Journal of Orthopaedic & Sports Physical Therapy

Official Publication of the Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association

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Muscle Energy Technique in Patients With

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Capt. Eric Wilson, PT, DSc,
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Katherine Dec, MD
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Address _____________________________________________________________________________________________
Study Design: A prospective, pilot clinical trial. low back pain occurs in people
Objective: Examining the outcomes of Muscle Energy Technique (MET) in patients with acute low with a wide variety of professions,
Address
back pain.
_____________________________________________________________________________________________
including those involving heavy la-
Background: MET is commonly used to treat patients with acute low
City _______________________________State/Province __________________Zip/Postal back pain. No randomized bor, repetitive work activities, and
Code _____________________
controlled trials examining the outcomes of this treatment in symptomatic populations has been extended sedentar y postures. 10
reported
Phone in the literature.
_____________________________Fax____________________________Email _____________________________
Half of the population will have
Methods and Measures: Ten men and 9 women diagnosed with acute low back pain were
experienced a significant incident
Would
randomlyyouassigned
like towith receive JOSPTtoemail
stratification 1 of 2updates
treatment and renewal
groups. were matched
according
Patientsnotices? Yes
No
to age, gender, and initial Oswestry score. The control group received supervised neuromuscular
of low back pain by age 30.34
re-education and resistance training while the experimental group received the same exercises Physical therapists attempt to
coupled with MET. Both groups received the selected treatment 8 times over a 4-week period (2 manage patients with acute low
Payment Information
times per week). Patients completed an Oswestry Disability Index on their first and eighth visits back pain by utilizing a wide vari-

and change
Check scores were
enclosed calculated.
(made payable to the JOSPT). ety of interventions, including ex-
Results: A 2-tailed t test (P⬍.05) demonstrated a statistically significant difference with the ercise and manual therapy. One of

experimental
Credit Cardgroup (circle one)greater
showing MasterCard
improvement inVISA American
the Oswestry DisabilityExpress
Index score than the the exercise approaches that may
control group. counter the potentially long-term
Conclusion:
Card NumberMET combined with supervised motor control and resistance exercises
___________________________________Expiration may be
Date _________________________________________
effects25 of acute low back pain is
superior to neuromuscular re-education and resistance training for decreasing disability and
improving______________________________________Date
Signature Phys Ther 2003;33:502- neuromuscular re-education and
function in patients with acute low back pain. J Orthop Sports __________________________________________________
512. resistance training. Unfortunately,
many of the randomized trials that
Key Words: Exercise, lumbar spine, manual therapy
investigate exercise have not fo-
To order call, fax, email or mail to:cused on neuromuscular re-
1111 North Fairfax Street, Suite 100, Alexandria, VA 22314-1436 education and resistance
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A
pain is treated a variety of healthcare
providers utilizing an array of treatment approaches. In Another common treatment for
1995, acute low back pain Thank was youthe for
fifth subscribing!
most common acute low back pain is the use of
reason for all physician visits in the United States. Over 22 manual therapy. While under the
$13 billion in medical expenses per year are attributed to broad umbrella of manual therapy,
low back pain, 7,35
which affects from 5% to 10% of the adult population Muscle Energy Technique (MET)
2
annually with a prevalence from 60% to 90% over a lifetime. 30,35
Acute does not fall into the subcategories
of manipulation or mobilization.
1
MET is an active technique5,20 in
Director, Cadet Physical Therapy Clinic, 10th Medical Group, United States Air Force Academy, CO.
2
Professor Emeritus, Department of Physical Therapy, Virginia Commonwealth University, Richmond, VA. that the patient, instead of the
3
Assistant Professor and Director of Clinical Education, Department of Physical Therapy, Virginia care provider, supplies the correc-
Commonwealth University, Richmond, VA. tive force.20 Greenman20 defined
4
Practitioner, Private Practice, Integrated Sports Medicine, Richmond, VA.
The opinions and assertions herein are the private views of the authors and are not to be construed as MET as a ‘‘manual medicine treat-
official or as reflecting the views of the Department of the Air Force or the Department of Defense. This ment procedure that involves the
research protocol was approved by the Chippenham Medical Center/Johnston-Willis Hospital (Richmond, voluntary contraction of patient
VA) and Rocky Mountain University of Health Professions (Provo, UT) Institutional Review Boards.
Send correspondence to Capt. Eric Wilson, 10MDOS/SGOSY - Cadet PT Clinic, 4102 Pinion Drive, Suite muscle in a precisely controlled
100, USAF Academy, CO 80840-2502. E-mail: jdjewilson@adelphia.net direction, at varying levels of in-

