🎾 Maintaining Body Thăng Bằng, Linh Hoạt & Stability A Practical Cẩm Nang To The Prevention & Treatment Of Musculoskeletal Pain & Dysfunction, 1e¶
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Chủ đề chính: Muscle, Flexibility, Practice, Thăng bằng
Tóm tắt nội dung (trích từ tài liệu gốc): Foreword I first met Leon Chaitow in 1988 when he taught a workshop in soft tissue manipulation in Seattle, Washington. What I learned in that workshop changed forever the way I would practice medicine. I was shown a set of tools that has allowed me to be far more help to my patients than I might otherwise have been. To this day, I use these techniques with almost every patient I see whether their complaint is musculoskeletal or not. The human body is a complex collection of bones, muscles, connective tissues, nerves, and organs. It is all of these parts, working together in concert, which mak
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Foreword
I first met Leon Chaitow in 1988 when he taught a workshop in soft tissue
manipulation in Seattle, Washington. What I learned in that workshop changed
forever the way I would practice medicine. I was shown a set of tools that has
allowed me to be far more help to my patients than I might otherwise have
been. To this day, I use these techniques with almost every patient I see whether
their complaint is musculoskeletal or not.
The human body is a complex collection of bones, muscles, connective
tissues, nerves, and organs. It is all of these parts, working together in concert,
which make us what we are. The important part of that last sentence is `working
together'. When these parts aren't cooperating, disease and dysfunction result.
In a very real sense, we are what we have become as a result of our adaptation
to stress. We may adapt well or we may adapt poorly, but we will adapt in some
way. What should be obvious is that we need to learn to adapt well.
Unfortunately, much of our adaptation is without thought and intent and
becomes maladaptation. We survive, but we don't function well.
Stress causes us to prepare for `fight or flight', but we don't fight or fly, we
just stay tight and ready. We armor, we guard, and we never let go. Many of us
sit all day slumped in front of a computer or over a desk with our heads forward
and our shoulders up. Eventually our brain begins to think that's the position
we want to be in and we adapt. Then we develop mid back pain and perhaps
chronic headaches. Often we begin to develop numbness and tingling in our
arms and hands that some inexperienced doctor thinks is carpal tunnel
syndrome and off we go to surgery that doesn't help. Instead, we should be
stretching the muscles in our neck and back that are crushing the nerves to our
arms. We should learn a better adaptation to that stress.
Sitting, we allow the muscles in the front of our thighs to shorten and
tighten and when we stand up that tension pulls our pelvis forward. When that
happens, we adapt with a `sway back', develop chronic low back pain and
occasionally sciatic neuralgia. And it's off to surgery we go for a herniated
lumbar disk that isn't really the problem.
I recently saw a patient with this very condition. He had been treated with
chiropractic. He had been treated with massage. He had been treated with
strengthening exercises by a physical therapist. He had been sent for an MRI
that showed a little disk disease, but he never got any relief from his low back
pain. A friend suggested that he come to see me.
I found that his quadriceps were tight (the muscles in the front of his thighs),
his pelvis was tilted forward, and his low back muscles were tight and short as
they adapted to the anterior tilt of his pelvis. I stretched his quadriceps and low
back extensors, adjusted his lumbar spine and pelvis, and showed him how to
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viii Foreword
stretch at home. After two visits he came back, said he felt better than he had
in 10 years, and asked me why no one had shown him the stretches before. All
I could say was `nobody who you saw knew'. With this book, no one has an
excuse for not knowing.
It is through the application of simple, straightforward techniques such as
those presented here that we learn a better way to adapt. I believe that everyone
alive today would benefit from the advice contained here. For those persons
lucky enough to have a practitioner who uses these techniques the book will act
as a reminder and guide for self-care. For anyone not that lucky, it may act as a
guide in the selection of a new (and better) practitioner.
I, and several thousand of my patients, owe a debt of gratitude to my friend
Leon Chaitow for introducing me to this work. Since 1990 I have taught much
of this material to my students at Bastyr University and it has served them well
in their practices also. I hope that you find the information contained herein to
be as useful for yourself. And I hope that you introduce the book to your
friends and families so that they might obtain and Maintain(ing) Body Balance,
Flexibility and Stability.
Douglas C. Lewis
Washington, USA, 2003
Preface
How to use this book
The most common problems we take to our doctors relate to aches and pains
and restrictions of the musculoskeletal system, the `machinery' of the body.
There is a great deal that individuals can do for themselves to prevent such
problems, as well as to help in treatment and rehabilitation once problems have
occurred.
The book is not intended to be a substitute for professional attention and
treatment, but should be used to support the treatment and guidance of the
treating practitioner. It offers ways of preventing new or recurrent musculo-
skeletal problems as well as outlining first-aid options for the self-management
of aches, pains and restrictions until professional advice and treatment can be
obtained. The book also contains numerous options for self-application of
toning, stretching and mobilizing exercises which may be used as part of a
planned recovery and rehabilitation program under the guidance of a medical
doctor, chiropractor, physiotherapist, osteopath, massage therapist, athletic
trainer or other healthcare provider.
The individual exercises and techniques described and illustrated should
therefore be seen as ways of complementing professional attention, not as a
substitute for this. Practitioners may wish to recommend that their patients
refer to the book as a reminder on how to carry out the exercises and
techniques they have instructed them to use. Many common muscle and joint
problems can be eased by the use of self-help variations of osteopathic systems
of care, known as muscle energy technique (MET) and strain/counterstrain or
positional release technique (PRT). A detailed summary of these useful and safe
first-aid bodywork methods is given in later chapters. Most descriptions of self-
help exercises or techniques will contain details of the aims and objectives of the
particular method and the correct position to get into, how to perform the
maneuver and the timing and frequency of the exercise or technique.
Sometimes there will also be notes on particular patterns of breathing and eye
movement to assist in successful application of the method. Choices for helping
to prevent, or to ease, musculoskeletal problems are therefore easy to identify,
either for first aid, or as homework following the advice of a healthcare provider.
