Awọn ilana imọ-ẹrọ Muscle: A revolution has taken place in manipulative therapy involving a movement away from high velocity/low amplitude thrusts (HVT � now commonly known as �mobilization with impulse� and characteristic of most chiropractic and, until recently, much osteopathic manipulation) towards gentler methods which take far more account of the soft tissue component (DiGiovanna 1991, Lewit 1999, Travell & Simons 1992).
Greenman (1996) states that: �Early [osteopathic] techniques did speak of muscle relaxation with soft tissue procedures, but specific manipulative approaches to muscle appear to be 20th century phenomena.� One such approach � which targets the soft tissues primarily, although it also makes a major contribution towards joint mobilization � has been termed muscle energy technique (MET) in osteopathic medicine. There are a variety of other terms used to describe this approach, the most general (and descriptively accurate) of which was that used by chiropractor Craig Liebenson (1989, 1990) when he described muscle energy techniques as �active muscular relaxation techniques�. Muscle energy techniques evolved out of osteopathic procedures developed by pioneer practitioners such as T. J. Ruddy (1961), who termed his approach �resistive duction�, and Fred Mitchell Snr (1967). As will become clear in this chapter, there also exists a commonality between Muscle energy techniques and various procedures used in orthopaedic and physiotherapy methodology, such as proprioceptive neuromuscular facilitation (PNF). Largely due to the work of experts in physical medicine such as Karel Lewit (1999), MET has evolved and been refined, and now crosses all interdisciplinary boundaries.
MET has as one of its objectives the induced relaxation of hypertonic musculature and, where�appropriate (see below), the subsequent stretching of the muscle. This objective is shared with a number of �stretching� systems, and it is necessary to examine and to compare the potential benefits and drawbacks of these various methods (see Box 1.1).
MET, gẹgẹ bi a ti gbekalẹ ninu iwe yii, o jẹ ki ọpọlọpọ awọn idagbasoke rẹ si awọn onisegun osteopathic gẹgẹbi TJ Ruddy (1961) ati Fred Mitchell Snr (1967), pẹlu awọn atunṣe to ṣẹṣẹ ti o wa lati iṣẹ awọn eniyan bii Karel Lewit (1986, 1999) ati Vladimir Janda (1989) ti atijọ Czechoslovakia, awọn mejeji ti iṣẹ rẹ ni a tọka si ọpọlọpọ igba ninu ọrọ yii.
TJ Ruddy (1961)
In the 1940s and 50s, osteopathic physician T. J. Ruddy developed a treatment method involving patient-induced, rapid, pulsating contractions against resistance which he termed �rapid resistive duction�. It was in part this work which Fred Mitchell Snr used as the basis for the evolution of MET (along with PNF methodology, see Box 1.1). Ruddy�s method called for a series of rapid, low amplitude muscle contractions against resistance, at a rate a little faster than the pulse rate. This approach is now known as pulsed MET, rather than the tongue-twisting �Ruddy�s rapid resistive duction�.
Gẹgẹbi ofin, o kere ju lakoko, awọn atẹgun ti iṣakoso ti alaisan yii ni ipa kan si idena, lilo awọn alatako si awọn ẹya kukuru. Eyi le ṣee lo ni gbogbo awọn agbegbe ti awọn ilana ilana imuduro isanmọ ti o ni ihamọ ti yẹ, o wulo fun itọju ara ẹni, tẹle itọnisọna lati ọdọ oniṣẹ oye. Ruddy ni imọran pe awọn ipa naa ni iṣelọpọ ti atẹgun ti agbegbe, ayanfẹ ati ọti-ẹjẹ, bi daradara bi ipa rere lori ipolowo ati ailera, nitori awọn ipa lori awọn ọna ipa-ọna ti ara ati awọn ibaraẹnisọrọ.
Ruddy�s work formed part of the base on which Mitchell Snr and others constructed MET and aspects of its clinical application are described in Chapter 3.
Fred Mitchell Snr
No single individual was alone responsible for MET, but its inception into osteopathic work must be credited to F. L. Mitchell Snr, in 1958. Since then his son F. Mitchell Jnr (Mitchell et al 1979) and many others have evolved a highly sophisticated system of manipulative methods (F. Mitchell Jnr, tutorial on biomechanical procedures, American Academy of Osteopathy, 1976) in which the patient �uses his/her muscles, on request, from a precisely controlled position in a specific direction, against a distinctly executed counterforce�.
Philip Greenman
Ọjọgbọn ọjọgbọn biochemistry Philip Greenman (1996) sọ pe:
Awọn iṣẹ ti eyikeyi ifarahan ti ara ti o le wa ni gbe nipasẹ iṣẹ iyọọda ẹda, boya ni taara tabi ni itọka, le ni ipa nipasẹ awọn ilana agbara agbara .... Agbara awọn imuposi agbara agbara le ṣee lo lati mu fifọ pọ, itọju tabi isan spastic; lati ṣe okunkun iṣan ti iṣan ti iṣan-ara-ara tabi ẹgbẹ ti awọn iṣan; lati din edema ti a ti wa ni agbegbe, lati ṣe iranlọwọ fun idaduro pajawiri, ati lati ṣe idaniloju ifarahan pẹlu iṣesi idiwọn.
Sandra Yale
Osteopathic physician Sandra Yale (in DiGiovanna 1991) extols MET�s potential in even fragile and severely ill patients:
Muscle awọn imuposi agbara ni o munadoko julọ ni awọn alaisan ti o ni irora nla lati ibanujẹ nla ti o tobi, gẹgẹbi awọn ti o ni ipalara ikọlu lati ijamba ọkọ ayọkẹlẹ kan, tabi alaisan kan pẹlu isan iṣan to lagbara lati isubu. Awọn ọna MET tun jẹ itọju itọju ti o dara julọ fun awọn alaisan tabi awọn bedridden alaisan. Wọn le ṣee lo ninu awọn alaisan ti o dagba ti o le ni ipalara iṣeduro lati inu ẹjẹ, tabi ti o ni egungun osteoporotic brittle.