502 Journal of Orthopaedic & Sports Physical Therapy

tensity, against a distinctly executed counterforce
applied by the operator.’’ It has been hypothesized
that MET can be used to lengthen and strengthen
muscles, to increase fluid mechanics and decrease
local edema, and to mobilize a restricted articula-
tion.20
The efficacy of manual therapy, primarily manipu-
lation, for the treatment of acute low back pain is
well documented in the literature.13,21,24,28,31,37,38
While there has been an abundance of research
advocating the use of manipulation in general, there
have been few articles published on the topic of
MET8,18,26 and little has been published in the way of
randomized controlled trials39,40 involving MET.
Schenk et al40 performed a randomized controlled
trial to determine the effectiveness of MET for
increasing lumbar extension in asymptomatic indi-
viduals. Each session lasted less than 5 minutes with
each subject receiving 4 repetitions of the MET
maneuver 2 times a week for 4 weeks. While the
authors did not mention the control group’s treat-
ment, they reported a statistically significant differ-
ence (P⬍.05) in the increase of lumbar extension in
the experimental group.
While MET has found an increased audience with
clinicians,16 very little has been published in the
peer-reviewed literature on this intervention. Its wide-
spread use in the clinic makes it imperative that we
determine if this technique is a viable procedure for
the treatment of acute low back pain. The purpose of
this prospective pilot clinical trial was to determine
whether patients with acute low back pain would
demonstrate a greater reduction in disability, as
assessed by the Oswestry Disability Index (ODI), after
being treated with MET treatment coupled with
supervised neuromuscular re-education and resis-
tance training as compared to patients treated with
supervised neuromuscular re-education and resis-
tance training alone. The research hypothesis investi-
gated was that there would be a statistically significant
difference (P⬍.05) between patients diagnosed with
acute low back pain with a concomitant diagnosis of a
lumbar flexion restriction treated with MET com-
bined with neuromuscular re-education and resis-
tance training (experimental group) as compared to
patients treated with supervised neuromuscular re-
education and resistance training alone (control
group), in that the experimental group would have a
greater change in ODI scores after 4 weeks of
treatment.
METHODS
Study Design
This study utilized a pretest-posttest matched-pairs
design. The independent variable was MET and the
dependent variable was the ODI. The ODI measures
disability in patients with low back pain using a
J Orthop Sports Phys Ther • Volume 33 • Number 9 • September 2003
10-item scale and is one of the most universally
accepted questionnaires for low back research.6,27
The ODI has been reported as both reliable (r = 0.91,
P⬍.001) and valid for assessing disability in patients
with low back pain11 and has a reported minimum
clinically important difference of 6 points.15 Patients
completed the ODI prior to treatment on their first
and eighth (final) visits. This study utilized version
2.0 of the ODI as advocated by the original author.12
Patients were placed into either the experimental
group or the control group upon entering the study.
A coin toss determined the group placement of the
first patient to enter the study. Further patients were
either randomly assigned or matched to patients
already participating in the study according to gen-
der, age (± 5 years), and initial ODI score. Patients
were matched by initial ODI score according to the
categories originally described by Fairbank11: moder-
ate (20%-40%) and severe (40%-60%). This range of
scores was selected based on 2 factors. First, retro-
spective analysis of patient records showed that the
vast majority of patients admitted into the clinic with
acute low back pain had initial ODI scores within this
RESEARCH
range. Second, the ODI is more sensitive to change
in patients with scores in this range.1
Subjects
Sixty-four patients referred to a single outpatient
physical therapy clinic with a diagnosis of low back
pain or lumbar sprain/strain were screened for inclu-
REPORT
sion in this study between May and December, 2000.
Of the initial 16 subjects who met the inclusion and
exclusion criteria, 3 did not complete the study. One
patient in the experimental group reported a dra-
matic decrease in symptoms and did not return for
continued treatment. Another patient from the ex-
perimental group went on vacation in the middle of
her treatment. One patient from the control group
was removed from the study after he was involved in
a motor vehicle accident before he completed the
study. Therefore, 3 additional subjects were recruited
and then matched according to age, gender, and
initial ODI score, as previously described, to replace
those who dropped out.
Inclusion criteria included low back pain of no
more than 12 weeks duration at the time of examina-
tion, a subject age range of 18 to 65 years old, an
initial ODI score of 20% to 60%, and a physical
