remedial ii learner guide...massage schools of queensland remedial massage ii 4 method of delivery:...

Remedial II

Learner Guide

Massage Schools of Queensland

Remedial Massage II

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UNIT DESCRIPTIONS: HLTMSG005: This unit describes the skills and knowledge required to prepare for and provide

remedial massage treatments based on the outcomes of an existing health assessment and treatment

plan.

HLTMSG006: This unit describes the skills and knowledge required to adapt remedial massage

assessment and treatment strategies to meet the needs of clients of different genders and at different

stages of life. It also includes the requirement to be able to identify and respond to other specific

needs with which the practitioner may be unfamiliar. HLTMSG008: This unit describes the skills and knowledge required to monitor and evaluate remedial

massage treatments, both from an individual client and whole of practice perspective.

ELEMENTS OF COMPETENCY AND PERFORMANCE CRITERIA: National Code: HLTMSG005 PROVIDE REMEDIAL MASSAGE TREATMENT

Element: 1. Prepare client for treatment

Performance Criteria:

1.1 Interpret treatment plan and clearly outline how the treatment will be provided and managed

1.2 Explain factors which may interfere with the effectiveness of the treatment

1.3 Inform the client of possible physical or emotional reactions during and following a session and the appropriate course of action to take

1.4 Follow established protocols to physically prepare the client for treatment

1.5 Confirm client consent for treatment

Element: 2. Use remedial massage techniques and sequences


2.1 Determine treatment sequence, location and degree of pressure according to assessment indications

2.2 Use the condition and response of the client as a continual feedback to the initial assessment

2.3 Position client to optimise their comfort and support while allowing for optimum application of techniques

2.4 Maintain client dignity through use of draping

2.5 Maintain therapist postures that ensure a controlled distribution of body weight

2.6 Maintain client-focused attention throughout the treatment session

2.7 Recognise reactions to treatment and respond promptly

Element: 3. Provide advice and resources to the client


3.1 Educate the client in relevant and practical techniques that support the treatment plan

3.2 Answer client queries with clarity, using language the client understands

3.3 Use honesty and integrity when explaining treatment plans, schedules and recommendations to the client

3.4 Promote client independence and responsibility in treatment

3.5 Discuss and agree on evaluation strategies

3.6 Accurately document treatment provided and details of client communications


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HLTMSG006 Adapt remedial massage treatments to meet specific needs Element: 1. Adapt assessment and treatment strategies to stages of life


1.1 Anticipate and take account of client sensitivities to ensure client dignity is maintained

1.2 Tailor approaches that take account of different cognitive abilities of clients at different stages of life

1.3 Adjust physical processes to take account of client capabilities and physical body features

1.4 Recognise norms and deviations associated with age and gender

1.5 Obtain consents from others when appropriate

Element: 2. Respond to unfamiliar presentations


2.1 Recognise situations where presenting cases or aspects of presenting cases fall outside current knowledge base or expertise

2.2 Refer client to other practitioners when case is not appropriate to own scope of practice

2.3 Identify, access and interpret sources of additional information and advice when appropriate to continue with the case

2.4 Enhance own capacity to deal with the case by conducting case specific research

2.5 Integrate findings into client treatment plans and record details

Element: 3. Extend and expand own knowledge base


3.1 Pro-actively identify and respond to professional development opportunities

3.2 Develop and adjust work practices as part of ongoing practice development

HLTMSG008 MONITOR AND EVALUATE REMEDIAL MASSAGE TREATMENTS

Element: 1. Evaluate client progress


1.1 Seek client feedback about treatment impacts and compliance with the treatment plan

1.2 Make own observations and assessment of client changes based on massage framework

1.3 Evaluate treatment impacts in relation to client’s physical, mental, spiritual and emotional wellbeing

1.4 Compare change and improvements with expectations in the treatment plan, existing research and evidence from own practiced

1.5 Seek additional information from clients when progress suggests this is needed

1.6 Accurately document progress in client treatment plan

Element: 2. Adjust treatment based on evaluation


2.1 Determine the need for adjustment to treatment plan based on evaluation of client progress

2.2 Identify and respond to factors that may be inhibiting client progress

2.3 Adjust treatment plans based on outcomes and sources of research or evidence that support massage practice

2.4 Accurately document any adjustments to treatment plans

Element: 3. Develop practice from client evaluation


3.1 Review progress of clients to context of own individual practice

3.2 Identify areas of own practice for further research or development to support client outcomes

3.3 Pro-actively seek and respond to professional development opportunities


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METHOD OF DELIVERY: Each session is of 3 hours duration and is a combination of theory and practical hands on work. Hand out notes and session review sheets are provided and students are advised that some note taking is recommended. Two-way sharing of information and experience is encouraged in all classes.

