The Clinical Application of

Osteopathic Manipulative Treatment Modalities

Dennis A. Burke, DO
 Objectives
Define and explain the theory of muscle
energy, counterstrain, and HVLA, including
the proposed mechanisms and physiology.
Discuss the applications, safety and efficacy
of each modality.
Discuss the typical steps involved in
performing the techniques.
Discuss the indications and contraindications
for each treatment modality.
Differentiate between direct versus indirect
technique, and active versus passive
techniques.
Muscle Energy Technique
The patient’s muscles are:
 Actively used on request,
 From a precisely controlled
position that engages the
restrictive barrier,
 In a specific direction,
 And against a precise counterforce
 Therefore, muscle energy is an
ACTIVE, DIRECT technique.
Fred Mitchell, Sr., DO developed
muscle energy technique.
 The roots of muscle energy
likely date back to Dr. Still.
 Dr. Still was known to utilize
resisted muscular contractions
during treatments.
 Student of Dr. Still, T.J. Ruddy,
DO was an ophthalmologist
that utilized patient muscular
contractions against resistance
for treatment of eye conditions.
 Muscle Energy Timeline
1940s-1950s: Mitchell develops his work
1958: Mitchell publishes his work for the first time in the
Yearbook of the American Academy of Osteopathy
1970: Mitchell gives his first 5 day course teaching other
osteopathic physicians muscle energy technique
1974: Fred Mitchell, Sr, DO dies. American Academy of
Osteopathy organizes a committee of physicians who
studied with Dr. Mitchell to start teaching faculty at the
colleges of osteopathic medicine
1974-1981: muscle energy techniques begin being taught
at osteopathic colleges
1995: Fred Mitchell, Jr, DO publishes The Muscle
Energy Manual, a 3 volume book highlighting further
refinements of the technique.
Muscle Energy-
Mechanism Involves the
Golgi Tendon Organ
Protective proprioceptor
– Responds to increased
tension in tendon, either
from contraction of skeletal
muscle or marked passive
stretch of the muscle
– Ib afferents to dorsal horn
– Inhibitory to alpha motor
neurons to relax muscles
Negative feedback mechanism prevents the
development of too much tension on the muscle by
causing muscle to relax.
from Kuchera, Osteopathic Principles in Practice
Muscle energy techniques require the
patient’s active cooperation in contracting
specific muscles.

For this reason muscle

energy cannot be used if the
patient is:
 in a coma
 uncooperative
 too young to cooperate
 unresponsive
 Unable to understand the
physician due to a language
barrier or hearing loss
 Muscle Energy
Used for both articular and muscular/myofascial
somatic dysfunctions. These can be from the
monoarticular, short restrictor muscles involved
with Type II dysfunctions, or the polyarticular,
long restrictor muscles involved in Type I
dysfunctions.
Can be useful in creating the soft tissue
relaxation necessary to accomplish HVLA
Many muscle energy and HVLA techniques are
done in the same position, so no repositioning of
the patient is required
Muscle energy techniques utilizing isometric
muscle contractions can be used to lengthen
muscles shortened by hypertonicity or
contracture.
Muscle energy techniques utilizing isokinetic
(eccentric or concentric) muscle contractions
can be used to strengthen weakened or inhibited
muscles, and improve muscle firing patterns.
Muscle energy techniques utilizing isolytic
muscle contractions can be used to stretch
 Physiologic Principles of ME