In general, if a muscle or joint restriction exists, one or other of the variations
of MET can be used to produce more relaxed soft tissues, so that stretching or
increased range of movement can follow. If muscular weakness exists, other
versions of MET can be used to increase tone and strength. Before using any of
these methods it is important to recognize that if any pain is felt while
performing them, which is more than simple discomfort, they should be
ix
x Preface
stopped. If the correct technique has been selected, and is used as described,
then there should be no pain. Detailed descriptions of how MET works are
given in Chapter 1.
MET, when used to generally loosen muscles which have become tight,
whether through misuse or overuse, is safe and effective. However, it is
important to remember that the human body is complex, and apart from using
these methods as first aid, individuals should always seek the advice of a
qualified expert before applying MET or other self-care methods.
Traditionally, the methods used in osteopathy to release and relax tense, tight
muscles and joints have involved a variety of maneuvers in which the tissues
have been stroked, stretched, pressed and generally manipulated by the
practitioner. In recent years we have learned to better understand the ways in
which the muscles and other soft tissues work, and this has led to new methods
of treatment. Some of these are suitable for self-use because they are so safe and
gentle that it is almost impossible to cause harm.
The words `muscle energy' suggest that the effort and energy of the person
or patient performing the movements provide the primary force involved in the
process, as distinct from the effort and energy of a practitioner.
The conditions which can be helped, and often completely overcome by
these methods are many, and include a wide range of joint and muscle
complaints involving stiffness, restriction of movement, pain and disability. If
the problem involves actual pathology, such as an arthritic condition in which
damage has occurred to aspects of the joint surface, then the amount of possible
improvement from use of (say) MET would be limited by the structural
damage. Even so, even with an arthritic joint in the background, MET methods
should usually be able to produce some degree of improvement in movement
or reduced discomfort, even if this is not always long lasting.
MET methods can be used to strengthen weak muscles as well as to loosen
tight ones. Not all the variations of MET are suitable for self-application, as
some require the restraining or supporting hands of another person. A family
member or friend can often provide this extra pair of hands if the method has
been approved by the practitioner/therapist. In many situations an expert is
required to control the precise directions and degrees of effort, and so in the
text of this book I have attempted to indicate just where self-use is possible, and
where outside aid is necessary.
It is recommended that anyone attempting to use any of the individual
techniques and exercises described in later chapters should first ensure that they
understand the reasons for the use of these methods and their underlying
mechanisms. There is no more certain way of failing to obtain benefits than by
wrongly using what appear to be simple methods.
The most common mistakes made when using MET are those which involve
excessive use of force, over too prolonged (or too short) a period of time. Apart
from the direction in which the effort is made, these two factors are the most
important, and emphasis will be placed on them many times.
Essential questions to ask are, therefore:
� For how long must a MET effort be maintained?
� With what degree of force?
� In which direction(s)?
� And what should be done after the contraction is complete?
These are the key elements in muscle energy technique.
Preface xi
CAUTION
� In none of the methods which will be described in this book should
any pain result.
� If pain is felt whilst they are being done, stop immediately.
Excessive effort is never required, and if there is any pain then either the
choice of method, or the way it is being used, is incorrect.
Positional release methods
Positional release technique (PRT) methods, such as strain/counterstrain, can
also usually be effectively used to deal with painful recent strains, before, after
and instead of muscle energy techniques. These are described in Chapter 8.
Once the principles of MET and PRT have been well understood they can be
modified to help most muscle and joint problems. PRT methods (such as
strain/counterstrain) are most useful in treating conditions where spasm and
contraction are features. This sort of acute problem is often associated with injury
or strain. The distressed tissues can often be gently `persuaded' to release by
careful positioning of the area or joint, using a local tender point as a guide to the
most suitable position for this release (this will be explained more fully in Chapter
3). No gentler method exists for relief of injury, especially if this is recent. Such
methods are just as suitable for self-help use as muscle energy techniques.
Core stability
Self-mobilization and exercise are self-explanatory terms, and the examples
selected for inclusion in this book will be found to offer a variety of means for
freeing restricted, tight areas, as well as for maintaining freedom once
achieved. Prevention of future problems is also the aim in many of the
exercises and techniques described. In recent years we have learned a lot about
the degree of stability that is provided to the back when the muscles of the
trunk � both front and back � are in balance. All too often the low back
muscles are very tight and the abdominal muscles are weak and flabby. This
problem (described as a `crossed syndrome') is best corrected by first having
treatment to release and stretch the tight low back muscles (and often the
hamstrings and other upper leg muscles as well) before the process of
strengthening the weak abdominal muscles is started. The term used to
describe the objective is creation of `core stability', and a number of the
exercises in Chapter 6 can help to achieve this.
Local pain and referred pain
In many cases of musculoskeletal pain there is an element of referred pain or
reflex activity, in which the area of pain is actually some distance from the source
of the problem. In Chapter 4 the nature of so-called `trigger points' that may
xii Preface
be responsible for some pain problems is outlined. A variety of methods have
been used in which the trigger points are deactivated, and some of these will be
explained, using combinations of MET, PRT and other methods.
CAUTION
Apart from being used as first aid, while waiting to see an appropriate
healthcare provider, the methods described in the book should only be
used where the cause of the problem is understood. There is little
value, and there may be risks, in attempting to minimize stiffness and
pain if the cause lies in a disease process which is being ignored. On
the other hand, if attention is being paid to underlying conditions,
there are few areas of soft tissue and joint disability and pain which
cannot benefit � even if only in the short term � from the intelligent
use of the soft tissue manipulation methods described in later chapters.
Many osteopaths, chiropractors, physiotherapists and massage
therapists are now employing these techniques because they are
gentler and safer than many traditional methods or treatment. Most
practitioners are also teaching their patients simple home applications,
especially of MET, and it is hoped that this handbook will expand that
trend, along with the use of home-applied core stability, balance and
agility exercises.
Osteopathy: The background of these methods
Osteopathic medicine is now over 120 years old, and is established in its home
country, the USA, as a complete alternative medical discipline, incorporating
much of mainstream medicine as well as unique approaches and concepts
arising from a deeply held holistic philosophy of health. This philosophy sees
the person as an integrated whole, in which mechanical dysfunction is capable
of affecting the overall health of a person just as markedly as can psychological
and biochemical (e.g. nutritional) influences.
