Effectiveness of Muscle Energy

Technique on Improving Hamstring

Extensibility in Healthy, Asymptomatic
Adults with Hamstring Tightness:
An Evidence-Based Review
Judy Pang, MS, DPT(c)
UCSF/SFSU Graduate Program in
Physical Therapy
Clinical Problem

Muscle extensibility is
an essential element of
normal biomechanical
functioning (Wassem et al., 2010)


The hamstring (HS)
muscles are
susceptible to
decreased extensibility


Significance of Problem


Do you have tight HS?


Have you treated
someone with tight HS?
http://www.cartoonstock.com/directory/h/hamstrings_gifts.asp
Significance of Problem
Difficult to determine prevalence of HS tightness

Decreased HS extensibility is often associated with:
Hip and knee movement dysfunctions
Patellofemoral pain/patella tendinopathy
HS strains
Lumbosacral postural changes/ low back pain
Bakhtiary et al., 2011, Wassem et al., 2010, Ayala, 2011, and Shadmehr et al., 2009

Relevance to PT
Benefits of flexibility (Wassem et al., 2010)
Improved ROM, function, coordination and movement
Reduced injury risk and improved athletic performance

PTs utilize a variety of interventions to treat HS tightness (Bakhtiary
et al., 2011)
Static and ballistic stretching
Proprioceptive neuromuscular facilitation (PNF)
Eccentric training (ECC)
Muscle energy technique (MET)





Purpose
Primary
Examine current literature regarding the
effectiveness of MET on improving HS extensibility
in healthy, asymptomatic individuals with HS
tightness

Secondary
Compare the effectiveness of MET to no treatment
or an alternative treatment for improving HS
extensibility in healthy, asymptomatic individuals with
HS tightness
Definition: Hamstring shortness
Hamstring shortness
Lacking >15-30 of knee
extension in popliteal
angle test

Active Knee Extension:
ICC=0.99 (Gajdosik and Lusin, 1983)


Passive Knee Extension:
ICC=0.93 (Gnat et al., 2010)
Wassem et al., 2010, Shadmehr et al., 2009, Smith and Fryer, 2008 & Ballantyne et al., 2003,
http://nexusphysicaltherapy.com/a_hamstring.html

Definition: Muscle Energy Technique
A manual technique that involves
A muscle, or group of muscles

Voluntarily contracted isometrically
Sub-maximal: 75% maximum voluntary isometric
contraction (MVIC)

Specific direction

Defined length of time
Mitchell & Mitchell, 1995

Application of MET
Stretch the muscle to a
palpated barrier
Produce sub-MVIC
Muscle relaxes; clinician
maintains stretch
Clinician takes up the slack
following relaxation
Muscle lengthened to new
barrier
Repeat process


Smith and Fryer, 2008
Theory Explanation Supported?
Neurological Reflex muscle relaxation
Biomechanical Viscoelastic changes
Sensory Tolerance to stretch
Theoretical Construct

The exact mechanism is still unclear

Magnusson et al., 1996, Ballantyne et al., 2003, Weppler et al., 2010, Folpp et al., 2006, Chaitow L, 2009
No
No
Yes
PNS: Gate Control
Theory of Pain
CNS: Activates
Brain Pain
Centers
Circulating
Biomarkers
Theoretical Construct: Sensory Theory
Decrease Pain
Muscle Energy
Technique
Increase Tolerance to Stretch
Increase HS Extensibility
Chaitow Leon, 2009
Gap in Literature

Limited research supporting and
validating the use of MET
No systematic review or meta-
analysis

Small sample sizes

High variability in MET
application parameters

Attempt to collect and pool
existing data
http://www.experienceproject.com/stories/Took-The-Do-You-Have-Gaps-In-Your-Knowledge-Quiz/1434705
Research Questions
Population Intervention Comparison Outcome
Healthy,
asymptomatic
persons with
short HS
Muscle
Energy
Technique
-No treatment

-Alternative
technique
-PKE

-AKE
Foreground
Primary

In healthy, asymptomatic persons with
short HS, how effective is MET at
improving HS extensibility?
Secondary