RESOURCES REQUIRED: Students are required to bring their own stationary and dress casually to prevent damage to good clothes. Students are also required to bring two towels to each class. All other required resources to facilitate learning will be supplied by MSQ.


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CONTENT Session 1: Stretching Techniques Session 2: Static stretching Session 3: MET/PNF Session 4: MET continued Session 5: MET and revision Session 6: practical assessment


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SESSION 1: Introduction to Stretching Techniques

FLEXIBILITY Flexibility refers to the ability of the musculotendinous unit to elongate with application of a stretching force and is related to stiffness, suppleness and pliability Range of Motion is the amount of mobility of a joint and is determined by the soft tissue and bony structures in the area Clinically, ROM measurements quantify both and are often used interchangeably The most common factor affecting flexibility is the inability of the muscles and tendons surrounding a joint to stretch to an optimal length. Limitations in flexibility result in restricted movement which can cause postural problems and increase the change of injury. Flexibility is improved by using controlled force to lengthen the muscle and tendon tissue surrounding the joint, therefore increasing the range of motion and reducing muscular tension. It is important that this does not lengthen the ligaments of the joints as this will cause instability. Flexibility training involves a planned, deliberate and regular program of exercises that can progressively and permanently increase the usable range of motion of a joint or set of joints, over a period of time (Alter, 1988). ACSM Position Stand (2011): Regular stretching can improve joint ROM after approximately 3 - 4 weeks and may also enhance postural stability and balance, particularly when combined with resistance exercise The goal of a flexibility program is to develop range of motion in the major muscle–tendon groups in accordance with individualised goals To ensure safety and effectiveness of stretching methods it is important to understand the properties of connective tissue; neuromuscular influences on ROM; and the precautions and contraindications of various stretching techniques


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COMPOSITION OF CONNECTIVE TISSUE All connective tissue consists of cells and extracellular matrix (ECM). The ECM is a collection of extracellular molecules secreted by cells that provides structural and biochemical support to the surrounding cells. The ECM of connective tissue consists of ground substance and 3 types of fibers: collagen, elastin and reticulin, which all vary in their tensile versus elastic properties. Collagen provides tissue with strength and stiffness Elastin provides a structure with extensibility (Elastin fibers have more flexibility, while collagen fibers are 5 times as strong) Reticulin - thin and delicate Type III collagen fibers which cross-link to form a fine meshwork for support Ground substance is a viscous gel-like substance in which the cells and fibers lie. This acts as a mechanical barrier to foreign matter and is a medium for the diffusion of nutrients and waste products. It plays a critical role in providing space between adjacent collagen fibers and thus stops them from sticking together and allows the fascia to maintain flexibility The strength of connective tissue is determined by the arrangement of the fibers: Loose irregular connective tissue has an unorganised fiber arrangement with long distances between cross-links. Thin collagen and elastic fibers are interlaced in several directions providing tensile strength and pliability e.g. fascia of skin and surrounding muscles and nerves Dense regular connective tissue is highly organised with parallel collagen fibers and more cross links to resist high-tensile loads and provide some flexibility e.g. tendons and ligaments Dense irregular connective tissue has a multidirectional fiber pattern e.g joint capsules and bone periosteum Mechanical properties of connective tissue Elasticity – ability to return to normal length after an elongation force or load e.g. a rubber band

Viscoelasticity – a combination of elastic and viscous properties that allows either a change in length or a return to former length, depending on the speed, duration and strength of the stretch force applied. Plasticity – the ability to undergo a permanent change in size or shape after a deforming force is applied, e.g. ball of putty Connective tissues plastic quality allows its length to change, while its elasticity allows some return to normal length.