Lara awọn ile-iṣẹ MET pataki jẹ Edward Stiles, ti o ṣe alaye lori akori ti awọn ohun elo MET ti o wa ni ọpọlọpọ (Stiles 1984a, 1984b). O sọ pe:
Awọn imọ-ìmọ imọ-ipilẹ ti o ni imọran ọna eto egungun yoo ṣe ipa pataki ninu iṣẹ awọn ọna miiran. Iwadi ṣe afihan pe awọn ẹya ti o ni nkan pataki ati awọn oju eeya ti o ni ipa ti o ni ipa kan le ni ipa lori ara wọn taara, nipasẹ awọn oju-ọna awọn oju-iwe ti awọn oju-ọna ati awọn iṣan-ara ti aarin. Dysfunction alakikan le ṣe alekun awọn ibeere ti agbara, ati pe o le ni ipa lori orisirisi awọn ilana ọna ara; iṣakoso vasomotor, awọn ilana fifun ara eegun (ni iṣeduro), iṣan axionic ti awọn ọlọjẹ neurotrophic, ẹlẹdun ati ọti-ẹjẹ ati pipin fọọmu. Ipa ti aifọkanbalẹ aifọwọyi lori orisirisi awọn akojọpọ ti awọn iṣẹ wọnyi le ni nkan ṣe pẹlu awọn aami aisan ati awọn ami. Aṣeyọṣe ti o le ṣafikun fun diẹ ninu awọn itọju ilera ti a woye ti ifọwọyi.
As to the methods of manipulation he now uses clinically, Stiles states that he employs muscle energy methods on about 80% of his patients, and functional techniques (such as strain/counterstrain) on 15�20%. He uses high velocity thrusts on very few cases. The most useful manipulative tool available is, he maintains, muscle energy techniques.
J. Goodridge ati W. Kuchera
Modern osteopathic refinements of MET � for example the emphasis on very light contractions which has strongly influenced this text � owe much to physicians such as John Goodridge and William Kuchera, who consider that (Goodridge & Kuchera 1997):
Agbegbe ti agbara jẹ diẹ pataki ju kikankikan lọ. Agbejade da lori imọran ti ara ẹni ti ara ẹni (tabi idaniloju si ronu) ni tabi nipa ifọkansi kan pato .... Ibojuwo ati awọn agbara ti o ni idapọ si ẹgbẹ iṣan tabi ipele ti aifọkanbalẹ aifọkanbalẹ lowo jẹ pataki fun ṣiṣe awọn ayipada to ṣe pataki. Awọn abajade ti ko dara julọ ni ọpọlọpọ igba nitori awọn ala-ilẹ ti ko yẹ, nigbagbogbo pẹlu iṣoro alaisan ti o pọju.
Awọn akoonu
MET ti wa ni idiwọ jade ninu atọwọdọwọ osteopathic, biotilejepe iṣeduro iṣeduro ti awọn ọna itọju, ti o ni idinku ati isunmọ ti isometric, n waye ni alailẹgbẹ ni itọju ailera, ti a npe ni PNF (wo apoti 1.1).
Fred Mitchell Snr (1958) quoted the words of the developer of osteopathy, Andrew Taylor Still: �The attempt to restore joint integrity before soothingly restoring muscle and ligamentous normality was putting the cart before the horse.� As stated earlier, Mitchell�s work drew on the methods developed by Ruddy; however, it is unclear whether Mitchell Snr, when he was refining MET methodology in the early 1950s, had any awareness of proprioceptive neuromuscular facilitation (PNF), a method which had been developed a few years earlier, in the late 1940s, in a physical therapy context (Knott & Voss 1968).
Ọna PNF tọju lati ṣe pataki fun awọn ẹya ara ẹrọ iyipo ninu iṣẹ awọn isẹpo ati awọn isan, o si ti lo awọn wọnyi nipa lilo awọn agbara ti isodi, ti o ni ipapọ pẹlu awọn iyatọ ti o lagbara pupọ. Ni ibẹrẹ, ifojusi ti PNF ṣe afiwe si okunkun ti iṣan ti iṣan ti ko ni iṣan, pẹlu ifojusi si tuṣiparọ isọdi ti iṣan lẹhin atẹhin lati eyi, ati lati mu ki iṣeduro iṣipopada ti o wa ni ipele intervertebral (Kabat 1959, Levine et al 1954) (wo Apoti 1.1).
Oro ti a lo pupọ ni awọn iṣẹlẹ ti o ṣẹṣẹ sii si awọn imudani agbara agbara jẹ itọju idaraya postisometric (PIR), paapaa ni ibatan si iṣẹ Karel Lewit (1999). Oro akoko isinmi postisometric ntokasi si ipa ti idinku diẹ ninu ohun ti o ni irun, tabi ẹgbẹ ti awọn isan, lẹhin awọn akoko kukuru nigba ti a ti ṣe itọku isometric.
The terms proprioceptive neuromuscular facilitation (PNF) and postisometric relaxation (PIR) (the latent hypotonic state of a muscle following isometric activity) therefore represent variations on the same theme. A further variation involves the physiological response of the antagonists of a muscle which has been isometrically contracted � reciprocal inhibition (RI).
Nigba ti a ba ti gba iṣan ni isometrically, a yoo gba oludaniloju rẹ kuro, yoo si ṣe afihan ohun orin dinku lẹsẹkẹsẹ tẹle eyi. Bayi ni alakikanju ti iṣan ti a ti kuru, tabi ẹgbẹ ti awọn isan, le ni isometrically ṣe adehun lati ṣe atẹle idiwọn ti irora ati afikun ipa iṣoro ninu awọn ti o dinku.
Sandra Yale (in DiGiovanna 1991) acknowledges that, apart from the well understood processes of reciprocal inhibition, the precise reasons for the effectiveness of MET remain unclear � although in achieving PIR the effect of a sustained contraction on the Golgi tendon organs seems pivotal, since their response to such a contraction seems to be to set the tendon and the muscle to a new length by inhibiting it (Moritan 1987). Other variations on this same theme include �hold�relax� and �contract�relax� techniques (see Box 1.1).