1. Post-isometric relaxation
2. Joint Mobilization using muscle force
3. Respiratory Assistance
4. Oculocephalogyric Reflex
5. Reciprocal Inhibition
6. Crossed Extensor Reflex
7. Isokinetic strengthening
8. Isolytic lengthening
9. Using muscle force to move one region
of the body to achieve movement of
another bone or region
 Typical sequence of steps using post-
isometric relaxation:
1. Diagnose joint or regional restricted motion;
2. Move the joint or region to the restrictive barrier for all planes
(localization). This has been described as the “feather edge” of the
barrier, the point where the restrictive barrier is just beginning to be
engaged;
3. Have the patient gently push away from the restrictive barrier for 3-
5 seconds against equal resistance/counterforce by physician
(isometric contraction);
4. Have the patient relax, as the physician releases his/her counterforce
simultaneously;
5. Relaxation lasts 3-5 seconds as the physician senses the tissue
relaxation;
6. Slowly move the joint or region to a new restrictive barrier (taking
up the slack)
7. Repeat the contraction and taking up the slack 3-5 times (add a good
stretch after the last contraction)
8. Re-evaluate
Joint Mobilization Using Muscle Force
Hypertonicity from somatic dysfunction tends
to compress joint surfaces and result in loss of
motion.
Isometric contractions can relax hypertonic
muscles and restore articular motion.
Respiratory assistance (rib and sacral
techniques)
The physician applies a fulcrum against which
the respiratory forces can work
Oculocephalogyric reflex
Eye movements reflexively engage the
cervical musculature to ensure the head moves
with the eyes
Also referred to as oculogyric reflex,
cephalogyric reflex, or oculocervical reflex
 Reciprocal Inhibition
Used to relax a muscle in an acute spasm,
cramp or strain, in which having this
muscle contract would be painful
Principle works via gently contracting an
agonist muscle, which will reflexively relax
the antagonist
 Crossed Extensor Reflex
 Used to affect muscles in an area that may be
severly injured, such as fractures or burns,
where manual contact with region is inadvisable
 Based on cross pattern locomotion reflexes,
patterned reflexes that cross the spine
 When a flexor in one extremity is contracted
voluntarily, the flexor in the contralateral
extremity relaxes.
 Isolytic Muscle Energy
Used for muscles that are shortened by
contracture and fibrosis.

Physician resists patient’s scalene muscle contractions while

oscillating with the fingers to suppress myotatic reflexes.
 Isokinetic Muscle Energy
Right Quadriceps are inhibited and weak from hamstring hypertonicty.
A concentric quadriceps contraction against a resistance that maintains a
constant velocity of motion (isokinetic) is used to strenghten the quadricep
and will secondarily relax the hamstrings. Can be done eccentrically as we

www.patellofemoral.org
Using muscle force to move
one region of the body in
order to achieve movement of
another bone or region.

Muscle energy treatment for an anterior sacral base

(bilaterally flexed sacrum)
There are 4 major factors that
ensure you get good results with
muscle energy technique:
 Begin with an accurate diagnosis
 Make sure appropriate levels of force
are used
Both you and the patient
This is not a wrestling match
 Allow the patient to relax between
contractions
Simultaneous relaxation by both patient
and physician
Sense the tissue relaxation with your own
proprioceptors
 Localize your treatment !
Muscle Energy
Contraindications
 Absolute:
• Lack of patient consent and/or cooperation
• Oculocephalogyric reflex techniques should not be
used in patients who recently had eye surgery or
eye trauma
• Fracture or dislocation of the involved joint
• Local malignancy or infection