therapy diagnosis of low back pain without radiating
symptoms. This was defined as pain confined to the
lumbar region without radiating into either the
buttocks or lower extremities. The final inclusion
criterion was a lumbar flexion restriction as diag-
nosed by the primary investigator (EW), which would
be termed an extended, rotated, side-bent (ERS)
dysfunction under the osteopathic model. The diag-
nosis of a lumbar flexion restriction was made with
range of motion measures correlated with a posi-
503
tional diagnosis as described by Greenman.20 Green-
man20 has described a flexion restriction as a
perceived segmental dysfunction that prevents the
patient from being able to forward flex, and/or side
bend the spine secondary to a range of motion
restriction and/or pain.
This diagnosis was made in 2 parts. First, spinal
range of motion was measured as described by
Fitzgerald et al.14 The patient stood erect with feet
shoulder-width apart and hands by his/her side prior
to performing 3 repetitions of maximal trunk side
bending, flexion, and extension. The mean of the 3
measures was used to determine if an asymmetry
existed in side bending. A subjective report of pain
greater with flexion than extension was considered a
positive finding. Data from Fitzgerald14 were used to
determine if an asymmetry existed in side bending.
The authors divided their sample into age groups of
10 years each (20-29, 30-39, etc). They determined a
standard deviation for right and left side bending for
each age group. If an asymmetry in side bending was
noted in our subjects that fell outside of the standard
deviation reported by Fitzgerald,14 the findings were
considered positive. Fitzgerald et al14 reported the
interrater reliability for measuring right side bending
of r = 0.76 and left side bending of r = 0.91.
Next, the positional diagnosis was made with the
patient in a seated, forward-flexed position (Figure
1). The patient sat on a stool with hips and knees
flexed to approximately 90° with feet flat and spread
approximately shoulder-width apart. The patient was
then instructed to place his/her hands together and
reach for the floor by bending forward at the waist
without allowing the arms to rest upon his/her legs.
Patients were asked to bend as far forward as
possible. The examiner then located the L5 spinous
process and moved his thumbs laterally over the area
of the transverse processes. Downey et al9 found an
overall weighted kappa of 0.92 for the palpation of
nominated lumbar spinal levels. The examiner then
observed for an asymmetry in the amount of rotation
FIGURE 1. Procedure for positional diagnosis.
504
TABLE 1. Descriptive statistics (mean, standard deviation, and
range) for subjects.
Experimental Control Group
Group
Gender (n)*
Men 4 4
Women 4 4
Age (mean ± SD [range] y)* 31 ± 9 (20-43) 32 ± 9 (19-44)
Duration of symptoms
(mean ± SD [range] wk)* 6 ± 2 (2-9) 5 ± 2 (2-7)
* No statistically significant difference between groups (P⬎.05).
at the spinal segment using his dominant eye20 in a
plane even with the spine. If the examiner observed
that the spinal segment was rotated to the right, and
the subject had decreased or painful side bending to
the left, a diagnosis of a left flexion restriction would
be made. This would be diagnosed as an ERS right
under the osteopathic model. (The direction of the
side-bending restriction and the rotation did not have
to match for the diagnosis to be made.) In this
instance, it would be thought that the subject had a
segmental restriction of flexion and left side bending
at L5. This procedure was repeated for each segment
of the lumbar spine.
Exclusion criteria included radiating pain,
paresthesia or numbness into the buttocks or lower
extremities, motor weakness, absent or diminished
muscle stretch reflexes (MSRs), spondylolisthesis,
chronic low back pain of more than 12 weeks, and
previous back surgeries. Patients who met all inclu-
sion and exclusion criteria after physical therapy
evaluation were then asked to participate in the study.
Full disclosure of the risks and benefits were provided
and informed consent was obtained from each sub-
ject prior to inclusion into the study. Eight men and
8 women completed this study (Table 1). The institu-
tional review boards of Chippenham/Johnston-Willis
Hospitals and Rocky Mountain University of Health
Professions approved this study.
Intervention
Patients assigned to the experimental group re-
ceived MET on the day of their initial evaluation by
the primary investigator. The primary investigator was
trained in MET by members of the faculty of Michi-
gan State University’s College of Osteopathic Medi-
cine. MET was performed as described by
Greenman20 (Appendix 1) with the patient side lying
on the side opposite of their flexion and side-bending
restriction (eg, if the patient had a left flexion
restriction, he or she would be placed in right side
lying). Following the MET procedure, the patient had
range of motion and positional diagnosis reassessed.
The MET procedure was considered a success if the
J Orthop Sports Phys Ther • Volume 33 • Number 9 • September 2003