Lewit & Simons (1984) gba pe lakoko idinamọ iyipada jẹ ifosiwewe ni diẹ ninu awọn ọna ti itọju ti o ni ibatan si awọn imọ-ẹrọ isinmi postisometric, kii ṣe ifosiwewe ni PIR funrararẹ, eyiti o jẹ iyalẹnu ti o waye lati inu iṣan ti iṣan, boya eyiti o kan awọn ẹya ara eegun (wo ọpọtọ 1.1 ati 1.2).
Awọn aaye meji si MRT [ie MET nipasẹ orukọ miiran] ni agbara wọn lati ṣe isinmi iṣan ti o ni inu didun ... ati agbara wọn lati mu isan ti ẹran ara ti o kuru tabi awọn nkan ti o ni ibatan pọ si nigba ti awọn asopọ ti a fi ara tabi ayipada viscoelastic ti ṣẹlẹ.
Awọn akọsilẹ meji ti o ni imọran ti neurophysiological fun aifọwọyi neuromuscular eyiti o waye lakoko lilo awọn ilana wọnyi. Ni akọkọ jẹ idena idọnkuro [tun mọ bi isinmi postisometric, tabi PIR], eyi ti o sọ pe lẹhin igbati a ti gba isanmọ, o jẹ laifọwọyi ni ipo isinmi fun akoko kukuru kan, latent, akoko. Keji jẹ ihamọ imudaniloju (RI) eyi ti o sọ pe nigbati a ba gba iṣan kan, o ti gba oludaniloju rẹ laifọwọyi.
Liebenson ni imọran pe o wa ni ẹri pe awọn olugbawo lodidi fun PIR wa laarin isan ati kii ṣe ninu awọ ara tabi awọn isẹpo (Robinson 1982).
Where pain of an acute or chronic nature makes controlled contraction of the muscles involved difficult, the therapeutic use of the antagonists can patently be of value. Thus modern MET incorporates both postisometric relaxation and reciprocal inhibition methods, as well as aspects unique to itself, such as isokinetic techniques, described later.
Ọpọlọpọ awọn oluwadi, pẹlu Karel Lewit ti Prague (Lewit 1999), ti sọ lori abalo awọn aaye ti MET ni itọju awọn okunfa okunfa, ati eyi ni ọpọlọpọ eniyan rii lati jẹ ọna ti o dara julọ lati ṣe itọju awọn ipinlẹ mofascial yii, ati ti ṣe aṣeyọri imunrada ti ipo kan nibi ti iṣan ninu eyiti awọn ẹtan eke naa jẹ agbara siwaju sii lati ṣe igbadun ipari gigun rẹ, laisi ẹri ti kikuru.
Travell & Simons (1992) mistakenly credited Lewit with developing MET, stating that �The concept of applying post-isometric relaxation in the treatment of myofascial pain was presented for the first time in a North American journal in 1984 [by Lewit]�. In fact Mitchell Snr had described the method some 25 years previously, a fact acknowledged by Lewit (Lewit & Simons 1984).
MET methods all employ variations on a basic theme. This primarily involves the use of the patient�s own muscular efforts in one of a number of ways, usually in association with the efforts of the therapist:
1. The operator�s force may exactly match the effort of the patient (so producing an isometric contraction) allowing no movement to occur � and producing as a result a physiological neurological response (via the Golgi tendon organs) involving a combination of:
� reciprocal inhibition of the antagonist(s) of the muscle(s) being contracted, as well as
� postisometric relaxation of the muscle(s) which are being contracted.
Awọn oniyipada miiran ni a le tun ṣe, fun apẹẹrẹ ti o ni:
l Whether the contraction should commence with the muscle or joint held at the resistance barrier or short of it � a factor decided largely on the basis of the degree of chronicity or acuteness of the tissues involved
Greenman summarises the requirements for the successful use of MET in osteopathic situations as �control, balance and localisation�. His suggested basic elements of MET include the following:
Ohun ti a ṣe lẹhin ti ihamọ naa le ni eyikeyi ninu nọmba awọn oniyipada, gẹgẹ bi a ti ṣe alaye.
The essence of MET then is that it uses the energy of the patient, and that it may be employed in one or other of the manners described above with any combination of variables depending upon the particular needs of the case. Goodridge (one of the first osteopaths to train with Mitchell Snr in 1970) summarises as follows: �Good results [with MET] depend on accurate diagnosis, appropriate levels of force, and sufficient localization. Poor results are most often caused by inaccurate diagnosis, improperly localized forces, or forces that are too strong� (Goodridge & Kuchera 1997) (see also Box 1.3).
As mentioned, a critical consideration in MET, apart from degree of effort, duration and frequency of use, involves the direction in which the effort is made. This may be varied, so that the operator�s�force is directed towards overcoming the restrictive barrier (created by a shortened muscle, restricted joint, etc.); or indeed opposite forces may be used, in which the operator�s counter-effort is directed away from the barrier.
Agbegbe gbogbogbo wa laarin awọn oniṣiṣiriṣi oṣoogun osteopathic ti sọ tẹlẹ pe lilo isinmi postisometric jẹ diẹ wulo ju idinku irọwọ ni ifarada iṣan ti musẹmu. Eyi, sibẹsibẹ, ko ni gbogbo igba lati jẹ ọran naa nipasẹ awọn amoye bi Lewit ati Janda, ti wọn wo awọn ipa pataki fun iyipada iyipada irọwọ.
Osteopathic clinicians such as Stiles and Greenman believe that the muscle which requires stretching (the agonist) should be the main source of �energy� for the isometric contraction, and suggest that this achieves a more significant degree of relaxation, and so a more useful ability to subsequently stretch the muscle, than would be the case were the relaxation effect being achieved via use of the antagonist (i.e. using reciprocal inhibition).
Following on from an isometric contraction � whether agonist or antagonist is being used � there is a refractory, or latency, period of approximately 15 seconds during which there can be an easier (due to reduced tone) movement towards the new position (new resistance barrier) of a joint or muscle.
Liebenson (1989, 1990) ṣe apejuwe awọn iyatọ mẹta ti Awọn Lewit ati Janda lo pẹlu bakannaa nipasẹ ara rẹ ni chiropractic eto atunṣe.