How does MET compare to no
treatment or other treatments at
improving HS extensibility in healthy,
asymptomatic persons with short HS?
Null Alternative
Application of MET on
the HS muscle will not
improve HS extensibility
in healthy,
asymptomatic persons
with short HS
Application of MET on the HS
muscle will improve HS
extensibility in healthy,
asymptomatic persons with
short HS

MET is not as effective
compared to no
treatment or an
alternative technique at
improving HS
extensibility
MET will be more effective
than no treatment or an
alternative technique at
improving HS extensibility







S
e
c
o
n
d
a
r
y












P
r
i
m
a
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y

Hypotheses
Expected Findings
At least 10 articles matching criteria

Reject both null hypotheses

Expect
MET to be effective at improving HS extensibility

MET is more effective compared to no treatment
and alternative treatments


Search Methods
Data bases Searched:











Recursive search
Keywords:
Muscle energy technique
MET
Post-isometric relaxation
Active muscular relaxation
technique
Hamstring
Tightness
Flexibility
Shortness
Extensibility
Length



Last search date: 5.02.12
Search Methods
Inclusion criteria
MET to the HS muscles
Outcome measure: PKE and/or AKE
No restrictions on age or gender
Persons with short HS

Exclusion criteria
PNF
Non-English language articles
Hamstring injuries or lower extremity injuries
Neurological impairments


Articles identified
through database and
recursive search:
(n=33)
Number of duplicates
removed:
(n=5)
Articles screened:
(n=28)
Articles excluded due
to irrelevance or to not
meeting following
inclusion criteria:
(n=24)
-Patient population
-Knee extension not an
outcome measure
-MET not performed
-If study directly used
PNF instead of MET





Articles selected for
inclusion in evidence
based review:
(n=4)
Search Results
*A secondary reviewer confirmed that the four studies met the inclusion and exclusion criteria and were
appropriate for this review.
All studies
were RCTs,
level 1b
Study Characteristics
Abbreviations: PA:popliteal angle, N=number of participants, y.o.:years old, PKE: passive knee extension,
AKE: active knee extension

Author
HS
Criteria
(PA)

N
Age
(y.o)

Female

Male

Outcome
Time of
Measurement
(days)
Ballantyne
A et al.,
2003

Not
stated

40
18-45
Ave
23.4

22

18

PKE

1
Shadmehr
A et al.,
2008

30

30

20-25

30

0

PKE

28
Smith M
and Fryer
G, 2009

15

40
Ave
22.1

17

33

AKE

1
Waseem
M et al.,
2010

20

40

18-25

0

40

AKE

5

Author MET Intervention Comparison Results

MVIC
(%)
Contraction
Time (sec)
Relaxation
Time (sec)
Ballantyne A et
al, 2003
75 5 3 Control MET
Shadmehr A et
al., 2008
50 10 10 Static,
passive
stretch

Both
Smith M and
Fryer G, 2009
40 2-3 10 Chaitows
MET
Both
Smith M and
Fryer G, 2009
40 30 10 Greenmans
MET
Both
Waseem M et
al., 2010
75 5 3 Eccentric
Training with
theraBand

MET
40-
75%
2-30 sec 3-10 sec
Abbreviations: MVIC: maximum voluntary isometric contraction, MET: muscle energy technique
Study Characteristics
Statistical Analysis

Extracted means and standard deviations for knee extension ROM
Single group effect size
Two- group effect size

Each study weighted by inverse variance prior to pooling data

Calculate Q statistic to determine homogeneity: random vs. fixed model

Grand effect sizes and 95% CI were calculated

Forest Plot

Grand effect sizes converted to clinical units








-1 0 1 2 3 4 5 6 7
Shadmehr
et al.
Smith &
Fryer:
Chaitow
Smith &
Fryer:
Greenman
Waseem
et al.
Ballantyne
et al.
Grand
Effect Size
Effect Size (d)
Results:
Single Group
Effect Sizes
Significant Q: Random effects model
Small <0.3
Moderate 0.3-0.8
Large >0.8

Jewell 2008
1.56 (0.58, 2.54)
STATISTICALLY
SIGNIFICANT!
Results:
Two-Group
Effect Sizes
Non-significant Q: Fixed effects
model