FIGURE 2. Muscle Energy Technique home exercise (flexion and
side-bending left restriction). Starting position (A) and stretch posi-
tion (B).
J Orthop Sports Phys Ther • Volume 33 • Number 9 • September 2003
positional asymmetry and the range of motion limita-
tion in flexion and asymmetry in side bending were
no longer observed.
Following the MET procedure, the patient received
a MET component to their home exercise program
(HEP). This home exercise sought to assist the
patient in maintaining spinal range of motion, thus
decreasing the need for further MET corrections. For
example, if a patient was diagnosed with a flexion
and side-bending left restriction, the patient was
instructed to place the left foot on a stool or chair
(hip and knee angles of 90° and 90°, respectively)
and slowly bend forward and rotate to the left
(Figure 2). Patients were instructed to stretch as far
as possible in a pain-free range and hold the stretch
for 5 to 7 seconds. The patient was then instructed to
place his or her hands upon the flexed knee to assist
in returning to a standing position with the use of
the upper extremities. Patients were to perform this
stretch ‘‘as often as possible.’’
The patient was also instructed to perform the
drawing-in maneuver33 (Appendix 2) ‘‘as often as
possible’’ as the final component of the initial HEP.
RESEARCH
The drawing-in maneuver was the first of 4 exercises
that would be integrated into the patient’s HEP over
the course of the first 3 visits. The patient’s HEP
increased with the addition of the simple supine
obliques and the standing extension stabilization
exercises utilizing a blue REP band (Magister Corp.,
Chattanooga, TN) on the second visit and the addi-
tion of the standing latissimus dorsi pull-down utiliz-
REPORT
ing a blue REP band on the third visit. These
exercises are described in Appendix 2. Patients were
asked to perform these home exercises once a day,
except on the day of their clinic visits. Patients were
provided with a home exercise log in an attempt to
monitor adherence. Patients in the control group did
not receive MET or a MET-specific HEP on the day of
their initial evaluation. Instead, they were provided
with an HEP that consisted solely of the drawing-in
maneuver. Their HEP progression was identical to
that of the experimental group.
Follow-up (Both Groups): Visits 2 Through 8
Patients were seen twice a week for 4 weeks (8 visits
total, including initial evaluation) with at least 1 day
between interventions. Each visit was broken down
into 2 parts with the primary investigator responsible
for part 1 and a second therapist responsible for part
2. All part 1 interventions were performed solely by
the primary investigator in a private treatment room
and began with 20 minutes of moist heat with the
patient in a supine recumbent position. The therapist
responsible for part 2 was masked to each patient’s
group assignment, initial ODI score, and direction of
spinal dysfunction. A flowchart depicting part 1 and
part 2 interventions can be found in Figure 3.
505
 Part 1
Primary investigator

Moist heat

Treatment Control
group group

MET reassess Randomized placebo manual

MET performed therapy
Review MET HEP

Part 2
Therapist masked
to group assignment

Exercises Performed
1. Drawing-in maneuver
2. Standing extension stabilization
3. Simple supine obliques
4. Standing latissimus dorsi pull-down
5. Multi-hip abduction
6. Dumbell overhead
7. Modified Romanian dead lift

Performance of
HEP

FIGURE 3. Intervention (visits 2-8). Abbreviations: MET, Muscle Energy Technique; HEP, Home Exercise Program.