Lewit�s (1999) modification of MET, which he calls postisometric relaxation, is directed towards relaxation of hypertonic muscle, especially if this relates to reflex contraction or the involvement of myofascial trigger points. Liebenson (1996) notes that �this is also a suitable method for joint mobilisation when a thrust is not desirable�.
Lewit�s postisometric relaxation method
(Lewit 1999)
The key elements in this approach, as in most MET, involve precise positioning, as well as taking out slack and using the barrier as the starting and ending points of each contraction.
Karel Lewit, jiroro awọn ọna MET (Lewit 1999), sọ pe idinadura igba otutu ko ni agbara lati ṣe alaye iṣẹ wọn. O ṣe akiyesi pe awọn esi ti a le ṣafọsẹ ti a gba le ṣe afiwe si awọn otitọ wọnyi:
O pinnu pe ọna yii ṣe afihan asopọ ti o wa laarin ẹdọfu ati irora, ati laarin isinmi ati aibaya.
Lilo awọn oju oju bi apakan ti ọna naa da lori iwadi nipasẹ Gaymans (1980) eyi ti o tọka si, fun apẹẹrẹ, pe irun ti ni ilọsiwaju nipasẹ alaisan ti n wo isalẹ, ati afikun nipasẹ alaisan ti n wo oke. Bakannaa, iṣeduro ti a ti ṣetan nipasẹ wiwa si ẹgbẹ ti o wa pẹlu. Awọn idii wọnyi ni a ṣe afihan nipasẹ iṣaro-ara ẹni: igbiyanju lati rọ okun ẹhin naa nigba ti o nmu oju ni oke (si iwaju) ọna itọsọna to wa ni ilọsiwaju ju aṣeyọri ti a ṣe lati rọra nigbati o n wo isalẹ. Awọn ohun elo idari oju-ara wa tun wulo ni ifọwọyi ti awọn isẹpo.
Awọn ipa ti awọn imuposi agbara agbara
Lewit (1999) discusses the element of passive muscular stretch in MET and maintains that this factor does not always seem to be essential. In some areas, self-treatment, using gravity as the resistance factor, is effective, and such cases sometimes involve no element of stretch of the muscles in question. Stretching of muscles during MET, according to Lewit (1999), is only required when contracture due to fibrotic change has occurred, and is not necessary if there is simply a disturbance in function. He quotes results in one series of patients in his own clinic in which 351 painful muscle groups, or muscle attachments, were treated by MET (using postisometric�isinmi) ni awọn alaisan 244. A ṣe ayẹwo lẹsẹkẹsẹ lẹsẹkẹsẹ ni awọn iṣẹlẹ 330 ati pe ko si ipa ni awọn iṣẹlẹ 21 nikan. Awọn wọnyi ni awọn abajade iyanu julọ nipasẹ awọn ipolowo eyikeyi.
Lewit suggests, as do many others, that trigger points and �fibrositic� changes in muscle will often disappear after MET contraction methods. He further suggests that referred local pain points, resulting from problems elsewhere, will also disappear more effectively than where local anaesthesia or needling (acupuncture) methods are employed.
Janda�s postfacilitation stretch method
Janda�s variation on this approach (Janda 1993), known as �postfacilitation stretch�, uses a different starting position for the contraction and also a far stronger isometric contraction than that suggested by Lewit and most osteopathic users of Muscle energy techniques:
Diẹ ninu awọn imọran ti igbadun ati ailera le wa ni ifojusọna fun igba diẹ nigba ti o tẹle itọsọna yii diẹ sii.
Iyipada iyipada ti o ni idaniloju
Ọna yii, eyiti o ṣe ẹya paati ti ilana PNF (wo Apoti 1.1) ati Awọn imuposi agbara Muscle, ni lilo akọkọ ni awọn eto nla, nibiti ibajẹ ti ara tabi irora ṣe idiwọ lilo ihamọ agonist ti o wọpọ, ati bakanna bi afikun si iru awọn ọna, nigbagbogbo lati pari lẹsẹsẹ ti awọn isan ohunkohun ti a ti lo awọn ọna miiran ti MET (Evjenth & Hamberg 1984):
Liebenson notes that �a resisted isotonic effort towards the barrier is an excellent way in which to facilitate afferent pathways at the conclusion of treatment with active muscular relaxation techniques or an adjustment (joint). This can help reprogram muscle and joint proprioceptors and thus re-educate movement patterns.� (See Box 1.2.)
Iyipada iyatọ
Another major muscle energy variation is to use what has been called isokinetic contraction (also known as progressive resisted exercise). In this the patient starts with a weak effort but rapidly progresses to a maximal contraction of the affected muscle(s), introducing a degree of resistance to the operator�s effort to put the joint, or area, through a full range of motion. The use of isokinetic contraction is reported to be a most effective method of building strength, and to be superior to high repetition, lower resistance exercises (Blood 1980). It is also felt that a limited range of motion, with good muscle tone, is preferable (to the patient) to having a normal range with limited power. Thus the strengthening of weak musculature in areas of permanent limitation of mobility is seen as�iṣiro pataki kan ninu eyiti awọn isinmi-ara ti o wa ni danti ṣe iranlọwọ.
Awọn iyatọ ti Isokineti kii ṣe okunkun nikan awọn okun ti o ni ipa, ṣugbọn tun ni ipa ikẹkọ ti o jẹ ki wọn ṣiṣẹ ni ọna ti o ni iṣọkan. Igbesi agbara pupọ ni kiakia. Nitori iṣeduro ti neuromuscular, iṣesi iṣoro ti iṣoro lagbara diẹ sii bi ọna yii ṣe tun. Awọn iyatọ ti Isokinetti, ati pẹlu sisọpọ ti agbegbe, ko yẹ ki o to ju 4 aaya ni ihamọ kọọkan lati le ni anfani ti o pọju pẹlu bi o ti ṣee ṣe, boya ti alaisan tabi oniṣẹ. Awọn ihamọ to yẹ yẹ ki o yee. Awọn ọna ti o rọrun julọ, ti o ni aabo, ati ti o rọrun julọ lati ṣakoso awọn ọna awọn ọna danitimu jẹ awọn isẹpo kekere, gẹgẹbi awọn ti o wa ninu awọn igun. Awọn isẹpo ọpa le jẹ irọra sii lati ṣakoye lakoko ti o ti ni kikun si ipa ti o ni iṣan.