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Collagen is elastic, viscoelastic and plastic! Collagen’s strength, resilience and form is the primary component restricting ROM and should be the primary target of stretching exercises The effectiveness of the stretch depends on amount of collagen and elastin in the gross structure, the amount of force applied, the duration of the stretch, and the temperature of the tissue. Physical properties of connective tissue Creep – elongation of tissue when a low-level load is applied over an extended time to cause plastic deformation permanent change in the tissue’s length Stress-Strain Stress is a force that changes form or shape Strain is the amount of deformation that occurs when a stress is applied All structures have a stress-strain curve that represents their own ability to resist deforming forces, but they share the same general characteristics

Fibers tear if the creep response causes too much deformity too quickly! In collagen, this occurs when the tissue is stretched to 6 - 10% beyond its resting length Hysteresis – Repetitive stretching with submaximal loads can be effective in increasing ROM due to the principle of hysteresis. Energy in the form of heat releases when stress is applied to tissue. As local tissue is heated with repetitive stretches, the tissue is more easily stretched. As the tissue changes length and is heated with repetitive stretches, high-level loads are tolerated in subsequent repetitions.


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Neuromuscular influences on ROM

Muscle spindles and Golgi tendon organs (GTO) are sensitive to tension in the muscle and its tendons and protect these structures from abrupt changes in tension (reducing strain-strain forces)

If a muscle stretches quickly, the muscle spindle produces a rapid reflex response

GTOs cause simultaneous inhibition of its own muscle and activation of the antagonist muscle

GTO are not as sensitive to stretch as muscle spindles but are very sensitive to contractions and tension in a muscle

Factors affecting flexibility Age

There tends to be a decrease in flexibility with aging (Chapman, 1971).

This is largely attributed to a loss in elasticity in the connective tissues surrounding the muscles which go through a normal shortening process resulting from a lack of physical activity

Due to this loss of joint mobility, older persons are more susceptible to injury from vigorous physical activity

Regular exercise, including stretching exercises, can minimize the effect of this age- related decrease in range of motion

Immobilisation

If motion is restricted, rapid changes in the structure and function of connective tissue occur, which can be permanent or reversible

Soft tissue changes are seen following one week of immobilisation and are increased by oedema, trauma, and impaired circulation

Immobilisation results in the loss of ground substance and more cross-links between collagen fibers tissue becomes more dense, hard and less supple

If a normal joint is immobilised for 4 weeks, the dense connective tissue that forms prevents normal motion

The longer the immobilisation, the more difficult the restoration to normal becomes Heat An increase in body temperature via a warm-up or the participation in physical activity will increase range of motion (Sapega, Quendenfild, Moyer, & Butler, 1981)


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Pregnancy During pregnancy the pelvic joints and ligaments are relaxed and capable of greater range of motion (Bird, Calguneri, Wright, 1981). The hormone responsible for this change in range of motion is relaxin. After pregnancy, relaxin production decreases and the ligaments tighten up. STRETCHING TECHNIQUES Stretches are either dynamic (with movement) or static (without movement) and the flexibility outcomes are proportional to the type of stretch applied Types of stretching techniques:

Ballistic

Dynamic

Static - Active

Static - Passive

Static - Isometric

MET (incl PNF stretching) Ballistic stretching

Involves quick, bouncing movements beyond normal ROM to increase dynamic flexibility

Often used as a ‘warm up’ for sporting activities

Stimulates both the muscle spindles and GTOs, but with uncoordinated firing their protective mechanisms are ineffective

It does not help the muscle to relax in a stretched position and may cause tightening up by repeated activation of the stretch reflex

Dynamic stretching

Controlled movement through the active ROM of a joint (not beyond)

Increases dynamic flexibility, elevates heart rate, increases muscle and core temperature

Positive effects on power, enhanced neuromuscular control and muscle activation

Evidence suggests that dynamic stretching is more appropriate than static stretching for activities that require balance, rapid changes in direction and movement time of the upper extremities (Chatzopoulos et al, 2014)

If the volume of dynamic stretching is too high, the benefits can be overruled by fatigue


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Active stretching

Stretches are performed without assistance from another person or equipment

Active static stretching involves holding the stretched position using the strength of the agonist muscle

Contracting the agonist will enhance relaxation of the stretched muscle (antagonist inhibition)

Many of the movements found in various forms of yoga are active stretches

Passive (relaxed) stretching

Passive stretching involves assistance of another person or equipment

The proximal segment of the joint is stabilized while a steady, firm pressure is applied slowly to the distal segment