Part 1 Treatment: Experimental Group
Following the moist heat, the patient was re-
evaluated for the presence of a flexion restriction by
the primary investigator in a private treatment room.
MET was performed if a restriction was found. If a
flexion restriction was not diagnosed, no MET was
performed. The patient had the MET home exercise
reviewed and was then turned over to a therapist
masked to group assignment for part 2 of the
treatment.
Part 1 Treatment: Control Group
Following the moist heat, patients received placebo
manual therapy performed by the primary investiga-

506 J Orthop Sports Phys Ther • Volume 33 • Number 9 • September 2003

tor in a private treatment room. The placebo manual
therapy was performed for 2 reasons. First, patients in
both groups were informed that they were participat-
ing in a ‘‘manual therapy’’ study at the time of
inclusion. The placebo treatment sought to control
for the ‘‘laying-on of hands’’ effect often associated
with manual therapy research.4,17,19 Second, it was
hoped that this would decrease any potential bias in
the subjects by further masking them to their group
assignment. This would also help reduce the poten-
tial for bias on the part of the therapist responsible
for part 2 treatment, who was masked to group
assignment, should the patient happen to discuss the
part 1 treatment with this therapist. Side-lying passive
range of motion was selected as the placebo manual
therapy because it most closely mirrored the MET
intervention without resulting in any perceived thera-
peutic effect. This placebo manual therapy was per-
formed at randomly selected treatment sessions as
determined by a coin toss. The placebo treatment was
randomized because patients in the experimental
group would not always receive MET during part 1 of
the treatment. The patient was instructed to lay on
the side opposite of the restriction diagnosed during
the initial evaluation while the primary investigator
passively moved the patient’s lumbar spine into flex-
ion and rotation and side bending into the direction
of the restriction. While this closely imitated the MET
procedure, the restricted spinal segment(s) were not
isolated and no muscle contraction was elicited. This
treatment was performed in a pain-free range of
motion and required approximately the same amount
of time (less than 5 minutes) to perform as the MET.
It should be stressed that this procedure was used as
a control only and no therapeutic effects were
attempted to be elicited. Following the random
application of the placebo treatment, patients in the
control group were then turned over to a therapist
masked to group assignment for part 2 of the
treatment.
Part 2 Treatment: Both Groups
A second therapist who was masked as to each
patient’s group assignment supervised part 2 of all
treatments. All patients received a standardized set of
supervised neuromuscular re-education and resis-
tance training exercises (Appendix 2). All patients
began each exercise at a standardized weight (Appen-
dix 2) that was individually progressed utilizing the
daily adjusted progressive resistance exercise proto-
col.45 Exercise selection was based upon motor con-
trol,23,33 anatomical and biomechanical studies,36,44
and from clinical experience.46 Patients performed
the following supervised motor control and resistance
exercises on their second visit: (1) drawing-in maneu-
ver,33 (2) standing extension stabilization,23,33,36,46 (3)
simple supine obliques,23,36,46 and (4) standing latis-
simus pull-down.23,33,36,46 On the patient’s third visit,
J Orthop Sports Phys Ther • Volume 33 • Number 9 • September 2003
the remaining 3 exercises (multihip abduction,
dumbbell overhead, modified Romanian dead lift)
were added to their supervised resistance program.
Statistical Analysis
Four males and 4 females participated in each
group. Prior to data analysis, a Levene’s test found no
statistically significant differences existed between
groups for age, duration of symptoms, and initial
ODI scores (P⬎.05). Pre- and posttreatment ODI
scores were converted to a change score as described
by Little and MacDonald.29 The following formula
was used:
Change score =
Pretreatment score - Posttreatment score × 100
Pretreatment score
According to Streiner and Norman,42 researchers
should only use change scores when the reliability of
their measure is greater than 0.50. The ODI has a
reported reliability of r = 0.91.11 The mean change
scores in the control and experimental groups were
analyzed using an independent groups t test.
RESEARCH
RESULTS
Every patient in the experimental group showed a
higher change in ODI scores than patients in the
control group. The mean percent change in score of
the experimental group was 83% compared to a
mean percent change in score of 65% for the control
REPORT
group. Pre- and posttest means are provided in Table
2. Data analysis (independent t test) revealed a
statistically significant difference in favor of the ex-
perimental group (t = 4.669, df = 7, 2-tailed test) at
the 0.05 level.
Patients in both groups had their home exercise
logs reviewed after their eighth visit. Each patient was
asked to perform the home exercises every day of the
week (5 days per week) except on days he/she was
treated in the clinic. Patients were considered to be
adherent with their home exercises if they performed
them 3 out of the 5 days. Both groups were found to
be adherent with their home exercise programs based
on the above criteria. All subjects who completed the
study attended all scheduled (8) physical therapy
sessions.
DISCUSSION
The data from this pilot study suggest that MET
coupled with supervised neuromuscular re-education
and resistance training exercises may be superior to
supervised neuromuscular re-education and resis-
tance training exercises alone for treating patients
with acute low back pain who are believed to have a
flexion restriction. This study is the only identified
clinical trial that has investigated the outcomes of
507
 TABLE 2. Outcome information by group (mean and SD was calculated only for those subjects who completed the study).
Experimental Group Control Group
% %
PreODI PostODI Change MET PreODI PostODI Change
Gender Age (y) (%) (%) in Scores Treatments Age (y) (%) (%) in Scores
Male 30 52 8 85 4 31 44 12 73
Male 26 40 4 90 2 28 46 16 65
Male 20 46 10 78 3 19 42 12 72
Female 35 30 8 73 2 34 36 14 61
Female 20 48 8 83 4 23 42 20 52
Male 43 52 4 92 3 44 50 22 56
Female 36 42 4 91 3 38 50 12 76
Female 41 48 12 75 4 40 42 14 67
Male* 23* 48* 28* 48*
Female* 25* 45*
Mean ± SD 31 ± 9 45 ± 7 7±3 83 ± 7 3±1 32 ± 9 44 ± 5 15 ± 4 65 ± 8
Abbreviations: SD, standard deviation; ODI, Oswestry Disability Index; MET, Muscle Energy Technique.
* Drop-out subject.