Awọn aṣayan ti o wa ni ṣiṣe aṣeyọri agbara nipasẹ awọn ọna wọnyi jẹ ki o yan laarin boya ihamọ isotonic kan ti a koju, tabi aṣeyọri iru ihamọ naa, ni akoko kanna bi iṣiro ti o wa ni kikun ti a ṣe (akiyesi pe awọn concentric isotonic ati awọn iyatọ ti o wa ni ihamọ yoo waye nigba akoko isokinetic ti apapọ). Meji awọn aṣayan wọnyi yẹ ki o jẹ ihamọ to pọju awọn isan nipasẹ alaisan. Itọju ile ti iru ipo bẹẹ ṣee ṣe, nipasẹ itọju ara-ẹni, bi ninu awọn ọna MET miiran.
Another application of the use of isotonic contraction occurs when a direct contraction is resisted and overcome by the operator (Fig. 1.4). This has been termed isolytic contraction, in that it involves the stretching, and sometimes the breaking down, of fibrotic tissue present in the affected muscles. Adhesions of this type are reduced by the application of force by the operator which is just greater than that being exerted by the patient. This procedure can be uncomfortable, and the patient should be advised of this. Limited degrees of effort are therefore called for at the outset of isolytic contractions. This is an isotonic eccentric contraction, in that the origins and insertions of the muscles involved will become further separated, despite the patient�s effort to approximate them. In order to achieve the greatest degree of stretch (in the condition of myofascial fibrosis, for example), it is necessary for the largest number of fibers possible to be involved in the isotonic contraction. Thus there is a contradiction in that, in order to achieve this large involvement, the degree of contraction should be a maximal one, and yet this is likely to produce pain, which is contraindicated. It may also, in many instances, be impossible for the operator to overcome.
The patient should be instructed to use about 20% of possible strength on the first contraction, which is resisted and overcome by the operator, in a contraction lasting 3�4 seconds. This is then repeated, but with an increased degree of effort on the part of the patient (assuming the first effort was relatively painless). This continuing increase in the amount of force employed in the contracting musculature may be continued until, hopefully, a maximum contraction effort is possible, again to be overcome by the operator. In some muscles, of course, this may require a heroic degree of effort on the part of the operator, and alternative methods are therefore desirable. Deep tissue techniques, such as neuromuscular technique, would seem to offer such an alternative. The isolytic manoeuvre should have as its ultimate aim a fully relaxed muscle, although this will not always be possible.
Iwe kan ninu Iwe akosile ti Royal Society of Medicine (Royal Society of Medicine 1983) nṣe apejuwe awọn iyipada ti o wa ni asopọ:
Ogbo yoo ni ipa lori iṣẹ ti awọn apapo asopọ diẹ sii kedere ju fere eyikeyi eto eto ara eniyan. Awọn fibrils ti Collagen ṣe nipọn, ati iye ti simẹnti polymer ti a tuka. Awọn ẹyin ti o ni asopọ ti o ni asopọ pọ lati kọ silẹ ni nọmba, o si ku si pa. Awọn ọkọ ayọkẹlẹ ti dinku diẹ si rirọ, ati pe awọn ti o ṣe iranlọwọ fun awọn proteoglycans yi pada ni iwọnpo ati qualitatively. Awọn ibeere ti o niye ni ọpọlọpọ awọn ọna ṣiṣe yii jẹ deede, ti o ṣe ifamọra ati ni aifọwọyi, ni ikọja ojuami ti wọn wulo? Ṣe idena ti awọn ogbologbo, ninu awọn ibaraẹnisọrọ asopọ, tumọ si ifaro ti agbelebu ti o so pọ ni awọn fibrils collagen, ati iṣesi diẹ ti iṣelọpọ ti proteoglycan chondroitin sulphate?
Awọn ipa ti awọn orisirisi awọ asọmu ti o sunmọ bi NMT ati Awọn isẹ agbara agbara yoo ni ipa taara lori awọn tisọsi wọnyi bakannaa lori sisan ati idẹruba ti awọn ẹya ti a fọwọkan, eyiti o ṣe afihan pe ilana igbimọ ti le ni ipa. Iparun awọn fibril ti collagen, sibẹsibẹ, jẹ ọrọ pataki (fun apẹẹrẹ nigbati o ba nlo awọn ọna isolytic), ati biotilejepe a le rọpo awọ ti fibrous ni ilana iwosan, ṣiṣe iṣelọpọ-ara ṣe ṣeeṣe, eyi si jẹ ki atunṣe ti dinku si awọn ohun ti o wa tẹlẹ , mejeeji ni awọn iṣẹ iṣẹ ati awọn ilana. Iyatọ ti isolytic ni agbara lati fọ awọn ohun elo ti o ni kukuru, awọn ohun ti o kuru ati pe awọn gbigbe pẹlu awọn ohun elo ti o ga julọ yoo dale, si iwọn nla, lori lilo ti agbegbe naa (idaraya, ati bẹbẹ lọ), ati ipo ti ajẹsara ti ẹni kọọkan. Ilana ikẹkọ ti gbẹkẹle lori Vitamin C daradara, ati ipese amino acids to pọju bii proline, hydroxyproline ati arginine. Ifọwọyi, eyiti o ni imọran si atunṣe atunṣe ti iwuwọn ni awọn ẹya asopọ pọ, o yẹ ki o jẹ kiyesi akiyesi awọn ibeere to dara.
The range of choices in stretching, irrespective of the form of prelude to this � strong or mild isometric contraction, starting at or short of the barrier � therefore covers the spectrum from all- passive to all-active, with many variables in between.
Many may prefer to use the variations, as described above, within individual settings. The recommendation of this text, however, is that they should be �mixed and matched� so that elements of all of them may be used in any given setting, as appropriate. Lewit�s (1999) approach seems ideal for more acute and less chronic conditions, while Janda�s (1989) more vigorous methods seem�apẹrẹ fun awọn alaisan alaisan pẹlu iṣan onibaje kikuru.