In Europe and other parts of the world osteopathy has become synonymous
with care of musculoskeletal problems and body maintenance. Over the past
century the methods and techniques of osteopathy have continued to evolve
and develop, until today osteopathic practitioners have at their disposal an array
of methods, techniques and systems from which to choose in dealing with the
various multiple dysfunctions of the human machine. Many of these methods
(including MET and PRT) are also now widely used by physiotherapists,
chiropractors and massage therapists.
Osteopathic healthcare and body maintenance always takes account of causes
rather than simply treating the obvious symptoms. A joint problem, for
example, would be looked at in relation to the other structures of the body and
how they influence it, and how it influences them, as well as the way the person
uses (and possibly abuses) their body in daily use: their working and sporting
activities, postural habits, emotional stresses, etc.
Preface xiii
A knee problem, for example, might be due to actual injury to knee
structures, but it might just as easily be caused (or aggravated) by imbalances
and restrictions in the foot, the hip, or even the low back or pelvis. It might be
due to local soft-tissue damage, or to irritation (muscle, tendon, joint capsule,
cartilage, ligament), or to nerve irritation some distance away. All these
elements, added to the history of the individual, provide the osteopathic
practitioner with a broad overview of the problem, and an understanding of
what is required, not only to help the present symptom picture, but to prevent
recurrence, if this is possible. In recent years emphasis has increasingly been
toward a greater appreciation of the importance of the soft tissues in
normalizing and easing such problems. In modern healthcare provision, which
bases much of its choice of treatment on what has been proven by research,
these same (osteopathic) principles are usually to be found embedded in the
practice of physiotherapy, massage therapy and chiropractic.
Tone, strength flexibility, agility and balance
The soft tissues include the muscles, ligaments, fascia, tendons, etc., which
provide the supportive matrix which normal bodily function requires. When
joint problems exist attention should first be given to the soft tissues, when
attempting to normalize joint function. It is after all the soft tissues which
support and move the joints.
The methods which make up the bulk of this book are therefore those which
pay particular attention to the soft tissues, and many of these methods can (and
indeed should) be self-applied at home as part of the homework aspect of
professional care. The methods, techniques and exercises outlined in this book
are therefore meant for first-aid and short-term use, or as part of rehabilitation
and prevention regimes. They may usefully accompany, precede, or follow
regular osteopathic, chiropractic or other manual treatment. Your practitioner/
therapist should therefore help you to select for home use appropriate methods
from the book that meet your specific needs.
So what is on offer in this book are methods anyone can use to loosen what's
too tight, to stabilize and strengthen what's not strong enough, and to create
better balance between the `tight' and the `loose' structures. Better agility and
balance is another objective, and some special guidance will be given to help
you achieve this if it is a problem.
London, 2003 Leon Chaitow
Acknowledgments
Many years ago, in a small book entitled `Osteopathic Self-treatment', I
attempted to lay out, in user-friendly terms, for practical self-application,
methods derived from osteopathic medicine. Although this now out-of-print
book sold well, it was soon clear, from letters and calls, that many of the people
purchasing it were therapists and practitioners, rather than the general public
for whom it had been designed. Now, in this new, and completely revised and
expanded version, this book is directed toward the needs of the therapist and
practitioner, to use in collaboration with their patients to help construct
individualized programs of `home work'. I wish to acknowledge the main lesson
taught by that first incarnation, that without the professional input of trained
healthcare providers, `self-help' can often produce inadequate results.
Although osteopathy is the primary source of many of the methods
described, the content of this book also relies on the pioneering work of many
� too many to list � medical physicians, physiotherapists, exercise physiologists,
chiropractors, massage therapists and others, who have over the years devised
useful ways of helping people to apply safe self-care and rehabilitation methods
at home. Without the experience of these many experts it would have been
impossible to compile the series of exercises and programs that make up the
bulk of this book.
I wish to also acknowledge the great help received from the Churchill
Livingstone publishing team in Edinburgh in the production of this book.
Leon Chaitow
xv
CHURCHILL LIVINGSTONE
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First published 2004
ISBN 0443 073511
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
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Notice
Medical knowledge is constantly changing. Standard safety precautions must be followed
but as new research and clinical experience broaden our knowledge, changes in treatment
and drug therapy may become necessary or appropriate. Readers are advised to check the
most current product information provided by the manufacturer of each drug to be
administered to verify the recommended dose, the method and duration of administration,
and contraindications. It is the responsibility of the practitioner, relying on experience and
knowledge of the patient, to determine dosages and the best treatment for each individual
patient. The Publisher, the Author and the Contributors do not assume any responsibility
for any 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 experience and knowledge of the patient, to determine the best
treatment and method of application for the patient. The Publisher
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The different forms of muscle 1
energy technique
When you bend your knee (or any other joint), a muscle or group of muscles
contracts in order to produce the desired movement. The active muscle(s) in
bending the knee are the hamstring group on the back of the thigh. The active
muscles in any action are known as the agonists.
At exactly the same time another set of muscles relaxes, so that the
movement will be produced in a smooth coordinated manner. When the knee
bends it is the muscles on the front of the thigh that relax in this way, the
quadriceps. These muscles, which are capable of performing precisely the
opposite movement if they contract (i.e. straightening the knee), are known as
the antagonists.
The coordination between the opposing muscles of any area is automatic and
it happens without conscious effort. It depends upon a physiological law which
declares that contraction of any muscle will produce, under normal conditions,
relaxation of its antagonist.
When we speak of muscles being antagonistic, we of course do not mean that
they have a grudge against each other. Rather, it indicates that one muscle's
action will be directly opposed by another's. They balance each other and thus
work together cooperatively by virtue of the one releasing its contraction, and
relaxing, as the other contracts, to produce coordinated movement.
