Treating Leg Abduction Restriction Using R.I.
Greenman summarises several of the component elements of MET as follows8
- Test for the sense of bind or increased effort as you abduct the limb, note the degree of excursion of the limb as it reaches this barrier, and then back off a few degrees.
- At this point the patient/model would be asked to try to abduct the leg themselves (20% of strength only), taking it towards the barrier, while you resist the effort.
- Following the end of the contraction a degree of release will occur in the short muscles. Following complete relaxation guide the limb to the new barrier.
- There is a Patient-active muscle contraction
- From a controlled position
- in a specific direction (away from the barrier = PIR/towards the barrier = RI)
- met by operator applied counterforce
- involving a controlled intensity of contraction.
Patient Errors During MET
- Contraction is too hard (remedy : give specific guidelines - e.g. use only ‘20% of strength’)
- Contraction is in wrong direction (remedy : give accurate instructions)
- Contraction is not sustained for long enough (remedy : instruct the patient to hold the contraction until told to ease off, and say how long this will be)
- Patient does not relax completely after the contraction (remedy : have them release and relax, inhale and exhale and ‘let go completely’)
To this list add -
- Starting and/or finishing the contraction too hastily. There should be a slow build-up of force and a slow letting go, easily achieved if a rehearsal is carried out to educate the patient.
Operator Errors in Application of MET Include:
- Inaccurate control of position of joint or muscle in relation to the resistance barrier (remedy: have clear image of what is required and apply it)
- Inadequate counterforce to the contraction (remedy: meet and match the force precisely)
- Counterforce is applied in an inappropriate direction (remedy: ensure precise direction needed for best effect)
- Moving to a new position too hastily after the contraction (there is around 25 seconds of refractory muscle tone release during which time a new position can easily be adopted or stretch introduced - haste is unnecessary and counter-productive)
- Inadequate patient instruction is given (remedy: get the words right so that the patient can cooperate)
Whenever force is applied, by the patient, in a particular direction, and when it is time to release that effort, the instruction must be to do so gradually. Any quick effort is self-defeating. The coinciding of the forces at the outset (patient and operator) as well as at release is important. The operator must be careful to use enough, but not too much, effort, and to ease off at the same time as the patient.
Contraindications and Side-effects of MET
If pathology is suspected no MET should be used until an accurate diagnosis has been established.
Pathology (osteoporosis, arthritis etc) does not rule out the use of MET, but its presence needs to be established so that dosage of application can be modified accordingly (amount of effort used, number of repetitions, stretching introduced or not etc)
As to side effects, Greenman explains, ‘All muscle contractions influence surrounding fascia, connective tissue ground substance and interstitial fluids, and alter muscle physiology by reflex mechanisms. Fascial length and tone is altered by muscle contraction. Alteration in fascia influences not only its biomechanical function, but also its biochemical and immunological functions. the patient’s muscle effort requires energy and the metabolic process of muscle contraction results in carbon dioxide, lactic acid and other metabolic waste products which must be transported and metabolised. It is for this reason that the patient will frequently experience some increase in muscle soreness within the first 12 to 36 hours following MET treatment. Muscle energy procedures provide safety for the patient since the activating force is intrinsic and the dosage can be easily controlled by the patient, but it must be remembered that this comes at a price. It is easy for the inexperienced practitioner to overdo these procedures and in essence to overdose the patient.’