interventions using the MET in symptomatic popula-
tions. The results of this study add support to the
hypothesized effects of MET in patients with acute
low back pain. This is an important first step in
validating the effectiveness of this popular manual
intervention.
In this study, the mean posttreatment Oswestry
score was 7% for patients in the experimental group
compared to 15% in the control group (Table 2). It
should be noted that the control group’s
neuromuscular re-education and resistance training
intervention produced good outcomes, but the addi-
tion of the MET improved the outcomes substantially.
The experimental group’s mean posttreatment score
represents an Oswestry questionnaire with a mini-
mum of 6 out of the 10 questions scored as ‘‘no
pain.’’ Most patients can return to preinjury occupa-
tional activities with scores as high as 10% to 12%.32
Only 2 subjects in the experimental group had scores
in this range with all other scores falling between 4%
to 8% (Table 2). Moreover, the difference between
each patient’s pre- and posttreatment Oswestry scores
more than exceeded the 6-point minimum clinically
important difference as described by Fritz and Ir-
rang.15
This study also found that the mean number of
MET procedures required for subjects in the experi-
mental group was 3 (range, 2-4). These data suggest
that a relatively small number of MET interventions
can result in significantly greater reductions in self-
reported disability. It would be interesting to compare
the number of MET interventions with other manual
therapy interventions on patient outcomes in future
studies.
While this study is an important first step in
validating the efficacy of MET in patients with acute
low back pain who demonstrate a flexion restriction,
several limitations exist that warrant discussion. Pa-
tients included in this study were limited to those
referred to a single outpatient sports medicine clinic
and evaluated and treated by a single investigator.
Three subjects were removed from this study and, as
such, potentially introduced an element of bias into
the study design. Another potential limitation was the
use of passive range of motion as a control for the
placebo effect often associated with manual therapy
research. No therapeutic effects were attempted to be
elicited with this treatment, however, it cannot be
stated definitively that none occurred. No data were
collected on patient demographics, time missed from
work, or recreational activities. This information
could provide some data addressing which sub-
categories of patients may benefit most from MET.
Future study designs should collect data that will
allow steps to be taken for specific inclusion criteria
to be developed that can identify which patients will
most benefit from MET. Future studies should also
address the efficacy of MET in treating patients with
multiple-region dysfunctions of an extension, flexion,
or neutral nature.
CONCLUSION
Results from this pilot study suggest that MET
combined with super vised neuromuscular re-
education and resistance training exercises may be
superior to supervised neuromuscular re-education
and resistance training exercises alone for decreasing
disability and improving function in patients with
acute low back pain. The MET and the
neuromuscular re-education and resistance training
exercises were operationally defined to allow the
intervention to be easily reproduced in the clinical
setting. The reader must keep in mind that this is an
initial study and while the results are clinically rel-
evant, they should not be over generalized. Much
more needs to be learned to clarify the role of
manual therapy, MET, and neuromuscular re-