Take another example, the elbow. As the muscles on the front of your arm
(the flexors) contract, in order to allow you to lift a glass to your lips, so the
muscles on the back of your arm, the extensors, relax, in order to allow this to
happen smoothly without jerking or hesitation. The flexors in this example are
Figure 1.1 Lifting a
glass of water is achieved
by a concentric
contraction
2 Maintaining Body Balance, Flexibility and Stability
Figure 1.2 When you
put a glass down the
muscles are contracting
while they are
lengthening. This is an
eccentric contraction
contracting and as they do so they are getting shorter. This is called a concentric
contraction (see Fig. 1.1).
While this is happening it is important for the antagonists to continue to
exert some effort, in order to maintain stability. If they were completely relaxed
(e.g. paralysed) then the movement would be uncontrolled, uncoordinated,
spastic and jerky (as occurs in people with nerve damage such as in cerebral
palsy).
When it is time to put the glass down again, the opposite happens. As the
extensors straighten out your elbow, the flexors, in a controlled manner, release
their hold on your bent elbow joint.
In this particular example, the flexors of your arm (which bent it in the first
place) do not just release all effort or there would be a sudden straightening of
your arm and the glass would smash onto the table. Rather, they continue to
contract but while they are doing so, they get longer and release the pull on
your elbow. Being able to contract and at the same time stretch is a most
important muscular facility. This is called an eccentric contraction.
To use MET efficiently we need to be aware of the fact that muscles are
mutually antagonistic to their opposite numbers and that this offers us a
wonderful way of making tight muscles relax. The automatic quality of an
antagonist relaxing when its opposite number is tightening (contracting) is
known as reciprocal inhibition (see Fig. 1.2).
The integrated manner in which the nervous system controls muscular
tension, and the importance in this process of minute reporting stations in the
soft tissues, have provided the osteopathic profession with an understanding of
the way all this happens. How can we use this knowledge?
EXAMPLE OF If the muscles of the front of your arm, to stay with that example, are tense, say
RECIPROCAL after gardening, tennis or an injury, you could use the muscles on the back of
INHIBITION IN MET your arm to relax these tight muscles. If you took that arm to its maximum
comfortable degree of straightness, ensuring that in doing so it does not
produce pain (which it would if it went beyond its present restriction barrier),
and at that point, whilst restraining your lower arm with your other hand (i.e.
The different forms of muscle energy technique 3
Figure 1.3 When the
flexor muscles are tight,
trying to straighten the
arm against resistance
without movement taking
place at all (an isometric
contraction of the
antagonists) relaxes the
flexor muscles by
reciprocal inhibition
preventing it from moving), tried to gently take your arm towards a greater
degree of straightness, by contracting the muscles of the back of your arm, what
would happen?
As you tried to make your arm straight (i.e. pushing gently towards the
restrictive barrier) you would be contracting the muscles of the back of your
arm. These are the antagonists of the tight muscles which are in trouble and by
preventing any movement from taking place (by using your other hand), it is
possible to ensure that no strain occurs at the painful joint or in the tight
muscle(s). You would in effect have a matching of forces. The extensor muscles
would be trying to pull your arm straight, while your free arm resists this,
completely and exactly. This is called an isometric contraction. The forces match
each other and no movement occurs (see Fig. 1.3).
As this isometric contraction of the extensor muscles is taking place to try to
straighten your arm, their antagonists (the shortened flexors) would be obliged
to relax, according to physiological law. Therefore, after this MET isometric
effort, which could last for 5�10 seconds, you would find that the arm which
was previously limited in its ability to straighten would be capable of an
increased degree of normality.
The barrier, or point of bind, would have been pushed back a little as the
flexor muscles relax. By repeating this whole procedure several times, until no
further gain in the range of movement is noted, it might be possible to
completely normalize the shortened muscles.
What I have described above is an example of an isometric contraction of the
extensor muscles. These are the antagonists to the short flexor muscles (the
agonists), and we would be using reciprocal inhibition (RI) to achieve the
objective of `switching off' the tight flexor muscles, allowing them to be more
easily stretched afterwards.
Achieving postisometric relaxation in an MET procedure
There is another, completely different method for achieving the same objective,
in order to relax the tight flexor muscles.
If your arm, with its limited ability to straighten, is taken as far as it can
comfortably go in that direction (to the current painless barrier of movement)
and this time you try to bend your arm, instead of making it straighter, and if
this effort to bend your arm is resisted by your other hand, you will be doing
4 Maintaining Body Balance, Flexibility and Stability
Figure 1.4 Contracting
the shortened muscles
against resistance so that
no movement occurs
(isometric contraction of
the agonists) produces
postisometric relaxation
(PIR)
the opposite of the previous example which involved reciprocal inhibition. Your
arm, having been taken to the point of restriction/bind, would be trying to
bend, but the counterforce of your restraining hand would stop it from doing
so, isometrically (see Fig. 1.4).
This time, the very muscles which had shortened (the agonists) would be
contracting against resistance and, after an appropriate period, say 5�10
seconds, of this isometric contraction (no movement allowed to occur, only
effort) a new phenomenon would become apparent. This is called postisometric
relaxation (PIR). This means that any muscle, or group of muscles, which is
isometrically contracted is obliged to relax afterwards. So if a muscle is tense or
tight and it is then isometrically contracted, it will, to some extent, release and
relax afterwards, allowing it to be more easily stretched afterward. A more
detailed look at the use of PIR and RI, in the elbow example, will be found in
Box 1.1.
Box 1.1 Detailed examples of the use of PIR and RI
USE OF PIR When you are trying to release and stretch
Let's look more carefully at MET treatment of an tissues which are chronically short (this usually
arm with some degree of muscular shortening, means they have been that way for a month or
making it difficult to straighten fully. Let us say more) then the isometric contraction should start
this is the right arm. The first objective in any with the arm (in this example) just short of the
MET procedure is to establish what the restriction barrier or point of bind.
restriction barrier is, whether this relates to an
arm that won't fully straighten or any other joint If the condition is acute (less than a month old
that has a limitation in its normal movement. To or acutely painful) the contraction should start at
establish its restriction barrier, the arm should the restriction barrier. The degree of effort used
therefore be taken gently to the limit of the in acute and chronic conditions also varies, as
available degree of movement, in the direction in you will see below.
which it is restricted. Going too far would force it
beyond the current barrier and would actually Sitting at a table, the right arm could be rested
irritate the tissues of the area, so it should on it (possibly on a cushion), as straight as it is
therefore be stretched out gently, until the `point comfortably possible to do, with the left hand
of bind' is felt, beyond which discomfort would placed at about wrist level in order to restrain a
start. contraction of the muscles which bend the arm
(the very ones which have shortened and which
are preventing full straightening).