If a two-joint muscle is stretched, one joint is positioned in the muscles lengthened position, then the second joint until maximum muscle length is achieved

A stretch is applied until the muscle is taut and the client feels tension but not pain

A prolonged stretch is effective in increasing ROM because of its impact on a tissue’s stress-strain curves and creep

Static- isometric stretching

Performing an isometric contraction of the lengthened muscles during a passive stretch to inhibit the stretch reflex – allowing tissues to stretch further following

More effective than passive or active stretching to improve static flexibility

Increases strength in a stretched position

Resistance is provided either manually by one’s own limb, by a partner or an apparatus such as a wall or the floor

Increased risk of injuring muscles by damaging tendons and connective tissue

Not recommended for children and adolescents during their growth phase


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Proprioceptive neuromuscular facilitation (PNF)

PNF is a combination of passive and isometric stretching to achieve maximum static flexibility and increase ROM

It can be done with/without the help of a partner, but mostly effective with the help of a partner

ACSM Guidelines suggest a 3- to 6-s contraction at 20%–75% maximum voluntary contraction followed by a 10- to 30-s assisted stretch

The hold-relax method of PNF stretching is facilitated by the GTO to allow a reflexive relaxation of the muscle

ACSM GUIDELINES FOR FLEXIBILITY EXERCISE Frequency: 2–3 days/week is effective in improving joint range of motion, with the greatest gains occurring with daily exercise Intensity Stretch to the point of feeling tightness or slight discomfort Time Holding a static stretch for 10–30 s is recommended for most adults In older persons, holding a stretch for 30–60 s may confer greater benefit Type A series of flexibility exercises for each of the major muscle–tendon units is recommended Static flexibility (active or passive), dynamic flexibility, ballistic flexibility, and PNF are each effective Volume Pattern: A reasonable target is to perform 60s of total stretching time for each flexibility exercise Repetition of each flexibility exercise two to four times is recommended Flexibility exercise is most effective when the muscle is warmed through light to moderate aerobic activity or passively through external methods such as moist heat packs or hot baths. Basic principles of stretching

Client should relax into stretch and breathe slowly and evenly Appropriate intensity is where the stretch is felt but does not cause pain, only

discomfort Client should feel the tension subside as the stretch is held Stretching is best undertaken when the muscles are warm Never over stretch beyond a point of active control Avoid potentially dangerous stretching


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Contraindications

Recent fractures when immobilisation is necessary for healing and movement is detrimental

Bony block that restricts motion Infection in the joint Acute inflammation in the joint Extreme or sharp pain with motion When tightness of soft tissue contributes to an area’s stability

Precautions

Explain to the client what you will do, the expected sensations and outcomes Apply and release the stretch slowly to avoid pain or muscle contraction Consider the structures that will be placed under stretch – including scar tissue, joint

capsule, ligaments, surrounding tendons, muscles, fascia, nerves, skin, and subcutaneous tissue

Stabilise the area to properly apply the stretch force in the correct structures Residual pain, especially accompanied by new oedema within a 24 hr period is an

indication that the stretch was too aggressive Special considerations

When stretching the trunk, avoid any stretch that causes pain or a change of sensation down the leg

Stabilise the pelvis when stretching the hip Stabilise the scapula when stretching the GHJ Stabilise the GHJ when stretching the elbow When stretching the wrist, apply force over the metacarpals, not the fingers

STRETCHING: STATIC stretching for your client Rules for stretching:

Breath slowly, deeply and evenly

do not stretch to a stage where breathing becomes unnatural

hold a stretch in a comfortable position, tension should relax as stretch is held

do not overstretch, particularly in early stages

warm up by walking briskly or light jogging on spot, before starting stretching Safety:

Normal massage contraindication apply to stretching

Bouncing type ballistic movements should always be avoided

Stretching should progress from major joints to more specific joints

Should be done before and after sport as close to start and finish as possible. 1/3 of benefits of pre-event stretching can be lost if athlete is stationary for the ½

hour before competing.

Sport specific flexibility should be developed


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Flexibility training should be doe regularly 3-4 times/week

Should be carried out slowly without forcing tight muscles

Hyperextension beyond ROM should be avoided especially of lower back

Special precautions are necessary during pregnancy

Static stretches can be held for 10-30 secs.