508 J Orthop Sports Phys Ther • Volume 33 • Number 9 • September 2003

education and resistance training exercises in the
management of acute low back pain.
ACKNOWLEDGEMENTS
The authors would like to thank Chippenham
Sports Medicine Center for the use of their facilities
and Jennifer Downey Wilson, PT, MS, PCS for her
review of this manuscript.
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Appendix 1
Muscle Energy Technique Procedure for Left Flexion Restriction at L3

A D

Patient lies on right side. Examiner palpates L3 Examiner rotates patient’s trunk until motion is
spinous process and extends patient’s legs until palpated at L3.

RESEARCH
motion is palpated at L3.
E
B

REPORT
Examiner side-bends patient’s trunk until motion is
Examiner flexes patient’s trunk superiorly until palpated at L3. Upon command, patient pushes her
motion is palpated at L3. legs down into examiner’s hand for a 5-second
isometric contraction. Entire process is repeated 4
times. L3 is re-evaluated for alignment (as shown in
C Figure 1) and range of motion symmetry.

Examiner flexes trunk inferiorly until motion is

palpated at L3.

J Orthop Sports Phys Ther • Volume 33 • Number 9 • September 2003 511

Appendix 2
Strengthening Exercises and Initial Resistance

Initial
Resistance
Exercise (kg) Description
1. Drawing-in maneuver 0 Patient supine with hips/knees slightly flexed (20°).
Instructed to draw the navel in towards the spine and
cephalad towards the head. To be held while respira-
tion occurs until fatigue.
2. Standing extension stabilization 4.5 Utilizing a high pulley, the patient grasps the bar with
hands shoulder width apart. Performs drawing-in ma-
neuver then an isometric gluteus maximus squeeze
and holds these as the patient extends his/her shoul-
ders (elbows extended) bringing the bar to the waist.
Patient raises the bar to the starting position and re-
laxes buttocks, then abdomen. 50 repetitions
3. Simple supine obliques 0 Patient supine with hips/knees slightly flexed (20°) and
arms by the side. Patient performs a drawing-in ma-
neuver and holds it as he/she simultaneously reaches
for the right ankle with the right hand and rotates the
trunk to the right, bringing his/her left shoulder off the
mat until the inferior angle of the left scapula clears
the mat. Holds for a count of 1 and returns to starting
position. Repeat on opposite side. Cervical spine may
not flex and shoulders may not protract. Performed
until patient’s technique deteriorates.
4. Standing latissimus dorsi pull-down* 9 The patient stands facing the high pulley and grasps
the wide bar with hands slightly wider than shoulder
width apart. The patient performs the drawing-in ma-
neuver and an isometric gluteus maximus squeeze
prior to beginning each set of exercise. The bar is
pulled down to a point on the patient’s chest between
the sternal notch and the nipple line. The patient is
not allowed to extend the back during the concentric
phase or be pulled forward during the eccentric phase.
5. Multi-hip abduction* 9 The patient utilizes the multi-hip machine with the
lever arm centered at 0. The pad is placed just proxi-
mal to the lateral joint line of the knee. Contralateral
side bending of the trunk is not allowed.
6. Dumbbell overhead* 4.5 The patient, supine with hips/knees slightly flexed
(20°), grasps a dumbbell over the chest. Drawing-in
maneuver and gluteus maximus squeeze are per-
formed. With elbows extended, the patient flexes
shoulders until the weight slightly touches the mat be-
hind the head then returns the weight to the starting
position.
7. Modified Romanian dead lift* 6.8 The patient is standing and grasps a dumbbell and re-
tracts the scapulae and bends forward at the hips,
stopping when the weight is slightly superior to the
patellae. The patient then performs an isometric
gluteus maximus contraction and attempts to raise up-
right using the gluteus maximus instead of multifidus.
* Progression of resistance is made utilizing the daily adjusted progressive resistance exercise protocol. The patient performs as many repetitions
as possible until the exercise technique deteriorates.

512 J Orthop Sports Phys Ther • Volume 33 • Number 9 • September 2003