Muscle energy techniques offers a spectrum of approaches which range from those involving hardly any active contraction at all, relying on the extreme gentleness of mild isometric contractions induced by breath-holding and eye movements only, all the way to the other extreme of full-blooded, total- strength contractions. Subsequent to isometric contractions � whether strong or mild � there is an equally sensitive range of choices, involving either energetic stretching or very gentle movement to a new restriction. We can see why Sandra Yale (in DiGiovanna 1991) speaks of the usefulness of MET in treating extremely ill patients.
Many patients present with a combination of recent dysfunction (acute in terms of time, if not in degree of pain or dysfunction) overlaid on chronic changes which have set the scene for their acute current problems. It seems perfectly appropriate to use methods which will deal gently with hypertonicity, and more vigorous methods which will help to resolve fibrotic change, in the same patient, at the same time, using different variations on the theme of MET. Other variables can be used which focus on joint restriction, or which utilise RI should conditions be too sensitive to allow PIR methods, or variations on Janda�s more vigorous stretch methods (see Box 1.1).
Ijiroro nipa awọn aṣiṣe ti o wọpọ ni lilo awọn ilana agbara agbara Muscle yoo ṣe iranlọwọ lati ṣe alaye awọn ero wọnyi.
Awọn abajade ti ko lagbara lati lilo awọn ilana agbara agbara Muscle le ṣe afihan si ailagbara lati wa iṣeduro iṣan ti o to, niwon ayafi ti iṣan iyọ agbegbe ti a ṣe ni agbegbe to wa ni aifọwọyi ti ailera, ọna ṣee ṣe lati kuna awọn afojusun rẹ. Pẹlupẹlu, dajudaju awọn ayipada ti iṣan ti ajẹsara le ti waye, ni awọn isẹpo tabi ni ibomiiran, eyi ti o ṣe iru ọna itọju kukuru nikan, nitori iru awọn ayipada yoo rii daju pe awọn igbasilẹ ti iṣan, nigbamii fere lẹsẹkẹsẹ.
MET yoo jẹ doko, tabi fa irritation, ti o ba lo agbara ti o pọ julọ ni boya ihamọ itusẹ tabi apakan alakoso.
Awọn bọtini lati ṣe aṣeyọri ohun elo Awọn isẹ agbara agbara nitorina ni o wa ni ifojusi ikọkọ ti iṣeduro iṣan, pẹlu ipele ti o yẹ fun igbiyanju ti a lo ninu itọku isometric, fun akoko to gun deede, tẹle itọju ailewu nipasẹ iṣena ihamọ iṣaaju, nigbagbogbo pẹlu iranlọwọ alaisan.
Use of variations such as stretching chronic fibrotic conditions following an isometric contraction and use of the integrated approach (INIT) mentioned earlier in this chapter represent two examples of further adaptations of Lewit�s basic approach which, as described above, is ideal for acute situations of spasm and pain.
Marvin Solit (1963), a former pupil of Ida Rolf, describes a common error in application of Muscle energy techniques � treating the �wrong� muscles the �wrong� way:
As one looks at a patient�s protruding abdomen, one might think that the abdominal muscles are weak, and that treatment should be geared towards strengthening them. By palpating the abdomen, however, one would not feel flabby, atonic muscles which would be the evidence of weakness; rather, the muscles are tight, bunched and shortened. This should not be surprising because here is an example of muscle working overtime maintaining body equilibrium. In addition these muscles are supporting the sagging viscera, which normally would be supported by their individual ligaments. As�awọn iṣan inu ti wa ni ominira o si ni gigun, nibẹ ni igbega gbogbogbo ti ẹdọ-ẹdọ-oju-ọrun, eyi ti o ṣe igbiyanju ori ati ọrun.
Attention to tightening and hardening these supposedly weak muscles via exercise, observes Solit, results in no improvement in posture, and no reduction in the �pot-bellied� appearance. Rather, the effect is to further depress the thoracic structures, since the attachments of the abdominal muscles, superiorly, are largely onto the relatively mobile, and unstable, bones of the rib cage. Shortening these muscles simply achieves a degree of pull on these structures towards the stable pelvic attachments below.
Imọna si iṣoro yii ti Rolfers gba lati jẹ ọfẹ ati lati ṣii awọn wọnyi ti o ti koju ati pe o jẹ alailera nikan. Eyi fun laaye fun iyipada si diẹ ninu awọn idiwọn, ti o yọ awọn ẹya ẹhin ẹhin ara ti o ni ẹhin, ti o si ṣe atunṣe aifọwọyi ti ile-iṣẹ. Fiyesi si awọn kukuru kukuru, ti o nira lile, eyi ti yoo tun ni idiwọ awọn iṣan ara wọn, o yẹ ki o jẹ aimọ akọkọ. Idaraya ko dara ni ibẹrẹ, ṣaaju ki o to idojukọ akọkọ yii.
The common tendency in some schools of therapy to encourage the strengthening of weakened muscle groups in order to normalise postural and functional problems is also discussed by Vladimir Janda (1978). He expresses the reasons why this approach is �putting the cart before the horse�: �In pathogenesis, as well as in treatment of muscle imbalance and back problems, tight muscles play a more important, and perhaps even primary, role in comparison to weak muscles� (Fig. 1.5). He continues with the following observation:
Clinical experience, and especially therapeutic results, support the assumption that (according to Sherrington�s law of reciprocal innervation) tight muscles act in an inhibitory way on their antagonists. Therefore, it does not seem reasonable to start with strengthening of the weakened muscles, as most exercise programmes do. It has been clinically proved that it is better to stretch tight muscles first. It is not exceptional that, after stretching of the tight muscles, the strength of the weakened antagonists improves spontaneously, sometimes immediately, sometimes within a few days, without any additional treatment.
Eyi ti o ni imọran, ti o ni idiyele, iṣeduro ati ijinle sayensi, eyi ti o ṣalaye ifojusi wa ati awọn igbiyanju si ilọlẹ ati iṣeduro ti awọn iru ti o ni kukuru ati ti o rọ, o dabi pe a ko ni idiyele, ati pe akori yii yoo tẹle siwaju ni Orilẹ 2.