Compare range both sides of body periodically to prevent imbalances occurring

Don’t stretch if a bone blocks motion

Don’t stretch if it causes pain

SESSION 3: Static Stretching for clients and friends In description in this table practitioner position will refer to stretch being applied to right side of the body obviously the opposite applies to stretch the left side. All stretches performed using safety factors above. Page numbers refer to St.George – Stretching Handbook for Self Stretching.

Target Muscle group

Athlete/client position

Stretch performance

Cervical ( neck ) Rotators P51 Lateral

flexors P52,53 Triceps P63 Latissimus

dorsi., Rhomboids,

lateral shoulder rotators P 66,67

Biceps Pectoralis

major P64

Sitting

From behind athlete, stabilise L. shoulder with hand, R hand on atheletes L. cheek, rotate toward your R. shoulder. L. hand on athletes head above ear, R. hand

on athletes R. shoulder draw apart. Flex athletes - elbow, shoulder, support behind shoulder joint, R. hand on point of elbow push toward posterior. Abduct shoulder, flex elbow stabilise L. acromion, pushing on elbow draw arm across body behind head. R side - Take hand to L shoulder, isolate R shoulder move R elbow toward L shoulder Extend arms fully at shoulder joint holding at wrists, palms down. Abduct shoulders place athletes hands behind head, hold elbows, stabilise trunk by leaning against back, draw elbows posteriorly.


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Serratus

anterior Forearm

extensors P66

Forearm flexors P66

Thoracic rotators & obliques P74

Lumbar

rotators P77,76

Trunk lateral

flexors P69,83

Lumbar

rotators Quadriceps

P 93 Psoas major

P95

Prone

Athlete’s arms at side, grasp lateral borders of scapula, draw medially. Fully extend elbow, apply full wrist flexion. Fully extend elbow, apply full wrist extension. From behind athlete, grasp R. wrist with L. hand, place R.hand against medial border of R. scapula, pull and push. Continue thoracic movement but moving R. hand down back locating on the lateral erector spinae, push, pull. Prone, arm under quads near knee, stabilise pelvis draw toward you Flex upper R. leg, drop patients R.shoulder posteriorly, place L.hand on front on R. shoulder, R. hand on R. gluteal, push pull, very slowly and carefully. Flex. Knee move heel toward gluts. From quad. Stretch, place L. hand onto quads., isolate gluts with R. hand. in line with Greater trochanter, lift leg upward. R side- Hip flexion L, patient holds, R leg over side table, overpressure on quads to ward floor


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SESSION 3: Muscle Energy Techniques (MET)

MUSCLE ENERGY TECHNIQUES (MET)

MET is an umbrella term which covers a number of ways of using the energy of the client’s contracting muscle, rather than the force of the therapist, to create a beneficial change in muscle balance. It was originally developed and used by Osteopaths to release muscles prior to joint manipulation but are now used widely by a range of other practitioners including remedial massage therapists. Typically, muscle contraction is used to help strengthen a muscle, much like doing weight training to development and increase a muscle’s strength. MET techniques are not designed for this purpose, but rather aimed at releasing excessive tension in a muscle to restore it to its normal length and elasticity. Muscles selected for MET are decided by assessing restriction in the range of motion of a joint where muscle tension is preventing full or normal range of motion. With a good knowledge of anatomy and biomechanical understanding, MET can be applied to any muscle in the body that contributes to this restriction of a joint. MET can be a standalone treatment, or more commonly, will be included as part of a remedial massage treatment. Also, muscles will respond better to MET once they have been warmed up, so add MET to the end of your treatment. MET may be more challenging to apply if you have to continually change the position of the towels to provide privacy, so consider applying the technique after the client has got dressed. If you think their clothes might restrict movement with MET, get them to remove certain items of clothing or ask them to wear more appropriate clothes for their next visit. Typically, to maintain the effect of MET, a client should be instructed to continue a regular stretching routine, that mimics or is specific to the muscles that MET was originally applied to. Principles of MET MET is based on two different principles that occur naturally through the neuromuscular system, both inducing a temporary state of deeper relaxation in the muscle. In this relaxed state, the tight muscle can be more easily and safely stretched and lengthened.