The different forms of muscle energy technique 5
As the attempt is being made to bend the tight agonists. RI is often more useful than PIR in
arm, the counterpressure from the left hand acute conditions.
should prevent this. Only about a quarter of the
available strength of the muscles of the right arm To do this, the arm should again be taken to its
should be used, with the start of the contraction full comfortable resting length, with the elbow on
synchronized with the counterpressure, to avoid the table, and this time the left hand is placed on
any jerking. This contraction should be the back of the wrist, as a counterforce. This time
maintained for a slow count of 7�10 before the effort would involve the extensor muscles,
being slowly released, in a coordinated manner, which would try to force the arm into a greater
together with the release of the counterpressure degree of straightness, against resistance from the
from the left hand. other hand. Again, only partial strength is used
and the timing is the same as above, starting with
After a moment during which the arm is a 5�10-second contraction.
relaxed fully, an attempt should be made to take
the arm to its fullest, pain-free, stretched-out After a slow easing of the dual efforts (the arm
length (an inhalation followed by a slow trying to straighten against resistance), the arm
exhalation can be used to make this more would again be tested to see if it could achieve a
effective; see below). This stretch should push just greater degree of normality in straightening.
beyond the previous restriction barrier if the
condition is chronic (an old problem, of more than Several attempts of this type should be made,
a month's duration) and just to the barrier if it is increasing the length and degree of effort
acute (a more recent, or an acutely painful, (always ensuring that no pain is produced and
problem). only increasing the amount of muscular effort if
the condition is chronic), until it becomes
Thus a new barrier would be engaged and evident that no further gains could be made and
there should be a greater degree of movement at this point muscle energy methods should be
than was possible before the isometric stopped for the day.
contraction. It should now be possible to take
the arm a little straighter without effort. In a Both PIR and RI would have been used and
chronic condition, if stretching is being carried maximum gains enjoyed in terms of greater
out, this stretch should be held for not less than degree of movement and lessened
30 seconds, to give the shortened muscle tissues discomfort.
a chance to lengthen. In an acute condition,
there is no stretching so the next isometric Variations in the direction of the contraction
contraction can be perfomed straight are possible during these various isometric
away. efforts, in which different angles of bending or
straightening are resisted, thus using different
Whether acute or chronic, the whole muscle fibers. For example, the hand of the arm
procedure is then repeated at least once more, resting on the table could be aiming for the face,
exactly as above, and once again, after as the contraction begins, or it could be aiming
coordinated release of the contraction and the for the right or left shoulder.
counterpressure, another attempt could be made
to see just how straight the arm could go, These variations in direction are always
painlessly, either to a new barrier if acute or to a possible when trying to normalize tight muscles
new stretched position if chronic. and should be incorporated into the variables of
amount of effort used, amount of time of each
USE OF RI contraction, number of contractions and type of
If the attempt at contracting the shortened contraction (PIR or RI).
muscles (agonists), as described in the exercise
above, was painful, it would be appropriate to Other variables in the previous example could
use the antagonists instead; in other words, include the position of the hand on the affected
using reciprocal inhibition to `switch off' the side during the contractions. This could be palm
downwards or palm upwards, thus bringing
different muscles into play. All such factors will
be outlined as appropriate, in the descriptions of
the various muscles and joints in the text.
6 Maintaining Body Balance, Flexibility and Stability
SUMMARY � By using the affected (tight, shortened, etc.) muscle(s) in an isometric con-
traction we induce postisometric relaxation (PIR) in the affected muscle(s).
This offers an opportunity to stretch the previously shortened muscle(s)
afterwards.
� By using the antagonists of affected muscles (tight, shortened, etc.) in an
isometric contraction we induce reciprocal inhibition (RI) in the affected
muscle(s). This also offers an opportunity to stretch the previously shortened
muscle(s) afterwards.
These are two of the most important aspects of the release of troubled
muscles and joints using MET methods and I will be repeating these basic
instructions many times during the course of this book.
In the many examples of MET in the book, different forms of counter-
pressure will be used. In some cases, the resistance to your contracting
muscle(s) will be provided by your own or someone else's hand(s); in other
instances it will be provided by an unyielding obstacle, such as a piece of
furniture or a wall, against which effort can be directed, and in other cases the
counterforce will be gravity.
In all of these examples, the aim is to use the affected muscles or their
antagonists appropriately, in order to achieve the release of tense, tight,
shortened muscles, which are often painful and which usually produce some
degree of limitation of movement.
Which method should be used � PIR or RI
The presence of pain is frequently the deciding factor in choosing one or other
of the methods described (PIR or RI). It is clear that when using PIR, the very
muscles which have shortened are being contracted. If the area is already painful
and any contraction could well trigger more pain, it might be best to avoid
using these muscles and choose instead the antagonists. The antagonists, which
are usually pain free, might well be your first choice for MET use, when the
shortened muscles are very sensitive. Later, when pain has been reduced by
means of muscle energy (or other) methods, PIR techniques (which use
isometric contraction of the already shortened muscles rather than the
antagonists used in RI methods) could be used. To a large extent, deciding
whether a condition is acute or chronic can determine the method best suited
to treating it and advice regarding this will be found later in this chapter.
Thinking back to the example of the arm which is putting down a glass, you
will recall that muscles are capable of both contracting and lengthening at the
same time. This should help an understanding of other MET procedures, the
isotonic variations.
