its pain or resistance barrier.
• It is important that the therapist communicates clearly with the patient as to how much pressure they exert; otherwise some patients believe their strongest effort is required, which could cause them to strain themselves, or even overwhelm the therapist.
• The therapist typically applies only a modest pressure that requires only 10-20% of their strength to resist the therapist’s force. In acute conditions, it only takes a few grams of pressure to create a neurological change. In chronic conditions you may have to use up to 50% resistance to create the heat in the muscle to gain any sensory awareness to that area which has been unconsciously hypertonic.
• This contract-relaxation cycle is typically repeated 3-5 times; however it may be repeated as many times as 20 in chronic conditions.
• It is often helpful to add a contraction to the opposite muscle (antagonist) after the contraction of the agonist. This is especially helpful after the PIR (Post Isometric Relaxation), as it not only adds a deeper level of relaxation, but also “sets” the involved muscle in a relaxed state in its lengthened position. This is accomplished through reciprocal inhibition.

The basic therapeutic intentions of METs for acute conditions:

• Reduce muscle spasm.
• To create a gentle pumping action to reduce pain, swelling, encourage oxygenation of the tissue, enabling removal of any waste product.
• Offer neurological contribution, to lessen muscular inhibition.
• To help sustain as much pain free joint motion as possible.

The basic therapeutic intentions of Mets for chronic conditions.

• Reduce muscle spasm.
• Strengthen muscles, lengthen muscles.
• Increase ROM of joints and increase in lubrication.
• Restores neurological function.
• Decreases excessive muscle tension.

It is always useful to reflect on one’s practice. In 2012 I wanted to examine further my assessment procedure. A reoccurring question in this field was ‘how do I create a meaningful plan which would benefit my patients?’

Often in literature, procedures are demonstrated without a clear indication of how to assess when a patient is in a great deal of pain. Often the advice is you should not to carry out any form of resistive assessment. This to me is common sense linked to the obvious ‘red flags’.

After gaining a full picture through our subjective and objective assessment prior to any treatment we should always be clear as to what our aim’s & objectives are within the treatment plan. You need to be clear about how you are going to achieve your aim.

Which techniques should be used?

Which structures are you going to address first?

What action is to be taken if they do not respond?

Plan when you are going to re assess.

Keep an open mind around other possible influences (postural dysfunction) not just at the site of pain, as often patients present with an acute pain overlying a long term chronic dysfunction.

On reflecting upon my own experience, it became clear that the synergists function, heavily influences the recovery process and need to be addressed within the treatment plan. This could come across as very basic information when treating an injury, but within my teaching/workshops it seems to be a regular occurrence that this is overlooked or not recognised.

Active assessment, although not possible when someone is in debilitating pain, is extremely useful when making a further assessment to fine tune your treatment outcome.

I have provided a very brief insight as to the areas to be addressed when putting together a plan of treatment. On the next page you will find a list of very useful books which can also provide further information around planning treatment protocol which is unique for each individual attending our practice.

On the back page of the newsletter, there are workshop dates for this Spring. The workshops led by myself include detailed assessment procedure and treatment outcomes. I will be at the regional meeting delivering a short presentation on ‘How METS can be used to enhance your practice.’

One of my favourite techniques, Muscle Energy Technique enables me to create treatment plans that can be specific, pain free, but most importantly, allow the patient/client to be ‘present’ in their own body. The patient takes part in their own recovery, which in my experience can lead to more rapid recovery.

It is important that the therapist “coaches” the patient into making the ‘contraction’ in isolation of a specific muscle, so that they do not recruit other muscles to create the movement.

To create a specific isometric contraction, the secret is to work out just how much resistance you need to give to allow a response within the muscle’s alpha nerves, to deliver a small isolated contraction, allowing the gamma nerves to set a new resting tone.

During my years in clinical practice I have found that the gentleness of the resistance being offered, along with gentle palpation, encourages the client to engage the correct muscles.
Leon Chaitow’s, ‘Muscle Energy Techniques’ and John Gibbons’ ‘Muscle Energy Techniques – A Practical Guide for Physical Therapists‘, both state that one should offer 10-20% resistance. The question I pose is how do we measure this pressure? Patients often don’t understand what 10-20% feels like, or how to measure that movement/contraction.

Tom Hendrickson offers the opinion that, ‘the therapist typically applies only modest pressure requiring only 10-20% of the clients available strength’. He goes on to state, ‘in acute conditions, only a few grams of pressure are required to make a neurological change.’ Hendrickson also goes on to mention, a good cue is ‘don’t let me move you.’ This cue allows the therapist to set the amount of resistance needed to create the correct amount of isometric contraction that will be of benefit. Another cue one can use is ‘match my touch’, which CAN be just a few grams of pressure. This encourages the patient/client not try too hard, during an isometric resistance. I have found that this approach works really well with those patient/clients presenting chronic pain patterns, as well as those patients that play semi-pro sport, where some muscles have become over dominant. For example, when quadriceps override hamstring function, the therapist must coach the client to contract the hamstrings, which neurologically establishes a new resting length on short, tight quadriceps. Thus enabling the tissue to return to correct functional balance.

Therapists attending the workshops facilitated by “Flexible Healing”, over the past eighteen months have requested that we run a series of one day classes, exploring Muscle Energy Technique in greater detail.

Upcoming workshop dates:

15- March 2014
Muscle Energy Technique for the upper quadrant
11- October 2014
Muscle Energy Technique for the lower quadrant

Due to the recent response during the introduction of the Hendrickson Method, led by senior instructor Giles Gamble, delegates attending wondered how they could become involved in this year’s upcoming Practitioner Programme. So, we are proud to announce a level 1 upper quadrant training commencing on the 22-25 September 2013, followed by level 2 upper quadrant training commencing on the 28 September – 1 October 2013.

With any questions or queries, contact Sue Bennett at info@flexible-healing.co.uk
or by phone at 01943 461756.