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Post Isometric Relaxation (PIR)

Following a short (6-8sec), mild contraction (<20% of maximum), a muscle becomes inhibited and more relaxed for a short period of time (up to 15sec, ‘stretch window’). How this occurs is not fully understood, but it appears to happen through a reflex action involving the Golgi tendon organs. The Golgi tendon organs respond to the muscle contraction by stimulating the sensory nerve to the spinal cord, where it creates a reflex inhibition through the motor nerves which release the tension in the muscle. However, a stronger contraction does not mean greater relaxation. The best results are actually seen with a mild contraction.

Reciprocal Inhibition (RI)

When a muscle contracts, the opposing muscle will automatically become inhibited and relax. This has to occur to allow the body to move. Consider if you contract your biceps brachii. The opposing muscle, triceps brachii, will have to relax to allow movement at the shoulder/elbow joint. If the triceps brachii was not inhibited, your arm would not move at all. This is called an isometric contraction. The inhibition of the opposing muscle is instant and only lasts as long as the muscle is contracted, unlike PIP, which can last up to 15 seconds. RI may be the better option for a recent injury as the client is in complete control of the stretch, or around critical areas like the neck. The Barrier Position (or ‘bind’) The barrier position is the common starting point for all applications of MET and is described as the position at which a muscle is taken to a length where the first sensation of tightness can be felt by the therapist or client. It is more important to find this subtle barrier position, than to feel as though you are giving your client a good stretch. Finding this barrier requires good tactile skills, very good client-handling skills and effective communication. It may take some practice before a therapist can feel this subtle barrier accurately. Even an experienced therapist should still ask their client if they can feel the slight tension in the muscle. The barrier position will vary from client to client and a good therapist will be able to adapt their technique to suit the range of motion of the client, rather than rely on a standard position for each muscle. An early barrier will also indicate excessive loading of the connective tissue (fascia).


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Muscle Energy Techniques (MET) VS Proprioceptive Neuromuscular Facilitation (PNF)

MET PNF Indicated for injury and weakness conditions Indicated for strong, healthy tight muscles

Light stretch to Barrier position Fairly full stretch

Light PIR technique Strong PIR technique

Clinical setting

Pre- or Post-event setting

MET application (PIR method)

1. Barrier: Therapist gently stretches the client into the direction of restriction to the barrier position

2. Isometric contraction: Client gently (<20% of maximum) contracts in exact opposite motion while the therapist resists and holds the patient in isometric contraction for 6-8 sec

3. Relax: Instruct client to relax and wait a second or two 4. Lengthen: Slowly and passively stretch the muscle into the new barrier position 5. Rest: The new barrier should be held for about 20 sec 6. Repeat: Repeat process until no further process is made (3-5 times) 7. Return: Passively return the muscle to its neural resting position

REMEMBER – we are not stretching the muscle in the typical way, only initiating reciprocal inhibition. The use of breathing has also been found to be beneficial.

breathe in during the mild contraction

breathe out during relaxation after contraction Contraindication for MET

If pathology is suspected (e.g. osteoporosis, arthritis), no MET should be applied until accurate diagnosis has been established

Modify amount of pressure, number of repetitions and whether stretch should be included as appropriate for such pathologies

MET should not be painful. If it is, consider alternative technique or referral

Remember to take into consideration end feel when applying MET (see next page)


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End Feel Types

End Feel Definition

Example

AB

NO

RM

AL

Bone to bone Painful, hard end feel osteophyte formation in cervical spine

Muscle spasm Guarded feel caused by movement reduction secondary to reactive myospasm to protect the injured tissue Early spasm – initial ROM (acute inflammation) Late spasm – end of ROM (instability and the resulting irritability)

instability or trauma

Capsular Firm, decreased ROM accompanied with pain, but not myospasm, boggy end feel Soft – acute conditions with stiffness occurring in early ROM and increasing until the end of range is reached e.g. synovitis Hard – chronic conditions or in full-blown capsular patterns. The limitation comes on rather abruptly after a smooth, friction free movement e.g. frozen shoulder

oedema, adhesions, synovitis

Springy block Bouncing or springy, seen in joints with menisci (knee mainly) associated rebound effect

menisci tears, internal derangement (progressive slipping or displacement of a component of the joint called the articular disc)