Isotonic MET methods
CONCENTRIC When the muscles of your arm contract as you bring a glass to your lips, they
ISOTONIC are both contracting and shortening. Technically this is called a concentric
isotonic contraction. This means that the two ends of the muscle(s), the origins
CONTRACTIONS
The different forms of muscle energy technique 7
Figure 1.5 The arm is
being flexed against a
degree of resistance which
does not fully match the
effort of the arm.
Therefore an isotonic
concentric contraction is
taking place, toning/
strengthening the arm
muscles that are working.
1 start (more distant
from face).
2 new position
and insertions, that are contracting are getting closer together. This is what
people do when they lift weights and, as is obvious from that activity, this helps
to tone, strengthen and `build' muscles. So we can usefully introduce
concentric isometric activities when we want to achieve increased strength and
tone (see Fig. 1.5).
In isotonic concentric contractions the effort of the contracting muscle is
resisted but not quite overcome. The movement is allowed to take place, with
effort. Should a group of muscles be weak, after disuse for example, and should
you wish to tone these up, you have a perfect tool in concentric isotonic
methods of muscle energy.
Now let us assume that the flexors of your arm (which bend your elbow) are
weak, for whatever reason. If your opposite hand were placed on your forearm
to partially restrain an attempt to bend your arm then, as they contracted, the
weak muscles would be working against a degree of resistance. By repeatedly
doing this, with variations in the degree of resistance applied, it would be
possible to strengthen the weak muscles.
A variation exists where an area is rapidly and repeatedly moved in a variety of
directions, while being partially resisted. This would produce a series of concentric
isotonic contractions, known as an isokinetic exercise. An example of this could
involve a weak ankle; while sitting with the affected leg resting across the other
knee, you could use your hands to restrain a forceful effort to put the ankle joint
through as full a range of movements as possible, in a short space of time (no
more than 5 seconds). This has a powerful toning effect on the whole joint.
ECCENTRIC In contrast to this last example, when your arm is putting a glass down, the
ISOTONIC muscles will be contracting but despite this they are also lengthening.
Technically this is known as an eccentric isotonic contraction. Here the muscle's
CONTRACTIONS origin and insertion (where the muscle attaches into bone as an anchor point)
get further apart, despite the contraction of the muscle. This can be used to
dual effect in particular exercises, especially if performed very slowly (note: a
slow eccentric isotonic stretch is abbreviated as a SEIS in this text). The two
effects of a SEIS are to tone the muscle that is slowly eccentrically stretching,
while at the same time this activity is creating a reciprocal inhibition of its
antagonist, so allowing the antagonist to be more easily stretched afterwards.
See the notes on the diaphragm and pursed lip breathing in Chapter 6 for an
example of an exercise that uses eccentric isotonic activity (see Fig. 1.6).
8 Maintaining Body Balance, Flexibility and Stability
Figure 1.6 The arm is
being forced to bend as it
tries to stay straight. The
effort of the arm is being
overcome, stretching the
contracting extensor
muscles of the arm (an
isotonic eccentric
contraction), toning them
while at the same time
inhibiting the tight flexor
muscles (which can be
stretched after this
maneuver is finished)
The major variables in MET
As in all the examples given, the essential features defining different uses of
MET are:
� the amount of effort used in the contraction
� the amount of effort used in restraining a contraction, i.e. whether the
contraction is matched (isometric) or overcome (isotonic eccentric) or only
partially resisted (isotonic concentric).
The other major variables which are controllable are, of course, how long the
contraction is allowed to continue and how often it is repeated.
� The degree of effort in isometric contractions should always be much less than
the full force available from the muscles involved. The initial contraction
should involve a quarter or less of the strength available. This, of course, will
not be an exact measurement but indicates that a wrestling match should never
develop between the contracting area and the counterforce, whether this be a
hand, a piece of furniture, another person's hands or gravity.
� After the initial, slowly commenced contraction, subsequent contractions
may involve an increase in effort but should never reach more than half of
the full strength of that muscle. We want above all to achieve a controlled
degree of effort at all times and this calls for the use of only part of the
available strength in a muscle or muscle group.
� The timing of isometric contractions is usually such as to allow at least 5 and
up to 10 seconds for the contraction, from beginning to end.
� It is important to remember that the start and the end of contraction should
always be slow. There should never be a snatching or a quick beginning or
end to the contraction. Always attempt a smooth build-up of power in the
muscle(s) and a slow switch-off of the contraction at the end. This will
prevent injury or strain and produces the best possible results.
� In some cases slightly shorter periods of time are suggested for the
contractions and in others they will be longer. Indeed, in many instances
there is a variation as the therapy progresses, with even longer periods of time
involved, although 30 seconds would be a top limit, unless otherwise stated
in the text. It is far safer and more effective to contract a muscle for a longer
period than it is to make the contraction stronger.
The different forms of muscle energy technique 9
� Use of breathing and eye movements can help some applications of MET
(see Box 1.2).
Guidance as to these variables will be given in the individual examples later
in the book. As a rough guide, though, the 5�10-second timing of initial
isometric contractions is a useful rule to bear in mind. Repetitions are normally
continued three or four times, although usually only for as long as
improvements continue to be achieved in the problem muscle(s) between
contractions.
Box 1.2 Influence of breathing and eye movements on MET
BREATHING breathing out, whereas the reverse is true if this
Another factor relating to these methods which area is being bent backwards.
has not been explained up to now is the use of
breathing patterns to enhance the effects of PIR There is therefore an advantage to be gained
and RI. by using the breathing phase that is most helpful
in any given movement. (Guidelines to these will
In some cases it is necessary to breathe in be given in the text of individual exercises where
deeply at the onset of a contraction and to hold this is useful.)
the breath for the duration of the effort,
releasing the breath at completion, as relaxation EYE MOVEMENTS AND MET
is taking place. In other instances it is helpful for If you try to bend forwards whilst looking
the breath to be sighed out as the effort upwards (with the eyes only, without any
commences and for this to be held out until the movement of the head), you will not be able to
end of the contraction. bend as far, or as easily, as if you were looking
downwards. The converse also applies to coming
In all cases it is desirable that after the upright from a bent position with the eyes
contraction, and before any attempt is made to looking downwards. So, when you bend
assess the degree of extra movement achieved, a forwards while looking down, the movement
full breath be taken and slowly sighed out, to help becomes easier while straightening up from such
release all muscular effort. a bend, or actually bending backwards, is easier
with the eyes rolled upwards.