 Relative:
• Inflammation, hematoma, or tear in the involved
muscle
• Rheumatologic conditions causing instability of the
cervical spine
• Undiagnosed joint swelling of involved joint
• Positioning that compromises vasculature
• Patients with low vitality (ie, post-MI patients in
CCU)
• Worsening of pain with technique
Safety, Efficacy & Application
• Muscle energy techniques are safe because
the corrective force is applied by the patient.
• If the physician can be very specific and
localized, it is extremely effective at
reducing both articular and myofascial
dysfunctions. Efficacy will be lost if
contractions are too forceful, and physician
and patient don’t relax at the same time.
• Too vigorous a contraction on the part of the
patient can render the technique less
effective and result in post-treatment
soreness or muscle spasm
• Too forceful of a contraction has been
reported to cause tendon avulsion and rib Fx
• Safe for children and adults
• Useful for patients who cannot relax easily.
High Velocity Low Amplitude (HVLA)
 HVLA
DIRECT technique with the
initial set-up stretching the
hypertonic muscles, engaging
the restrictive barrier, followed
by overcoming the tissue
resistance with a quick thrust
through the restrictive barrier.
Often associated with
cavitation- release of gas
bubbles in joint from reduced
pressure producing an audible
“pop”.
Patient is PASSIVE.
 Thought to involve an
overwhelming barrage of
afferents from the muscle spindle
which forces the CNS to turn
down the gamma motor activity,
as well as involvement of the
golgi tendon mechanism from the
forced stretch of muscles.
 HVLA overcomes restrictions in
ROM by restoring normal
articular relationships, reducing
segmental muscle hypertonicity,
reducing articular capsular
tension, and reducing focal
edema and swelling.
 Joint cavitation (“pop”) may add
a psychological benefit.
 HVLA has also been shown to
modify central processing of pain.
It may be sympathoexcitatory, so
caution with acute viscero-somatic
reflexes.
 Can activate the endogenous opiate
system.
 Meniscoid theory- HVLA releases
trapped meniscoids (synovial, fat
or fibrous folds) in facet joints.
Intervertebral Foramen (IVF)
Aperture that transmits the spinal nerves, spinal
arteries and veins, the recurrent meningeal nerves
and lymphatics. Also contains the dorsal root ganglia.
Bounded by two movable joints: ventrally by
intervertebral disc and PLL, and dorsally by the
capsule of articular facets and ligamentum flavum.
HVLA at articular facets can effect the contents of
the IVF.
Unique Features
Increased concentration of Na+ channels in dorsal root
ganglia
Spinal nerves are more vulnerable to mechanical
compression (less collagen in endoneurium; proximity
to joints prone to degenerative changes)
 HVLA
Indications:
 Articular somatic dysfunction
(identified with TART)
 Firm, distinct (articular)
restrictive barrier
Absolute Contraindications:
Upper cervical
Rheumatoid arthritis, Down syndrome,
Achondroplastic dwarfism, Chiari
malformation
 Fracture / dislocation / spinal or joint
instability
 Ankylosis / spondylosis with fusion
Surgical fusion
Klippel-Feil syndrome
Vertebrobasilar insufficiency
Inflammatory joint disease
Joint infection
Bony malignancy
Patient refusal
Relative Contraindications:
Acute herniated nucleus
pulposus
Acute radiculopathy
Acute whiplash / severe
muscle spasm / strain/sprain
Osteopenia / Osteoporosis
Spondylolisthesis
Metabolic bone disease
Hypermobility syndromes
 Safety, Efficacy & Application
AOA position paper on cervical HVLA
Since 1925 there have been 275
reported adverse reactions reported from
cervical spine manipulations (HVLA).
Risk of major impairment from cervical
spine HVLA is 6.39 per 10 million C-
spine manipulations per year.
In the U.S. GI complications from
NSAIDs are responsible for >100,000
hospitalizations per year, and at least
16,500 deaths.
AOA- continue teaching cervical spine
manipulation at the COMs.
HVLA Safety, Efficacy
& Application