Awọn ọna ti fisioloji ti awọn iṣan ati awọn tendoni ni o yẹ fun ìyí ti atunyẹwo, ni bii awọn ilana agbara agbara Muscle ati awọn ipa rẹ (wo tun 1.5 apoti). Ohun orin ti iṣan jẹ iṣẹ-ṣiṣe ti ara-ara tendoni Golgi. Awọn wọnyi n wo ẹrù ti a lo si tendoni, nipasẹ ihamọ ti iṣan. Awọn abajade ti o ni imọran, ninu awọn isan ti o yẹ, ni abajade ti alaye yii ti o ti kọja lati inu ohun ara Golgi tendoni pada pẹlu okun. Ẹrọ awoṣe jẹ ọkan ti o lodi, o si yato si iyọda iṣan ti iṣan. Sandler (1983) ṣe apejuwe diẹ ninu awọn ilana ti o ni:
Nigba ti ẹdọfu lori awọn iṣan, ati nihinyi tendoni naa, di iwọn, ipa ti ko ni idiwọ lati ara-ara tendoni le jẹ nla pe isinmi lojiji ti gbogbo isan labẹ isanwo. Ipa yii ni a npe ni ilọsiwaju gigun, ati pe o jẹ ailewu idaabobo si ipa ti, ti a ba pa, le fa irun tendoni kuro lati awọn asomọ asomọ rẹ. Niwon awọn ara tendoni Golgi, laisi awọn ami [iṣan], wa ni awọn ọna pẹlu awọn iṣọn iṣan, wọn ni ifunni nipasẹ awọn mejeeji ti o kọja ati awọn ihamọ lọwọ ti awọn isan.
Pointing out that muscles can either contract with constant length and varied tone (isometrically), or with constant tone and varied length (isotonically), he continues: �In the same way as the gamma efferent system operates as a feedback to control the length of muscle fibers, the tendon reflex serves as a reflex to control the muscle tone�.
In terms of longitudinal soft tissue massage, these organs are very interesting indeed, and it is perhaps the reason why articulation of a joint, passively, to stretch the tendons that pass over the joint, is often as effective in relaxing the soft tissues as direct massage of the muscles themselves. Indeed, in some cases, where the muscle is actively in spasm, and is likely to object to being pummelled directly, articulation, muscle energy techniques, or functional balance techniques, that make use of the tendon organ reflexes, can be most effective.
The use of this knowledge in therapy is obvious and Sandler explains part of the effect of massage on muscle: �The [muscle] spindle and its reflex connections constitute a feedback device which can�ṣiṣẹ lati ṣetọju igbasilẹ isan, bi ninu ipolowo; if the muscle is stretched the spindle discharges increase, but if the muscle is shortened, without a change in the rate of gamma discharge, then the spindle discharge will decrease, and the muscle will relax.�
Sandler gbagbo pe awọn itọju imunni nfa idiwọn diẹ ninu ifamọ ti gamma efmma, ati bayi mu ipari awọn okun iṣan dipo ju kukuru diẹ si wọn; Eyi n ṣe awọn ti o fẹ isinmi ti isan. Awọn iṣeduro agbara agbara n pese fun agbara lati ni ipa mejeeji awọn isan iṣan ati awọn ẹya ara iṣan Golgi.
Bourdillon (1982) tells us that shortening of muscle seems to be a self-perpetuating phenomenon which results from an over-reaction of the gamma-neuron system. It seems that the muscle is incapable of returning to a normal resting length as long as this continues. While the effective length of the muscle is thus shortened, it is nevertheless capable of shortening further. The pain factor seems related to the muscle�s inability thereafter to be restored to its anatomically desirable length. The conclusion is that much joint restriction is a result of muscular tightness and shortening. The opposite may also apply where damage to the soft or hard tissues of a joint is a factor. In such cases the periarticular and osteophytic changes, all too apparent in degenerative conditions, are the major limiting factor in joint restrictions. In both situations, however, Muscle energy techniques may be useful, although more useful where muscle shortening is the primary factor.
Idinidii ti o waye ni abajade ti o nira, awọn isan kukuru ti wa ni deede pẹlu pẹlu diẹ ninu awọn ipele ti gigun ati imuna awọn alakoso. Ọpọlọpọ awọn orisirisi awọn permutations ti o ṣee ṣe wa ni ipo eyikeyi ti a fun ni eyiti o ni itọsẹ ti iṣan ti o le bẹrẹ, tabi jẹ atẹle si, iṣiro apapọ ti o dara pọ pẹlu ailera ti awọn antagonists. Ajọpọ awọn ọna isometric ati ọna isotoni yoo le ṣe oojọ lati mu ki o gbooro ati ki o na awọn ẹgbẹ ti o kuru, ati lati ṣe okunkun ati lati dinku awọn alailera, awọn iṣan to gaju.
Paul Williams (1965) sọ ọrọ ti o jẹ pataki ti eyiti awọn iṣẹ-iṣe ti o ni ibamu pẹlu aiṣedede iṣan ti ẹran-ara jẹ igbagbe nigbagbogbo:
Itọju ilera eyikeyi isẹpo jẹ igbẹkẹle lori idiwọn ni agbara awọn iṣan arata. Ti o ba fun idi kan, ẹgbẹ ti o ni pipin npadanu apakan, tabi gbogbo iṣẹ rẹ, ẹgbẹ ẹgbẹ ẹgbẹta ti o lodi si yoo fa igbẹpọ pọ si ipo ti a ti fi ara rẹ pamọ, pẹlu itọju ajeji lori awọn asopọ apapọ. Ipo yii wa ni opo ti lumbar ti eniyan igbalode.
Laisi ifojusi si awọn ẹya ara ti iṣan ti awọn isẹpo ni apapọ, ati awọn isẹpo ọpa ni pato, yoo ni abajade ninu itọju ti ko yẹ fun awọn isẹpo bayi ti o kan. Imọyeye ti o ye nipa ipa ti musculature atilẹyin yoo nigbagbogbo mu si normalization ti awọn wọnyi tissues, laisi nilo fun awọn heroic igbiyanju akitiyan. Awọn iṣoro agbara agbara ati awọn awọ miiran ti o ni irẹlẹ mu idojukọ lori awọn ẹya wọnyi ati ki o funni ni anfani lati ṣe atunṣe awọn iṣan ti o dinku ati awọn kukuru kukuru, igba otutu julọ, awọn antagonists.