The reason for the suggested breathing
patterns during isometric and isotonic Eye involvement is important in other
contractions is that there is evidence that certain movements as well. Try this experiment. Sit in a
muscle movements are helped by one or other chair and turn your trunk and head to one side,
phase of the breathing cycle. For example, if you while your eyes are looking in the opposite
bend towards your toes whilst breathing in, you direction. Note how far you can go without
will not be able to reach as far as if you bend undue strain and make a mental note on the
whilst breathing out. This is true for many other wall, indicating your furthest point of rotation.
movements of the body as well. Bending the Then do the same turn exactly but this time have
neck forward and general side bending are two the eyes traveling in the same direction as the
examples of this. The neck and low back are turn. You will find that you can go much further
easier to bend backwards as you breathe out, because the rotation of the body is improved by
whereas the thoracic spine is easier to bend the direction in which the eyes are looking.
backwards when the breath is being taken in. For (Guidelines to these variables will be found in the
instance, a bending forwards of the thoracic text.)
spine (where the ribs attach) is made easier by
10 Maintaining Body Balance, Flexibility and Stability
Pulsed MET
There is another MET variation, which is powerful and useful. This is pulsed
MET, also known as the Resistive duction method, first described by the
osteopathic physician TJ Ruddy in the 1960s. This simple method is very useful
since it effectively accomplishes a number of changes at the same time,
involving the local nerve supply, improved circulation and oxygenation of
tissues, reduction of contraction, etc. I now use the term `pulsed MET' to
describe Ruddy's safe and effective method, which depends entirely for its
success on the `pulsed' efforts of the person producing them being very light
indeed, with no `wobble' or `bounce', just the barest activation of the muscles
involved.
AN EXAMPLE OF � Sit at a table, rest your elbows on it and tilt your head forwards as far as it
PULSED MET will go comfortably. Rest your hands against your forehead.
� Use a pulsing rhythm of pressure with your head, about two per second (as
though bending it further forwards against your hands) of one-one, one-
two; two-one, two-two; three-one, etc. until ten-two is reached.
� After 20 pulsations retest the range of forward bending of your neck. It
should go much further, more easily than before. This method will have
relaxed the muscles of the region, especially those involved in flexion, and
will have produced 20 small reciprocal inhibition `messages' to the muscles
on the back of your neck which were preventing easy flexion.
� Variations may be used for all positions of movement of your head or any
other part of your body. The simple rule is to engage the restriction barrier,
provide a point of resistance (with your hands if possible) and to pulse
towards the barrier rhythmically.
� If pain is felt, push less hard.
The pulsing method should always be against a fixed resistance, provided by your
own (or a friend's) hands, just as in other MET methods. You can use the same
positions outlined in the muscle energy chapters, for the various regions and
Figure 1.7 The head
and neck are flexed to
their comfortable end of
range and the hands offer
resistance as the head is
`pulsed' 20�30 times, in
the direction of resistance,
against the firmly fixed
hands. The pulsing
contractions release the
tight muscles at the back
of the neck (by means of
RI), allowing further
movement into flexion
afterwards
---
[Cuối tài liệu]
Sheet 6A Strengthening exercises
Strengthening (left) gluteus medius
Lie on right side, right leg straight, left
leg bent slightly at hip and at knee so
that foot rests on floor just below the
right knee. Keeping your foot on the
floor, raise left knee 45�. Hold this for
at least 10 seconds and lower. Repeat
5 times. Do same other side. Note:
ability to maintain leg in this position
for 10�15 seconds suggests normal
strength.
Strengthening gluteus maximus
Lie face down. Bend knee on side to be
toned. Lift that leg 2 inches (5 cm) off
the floor, without arching your back.
Hold this position for at least
10 seconds. Slowly lower leg to the
floor and repeat 5 times. Do same on
other side. Note: ability to maintain leg
in this position for 10�15 seconds
suggests normal strength.
Strengthening rhomboids, mid/lower trapezius
Sit upright with arms hanging down,
palms forward. Start repetitive
mini-contractions (start/stop,
start/stop), bringing shoulder blades
together and turning arms further
outward. Perform 20 rhythmic
mini-contractions in 10 seconds, then
rest. Repeat 3 more times to tone these
muscles.
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Maintaining Body Balance, Flexibility and Stability 2004. ISBN 0 443 07351 1
Sheet 6B Strengthening exercises
Toning deep abdominal muscles (`dead-bug' exercises)
Lie on back, legs out straight. Raise
your head, then your shoulders from
the floor, arms at your side. Can you
do this comfortably, for at least
10 seconds, without your abdomen
`doming' or your low back arching?
If not, do the next 4 exercises until
you can.
Abdominal retraction (`bring navel to
spine', as in this example) and normal
breathing should be maintained
throughout all stages of these exercises.
Exercise A: Raise both arms and one
foot 2 inches (5 cm) from the floor and
hold for 5�8 seconds. Do this with
each leg 5�10 times until it is easy.
A
Exercise B: Same as previous exercise
except raised leg needs to come
12 inches (30 cm) off the floor.
Do this with each leg 5-10 times
until it is easy.
B
Exercise C: Same as previous exercise
except both feet are held 12 inches
(30 cm) from floor for 5�8 seconds.
Repeat 5�10 times until it is easy.
C
Exercise D: Same as previous exercise
except both feet are raised 24 inches
(60 cm) from the floor for
5�8 seconds. Repeat 5-10 times
until it is easy. In this final position
gentle `cycling' motions add to the
D
toning effect.
Free to photocopy � 2004 Elsevier Science Limited. All rights reserved. Taken from Chaitow:
Maintaining Body Balance, Flexibility and Stability 2004. ISBN 0 443 07351 1
Sheet 7A Spinal self-mobilization exercises
Mobilizing lower back
Sit in upright chair, feet flat, resting palms of hands on
thighs above knees, fingers facing each other. Let
elbows bend outwards as you bring head and chest
toward your knees until a slight low back stretch is
experienced. Hold this position, breathing slowly for
3 full cycles. As you exhale move back to start position.