Age ranges: typically not

done in young children;
adolescents can tolerate.
Offers almost immediate
relief of pain due to
articular restriction.
If very specific and truly
small amplitude, can be
performed in geriatric age
group.
 Counterstrain
 An osteopathic system of diagnosis and
INDIRECT treatment in which the
patient’s somatic dysfunction, diagnosed
by an associated myofascial tender
point, is treated by using a position of
spontaneous tissue release while
simultaneously monitoring the tender
point.
 PASSIVE technique
 History
 Developed by Lawrence H. Jones, DO,
FAAO
 Dr. Jones mapped over 300 points
associated with specific somatic
dysfunctions.
 Tender Point
 The tender point is a palpable tissue
texture change. They are discrete, small,
tense and edematous areas approximately
the size of a dime. It is tender to an
amount of pressure that would not
normally cause pain. Patients usually
wince, but the physician should verify by
asking the patient, “Is this point tender”.
 The location of specific tender points is
consistent from one patient to another.
 They can be anterior or posterior, and can
be located in ligaments, tendons, muscle
or fascia.
Proposed Mechanism
 The most widely held theory is activation of
the muscle spindle.
 Dr. Jones believed the gamma system was
responsible for an inappropriate proprioceptive
reflex (“gamma gain”).
 Decrease the gamma gain-"...stop
inappropriate proprioceptor activity...
shortening the muscle that contains the
malfunctioning muscle spindle by applying a
mild strain to its antagonist." (Jones).
 It will also decrease nociception (nociceptive
model of somatic dysfunction), and improve
circulatory mechanisms.
The central portion of the intrafusal fibers are devoid of
significant actin and myosin, and contains Ia and II
afferents. The ends of the intrafusal fibers are innervated
by gamma motor neurons.
The muscle spindle will increase its afferent signalling to the spinal cord if:
-extrafusal skeletal muscle is stretched
-if the ends of the intrafusal fibers contract from gamma motor input
The result will be skeletal muscle contraction to counter the perceived stretch
and quiet the spindle.
 Gamma Motor Neurons
 Gamma tone will be preset by CNS for
anticipated activities.
 If there is a mismatch between expected
activity and actual activity, somatic
dysfunction can result. (ie. Lifting box;
expected a heavy box but it was empty)
Suddenly shortened muscle quiets the
muscle spindle, requiring the gamma tone to
increase, resetting a baseline level. As the
muscle is restretched, it reports strain before
any real strain is reached, and becomes
hypersensitive to changes in length.
The length of extrafusal fiber will not
correspond to what the intrafusal fibers are
set to (mismatch).
Gamma Motor Neurons
Chronically increased gamma gain,
such as in patients who are anxious
and tense, increases the sensitivity
of the spindle as well, with
stretching of a shortened muscle
being interpreted as potentially
damaging.
Chronically shortened muscles
restrict joint motion.
Gamma “gain” is important in both
acute and chronic somatic
dysfunctions.
 Counterstrain

 During positioning, the muscle origin and

insertion are brought closer together, thereby
shortening the extrafusal fibers which in turn
shortens the intrafusal fibers and turns off the
muscle spindle firing.
 The position of ease (indirect technique) is held
for 90 seconds (ribs 120 seconds, allowing the pt.
additional time to relax) and the patient is
returned to neutral passively and slowly. Why
slowly??
 Maintaining the position of comfort for 90
seconds allows the proprioceptive firing to
decrease, the extrafusal and intrafusal mismatch
to correct, and for the muscles to relax.
 Therapeutic Pulse
Counterstrain
A clue to the treatment time is with the palpation
of a pulsation, the therapeutic pulse, at the
tender point.
The frequency is the same as the cardiac rate and
would suggest a circulatory relationship.
The pulsation IS NOT present before positioning
the patient, and develops as the position of ease
is attained. It then disappears as the myofascial
tissue relaxes. The pulsation isn’t present with
every tender point, but when present correlates
with an improved treatment response.
Principles of Counterstrain Treatment
1. Thorough structural exam
2. Tender point localization
3. Establish tenderness assessment; “pain scale”
4. Continuously monitor the point. Check in multiple times
during treatment. Avoid using thumb for monitoring.
5. Place the patient passively in a position that results in the
greatest reduction (>70% with a goal of 100%) of
tenderness at that point
a) First approximate position
b) Then fine-tune position through small arcs of movement
(finding the greatest position of ease, usually fine-tune in
multiple planes of motion).
6. Maintain the position for 90 seconds while continuously
monitoring the point
7. Slowly return the patient passively to a neutral position
8. Re-test for tenderness at the tender point

9. Can treat multiple points at once (stacking)

 Counterstrain
Indicated for somatic dysfunction
evidenced by tenderpoints
Contraindications: patients who have
difficulty voluntarily relaxing; children
who cannot remain passive; lower
extremity CS in patients with DVT;
manifestation of neurological symptoms
brought on by the treatment position;
fracture in the region of the tenderpoint to
be treated; ligamentous tear in which the
treatment position could risk further
tearing; severe vertebral artery
atherosclerosis; vertebral artery dissection
Safety, Efficacy & Application
Overall very safe and well tolerated.
Be careful with cervical extension
positioning
Patients can be sore for 24-48 hours after Tx
Good for ALL age groups, as long as
patient can appropriately relax.
Can give complete relief of pain if
tenderpoint is the primary source of
patient’s pain.
Effective for hospitalized patients,
including acuite viscero-somatic reflexes.
Effective at relieving pain; can give home
counterstrain positions to patients to
support treatment.
Thank you!