Empty Lack of normal end ROM resistance, usually associated with an increased ROM

instability, hyper mobility, ligament rupture, acute subacromial bursitis

Common application errors

Common patient errors

Common therapist errors

Contraction to hard

Wrong muscle used

Contraction time too short

Incomplete relaxation after contraction

Starting & finishing too quickly

Inaccurate control of position

Inadequate counterforce

Inappropriate direction of counterforce

Moving too quickly to new barrier

Poor instruction to client

Lengthened position not held long enough

Ineffective communication


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SESSION 4: Applying MET

Box 2.7 Patterns of imbalance

Patterns of imbalance as some muscles weaken and lengthen, and synergists become

overworked, while antagonists shorten (see this chapter for cross syndromes, and Ch. 5 for

Janda’s functional tests for muscle imbalance):

Lengthened or underactive

stabiliser

1. Gluteus medius

2. Gluteus maximus

3. Transverse abdominis

4. Lower trapezius

5. Deep neck flexors

6. Serratus anterior

7. Diaphragm

Overactive synergist

TFL, quadratus lumborum,

piriformis

Iliocostalis lumborum and

hamstrings

Rectus abdominis

Levator scapulae/upper trapezius

SCM

Pectoralis major/minor

Shortened antagonist

Thigh adductors

Iliopsoas, rectus femoris

Iliocostalis lumborum

Pectoralis major

Suboccipitals

Rhomboids

Scalenes, pectoralis

major

Practical application of MET


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When should MET be applied to a muscle?

When should MET (PIR, RI or postfacilitation stretch) be applied to a muscle to relax

and/or stretch it?

1. When it is demonstrably shortened – unless the shortening is attributable to associated joint restriction, in which case this should receive primary attention, possibly also involving MET (see Ch. 6).

2. When it contains areas of shortening, such as are associated with myofascial trigger points or palpable fibrosis. It is important to note that trigger points evolve within stressed (hypertonic) areas of phasic, as well as postural muscles, and that these tissues will require stretching, based on evidence which shows that trigger points reactivate unless shortened fibres in which they are housed are stretched to a normal resting length as part of a therapeutic intervention (Simons et al 1998).

3. When periosteal pain points are palpable, indicating stress at the associated muscle’s origin and/or insertion (Lewit 1999).

4. In cases of muscular imbalance, in order to reduce hypertonicity when weakness in a muscle is attributable, in part or totally, to inhibition deriving from a hypertonic antagonist muscle (group).


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TFL Psoas

Piriformis QL MET is a particularly way to restore normal resting length to muscles post trigger point release


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SESSION 5:

Pec Major Lat Dorsi

SESSION 6:

Scapulohumeral rhythm test

Greenman bases his description on Janda (1983), who notes the ‘correct’ sequence for shoulder abduction, when seated, as involving: supraspinatus, deltoid, infraspinatus, middle and lower trapezius and finally contralateral quadratus. In dysfunctional states the most common substitutions are said to involve: shoulder elevation by levator scapulae and upper trapezius, as well as early firing by quadratus lumborum, ipsilateral and contralateral.


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Scalenes Lev scap

Subscapularis Supraspinatus

Supraspinatus shortness test (a) The practitioner stands behind the seated patient, with one hand stabilising the shoulder on the side to be assessed while the other hand reaches in front of the patient to support the flexed elbow and forearm. The patient’s upper arm is adducted to its easy barrier and the patient then attempts to abduct the arm.


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Paravertebral muscle assessment

Paravertebral muscle shortness test (a) The patient is seated on a treatment table, legs extended, pelvis vertical. Flexion is introduced in order to approximate forehead to knees. An even ‘C’ curve should be observed and a distance of about 4 in (10 cm) from the knees achieved by the forehead. No knee flexion should occur and the movement should be a spinal one, not involving pelvic tilting

A Normal length of erector spinae muscles and posterior thigh muscles. B Tight gastrocnemius and soleus; the inability to dorsiflex the feet indicates tightness of the plantar – flexor group. C Tight hamstring muscles, which cause the pelvis to tilt posteriorly. D Tight low back erector spinae muscles. E Tight hamstrings; slightly tight low back muscles and overstretched upper back muscles. F Slightly shortened lower back muscles, stretched upper back muscles and slightly stretched hamstrings. G Tight low back muscles, hamstrings and gastrocnemius/soleus. H Very tight low back muscles, with lordosis maintained even in flexion.

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