Repeat 5 times, going a little further each time. Hold
B
the final stretch for 30 seconds. Repeat daily.
Mobilizing lower back
Sit on floor on right buttock, knees bent, feet
together on the left, supported by straight right arm.
Push against the floor to slightly straighten your body,
until you feel a slight stretch in the lower back.
Keeping elbow straight introduce rhythmic
mini-pushes against the floor, taking your left
shoulder toward the left. Rest after 20 `pulsations'.
Ease trunk toward the midline a little, and repeat
20 pulsations. After third sequence stay in position
30 seconds, then change sides. Repeat daily.
Lower spinal twist
Lie on carpeted floor, both knees bent. Cross left leg
over right. Let gravity ease left foot toward the floor.
`Stretch' but not pain should be felt. Lift the left foot
slightly (3 inches/7 cm) and rhythmically bounce the
foot toward the floor, and back again, `springing' the
lower back. After 5 pulsations, rest in the twisted
position for 30 seconds. Repeat the exercise on the
other side. Repeat daily.
Upper spinal twist
Lie on floor, hands behind neck, elbows together,
knees bent, feet flat. Raise head 2 inches (5 cm) and
rhythmically, repetitively, twist trunk in opposite
directions so that first one elbow then the other
touches the floor. Repeat 5�10 times each side. Rest.
Repeat daily.
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Maintaining Body Balance, Flexibility and Stability 2004. ISBN 0 443 07351 1
Sheet 17AB TGreanteinragl shelof-rmt/otibgihlitzamtiuosnclexseursciinsgesMET
Mobilizing upper spine
Get onto hands and knees, thighs
vertical to the floor, hands flat on floor
at head height. Don't let head hang
down. Bend elbows outward to lower
head toward hands. On exhalation,
take chin as close to hands as possible
and imagine rolling a pea toward your
knees with your chin � slowly. Return
to start position and inhale. On next
exhalation roll invisible pea from knees
toward hands. Return to start and
inhale. Repeat 5 times in each
direction. Repeat daily.
Trunk stretch
Sit on floor, legs outstretched with left
leg crossed over right. Place right hand
between crossed knees touching floor.
Place left hand 6�8 inches (15�20 cm)
behind buttocks to produce painless
twist. Turn head left, as far as possible.
Breathe in and out slowly 5 times. On
final exhalation, twist a little further.
Hold this for 30 seconds. Return to
neutral and repeat on other side.
Repeat daily.
Gravity stretch for spine
Lie face up, pillow under head. Bend
knees, feet flat on floor. Stretch arms
sideways, palms up. Keeping shoulders
and feet flat, let both knees fall to one
side as far as possible. Breathe in and
out slowly for 30 seconds, then hold
your breath for as long as is B
comfortable. On exhaling let knees fall
further toward the floor. Hold this for
another 30 seconds. Repeat on other
side. Repeat daily.
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SShheeeett81AA GTerenaetrianlgseshlfo-mrto/tbiiglihztatmiounscelxeesrucsisinegs MET
Low back release
Lie on back (no cushion). Knees apart,
bend knees and hips. Place a hand on
each knee and painlessly pull these
toward shoulders (not chest) as far as is
possible. Breathe in and hold breath as
long as comfortable. On exhalation,
draw knees closer to shoulders. Hold
for 30 seconds. Repeat once more.
Repeat daily.
Springing the sacroiliac joint
CAUTION: Only do this exercise on
advice from a practitioner
Lie on unaffected side, pillow under
head, lower leg straight. Flex upper leg
at knee and hip, and let knee rest on
floor. Place palm of upper hand on
front of pelvis, palm toward floor.
With minimal force rhythmically and
repetitively `spring' the bone in a
direction toward the opposite side
lower ribs, for 20 seconds. Follow this
with the pelvic stabilizing exercise
described below.
Pelvic stabilizing exercise (to follow previous exercise,
on practitioner's advice only)
Lie on your back, hips and knees
flexed, feet flat on floor. Place a firm
cushion between knees. Using full
strength squeeze your knees together
for 5 seconds. Relax. Repeat twice
more. This helps stabilize the pelvic
joints.
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Sheet 18AB TGreanteinragl shelof-rmt/otibgihlitzamtiuosnclexseursciinsgesMET
Upper and lower spine flexibility (`cat/camel') exercise
Kneel on a carpeted floor, weight on
your knees and elbows for upper spine,
and on knees and hands for lower
spine. As you inhale, arch your back
upward while pulling your navel
toward your spine, allowing your head
A
to drop toward the floor. Hold for
5 seconds. As you exhale, lower your
spine and lift your head. Hold for
5 seconds. Repeat sequence 5 times in
each direction. Repeat daily.
Upper spine and rib flexibility
Sit on edge of table, knees apart, legs
hanging free. Bend forward. Let left
arm hang between legs. Turn head
right. Relax shoulder blade area. Inhale
fully and turn head further right, and
stretch left hand toward floor. Hold
stretch as long as you hold the breath.
As you exhale, relax in this position for
20�30 seconds. Repeat. Repeat on
other side (right hand hangs between
legs, head turns left). Repeat daily.
Mobilizing upper spine
Sit, arms fully outstretched sideways,
fingers widely spread. Rotate arms so
thumb of one hand points up, and the
other down. Turn head toward side of
thumb-down hand. After 5 seconds
simultaneously (a) inhale, (b) fully
rotate arms in opposite directions
(thumb down becomes thumb up) and
(c) turn head toward side of thumb
down. Exhale. On inhalation reverse
all movements, taking care not to tense
or hunch shoulders. Repeat 10 times.
Repeat daily.
Free to photocopy � 2004 Elsevier Science Limited. All rights reserved. Taken from Chaitow:
Maintaining Body Balance, Flexibility and Stability 2004. ISBN 0 443 07351 1