-1 -0.5 0 0.5 1 1.5 2
Waseem et al.
Ballantyne et
al.
Shadmehr et al.
Grand Effect
Size
Effect Size (d)
Small <0.3
Moderate 0.3-0.8
Large >0.8

Jewell 2008

0.56 (0.18, 0.95)
STATISTICALLY
SIGNIFICANT!
Discussion
Null Alternative
Application of MET on the
HS muscle will not
improve HS extensibility
in healthy, asymptomatic
persons with short HS
Application of MET on the HS
muscle will improve HS
extensibility in healthy,
asymptomatic persons with short
HS

MET is not as effective
compared to no treatment
or an alternative
technique at improving
HS extensibility
MET will be more effective
than no treatment or an
alternative technique at
improving HS extensibility




S
e
c
o
n
d
a
r
y














P
r
i
m
a
r
y

Discussion: Why is MET effective?
PNS: Gate
Theory
CNS: Activates
Brain Pain
Centers
Circulating
Biomarkers
Decrease Pain
Muscle Energy
Technique
Increase Tolerance to Stretch
Increase HS Extensibility
Response Bias
Chaitow Leon, 2009
Discussion: Effect of Dosing
100
110
120
130
140
150
160
170
180
Shadmehr et
al.
Smith & Fryer:
Chaitow
Smith & Fryer:
Greenman
Waseem et al. Ballantyne et
al.
Study
K
n
e
e

E
x
t
e
n
s
i
o
n

(
d
e
g
r
e
e
s
)
Pre-MET
Post-MET
-1 0 1 2 3 4 5 6 7
Shadmehr
et al.
Smith &
Fryer:
Chaitow
Smith &
Fryer:
Greenman
Waseem
et al.
Ballantyne
et al.
Grand
Effect Size
Time of measurement (days)
28 1 1 5 1
5X
Discussion: Harm and Cost
Harm & Risk
No studies indicated any
harm or adverse effect
May potentially
strain/tear HS or cause
neural symptoms

Cost
Not addressed in literature
No materials needed
Time efficient
Direct PT care
Cost of PT education and
possibly continuing education

Clinical Units Conversion

Commonly assume 5 measurement error and a 10
Minimally Clinically Important Difference (Weijer et al., 2003)

ES (95% CI)
Clinical Units Significant?
Single Group 1.56 (0.58, 2.54)
Two-Group 0.56 (0.18, 0.95)
Abbreviations: ES: effect size, CI: confidence interval
No

No

2.2 -9.7
1.4 -7.1
Clinical Implication

Statistically significant but not clinically significant
Dependent on type of population
Longer treatment duration

MET should be trialed
Statistically significant
Trends toward 10 MCID
Low cost
Money
Time
Low risk of harm

Recommended
Parameters
MVIC: 40-75%
Contraction Time: 2-3 sec
Relaxation time: 3-10 sec

*Based on qualitative analysis

Limitations
Only one primary researcher

English language

Limited # of databases, narrow search terms

Limited # of studies

Small sample sizes

Heterogeneity in qualitative aspects of study designs
Lack of standardization for MET parameters
Subjective MVIC
No studies had muscle-tendon stiffness data
Real versus apparent muscle extensibility

Directions for Further Research
Larger sample size

Standardize MET protocol

More representative population
Age
History of HS injury
Abnormal fibrous tissue & cross-linkages

Longer term of treatment

Muscle-tendon stiffness data

http://scholasticadministrator.typepad.com/.a/6a00e54f8c25c9883401676355388a970b-popup
Conclusions
MET is a statistically
significant intervention at
improving HS extensibility

MET is more effective than
no treatment or alternative
treatments

Not clinically significant

Further research needed to
provide standardization and
clear guidance for the use of
MET in patients with HS
injuries

-1 0 1 2 3
Single Group
Grand Effect
Size
Two-Group
Grand Effect
Size
0.56 (0.18, 0.95)
1.56 (0.58, 2.54)
Effect Size (d)
Acknowledgements
Betty J. Smoot, PT, DPTSc
Erica A. Pitsch, PT, MPT, DPT
Diane Allen, PT, PhD
Kristine Amii, MS, DPT(c)
Aaron Chung, MS, DPT (c)
UCSF/SFSU MS-DPT class of 2012
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Questions