Laipẹ diẹ, Norris (1999) ti ṣe akiyesi pe:
Iduroṣinṣin ati ailera ti a ri ninu ilana isanku ti iṣan alters body segment alignment ati yiyipada ipo idiyele ti apapọ. Deede deede isinmi isinmi ti agonist ati awọn isangistist muscles gba asopọ lati gbe ipo ti o ni iwontunwọnwọn nibiti awọn ipele ti o wapọ ti wa ni wiwọn deede ati awọn awọ iner ti isopọ naa ko ni idojukọ pupọ. Ṣugbọn ti o ba jẹ pe awọn iṣan ni apa kan ti isopọpọ ni o nira ati awọn isan ti o lodi si isinmi, isẹpo yoo fa jade kuro ni sisọ si iṣan ti o nira.
Iwọn sisọ iru bẹyi n mu awọn ipọnju ti o ni iwọn-ara lori awọn apapo ti opo, ati awọn esi tun ni awọn ohun elo ti o ni kukuru ti o ni iṣeduro ni igba akoko. Pẹlupẹlu iru awọn ipalara yii n mu ki iṣakoso apakan ti dinku pẹlu awọn aati ti a n ṣe ni wiwa (wo Ch. 2).
Ọpọlọpọ awọn ijinlẹ yoo wa ni alaye (Chs 5 ati 8) ti o nfihan ifarahan awọn ilana imu agbara agbara Muscle ni orisirisi awọn ẹgbẹ olugbe, pẹlu iwadi Polandii lori awọn anfani ti Awọn isẹ agbara agbara ni awọn isẹpo ti ibajẹ nipasẹ haemophilia, ati imọran Swedish lori awọn ipa ti Muscle awọn imupese agbara ni didaju aifọwọyi span lumbar, ati pẹlu iwadi Amẹrika / Czech eyiti o ni awọn iṣoro irora ti ara ẹni. Ni akọkọ, awọn abajade fihan ipo ti gbogbo agbaye ni fifi ipese tabi iderun fun awọn iṣoro bẹ nipasẹ lilo awọn ilana imudani agbara iṣan ati abo.
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Oogun 9 (9): 115 127
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Ori, Philadelphia
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Alaye ninu rẹ lori "Awọn ilana imọ-ẹrọ Muscle (MET): Ifihan"Ko ṣe ipinnu lati rọpo ibatan ọkan-si-ọkan pẹlu alamọdaju itọju ilera ti o pe tabi dokita ti o ni iwe-aṣẹ ati kii ṣe imọran iṣoogun. A gba ọ niyanju lati ṣe awọn ipinnu ilera ti o da lori iwadii ati ajọṣepọ rẹ pẹlu alamọdaju ilera ti o peye.
Alaye bulọọgi & Awọn ijiroro Dopin
Alaye wa dopin ni opin si Chiropractic, musculoskeletal, awọn oogun ti ara, ilera, idasi etiological awọn idamu viscerosomatic laarin awọn ifarahan ile-iwosan, awọn ipadaki ile-iwosan somatovisceral reflex ti o somọ, awọn eka subluxation, awọn ọran ilera ifura, ati/tabi awọn nkan oogun iṣẹ, awọn akọle, ati awọn ijiroro.
A pese ati bayi isẹgun ifowosowopo pẹlu ojogbon lati orisirisi eko. Olukọni alamọja kọọkan ni ijọba nipasẹ iwọn iṣe adaṣe wọn ati aṣẹ aṣẹ-aṣẹ wọn. A lo ilera iṣẹ-ṣiṣe & awọn ilana ilera lati tọju ati atilẹyin itọju fun awọn ipalara tabi awọn rudurudu ti eto iṣan.
Awọn fidio wa, awọn ifiweranṣẹ, awọn koko-ọrọ, awọn koko-ọrọ, ati awọn oye bo awọn ọran ile-iwosan, awọn ọran, ati awọn akọle ti o ni ibatan si ati taara tabi ni aiṣe-taara ṣe atilẹyin iwọn iṣe iṣegun wa.
Ọfiisi wa ti gbiyanju ni idiyele lati pese awọn itọka atilẹyin ati pe o ti ṣe idanimọ iwadi ti o yẹ tabi awọn ikẹkọ ti n ṣe atilẹyin awọn ifiweranṣẹ wa. A pese awọn ẹda ti awọn ẹkọ iwadii ti o ni atilẹyin ti o wa fun awọn igbimọ ofin ati gbogbo eniyan ti o ba beere.
A ye wa pe a bo awọn ọrọ ti o nilo alaye ni afikun ti bi o ṣe le ṣe iranlọwọ ninu eto itọju kan pato tabi ilana itọju; nitorina, lati jiroro siwaju si koko-ọrọ ti o wa loke, jọwọ lero ọfẹ lati beere Dokita Alex Jimenez, DC, tabi kan si wa ni 915-850-0900.
A wa nibi lati ṣe iranlọwọ fun ọ ati ẹbi rẹ.
Ibukun
Dokita Alex Jimenez D.C., MSACP, RN*, CCST, IFMCP*, CIFM*, ATN*
imeeli: ẹlẹsin@elpasofunctionalmedicine.com
Ti ni iwe-aṣẹ bi Dokita ti Chiropractic (DC) ni Texas & New Mexico*
Iwe-aṣẹ Texas DC # TX5807, New Mexico DC License # NM-DC2182
Ti ni iwe-aṣẹ bi nọọsi ti o forukọsilẹ (RN*) in Florida
Florida License RN License # RN9617241 (Iṣakoso No. 3558029)
Ipo Iwapọ: Olona-State License: Ti fun ni aṣẹ lati ṣe adaṣe ni Awọn ipinlẹ 40*
Dokita Alex Jimenez DC, MSACP, RN* CIFM*, IFMCP*, ATN*, CCST
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