LETTER TO THE EDITOR

In response to your editorial detailing the long-running altercation with chiropractors concerning manipulation¹, I have a simple and effective answer. When the dust from the car in front of you is making your breathing difficult, the most effective answer is to pass that car; go out in front and let them eat your dust.

When Fred Mitchell Sr. back in the early days of osteopathy conceived of the muscle energy technique he was on the right track but missed the mark because he was focused on the articular dysfunction and was unaware of the essential myofascial trigger point (MTP) component. Osteopaths, chiropractors, and physical therapists have perpetuated that omission ever since. The fact of the matter is that the relatively few clinicians really skilled and knowledgeable both in manipulation techniques and MTPs are acutely aware of the fundamental fact that articular dysfunctions and MTPs in muscles crossing that joint establish a positive feedback loop so that one aggravates the other. Your problem is largely one of semantics so the simple answer is to change the playing field and the semantics that go with it. If you get the same effective results for the same patient problem by treating the MTPs rather than the joint and use different terminology you leave the other side without an argument. You are applying muscle contract-release to release the muscle(s) that are restricting joint movement not manipulating the joint to treat your patients.

I not only have years of experience treating patients, but at age 85 I have a collection of muscles, nearly all of which have latent MTPs that often are occasionally activated by my dynamic life style. My experience has been that by far the most effective and easily applied treatment of a newly activated MTP is what Mitchell would call a muscle energy technique. To avoid confusion, I would suggest we call it a Contract-Release technique. This simply is an isometric contraction of the muscle with the MTP followed by either an active or passive (or both) stretch of the muscle(s) restricting joint range of motion. The reason this is so effective is described and illustrated in a published paper². What that paper does not describe is that the reason the initial contraction facilitates the subsequent stretch is that it helps to release the tangled sticky titin molecules in the shortened sarcomeres. The reason the process must by done slowly is that it takes time for those molecules to work free of their stuck-together state. As usual in the MTP “business”, there are precious few scientific articles documenting this feedback loop between the restricted joint motion and the shortened muscles associated with it. However, there is a wealth of clinically oriented references, including the book by Lewit³.

Sometimes the answer is at hand, but one must think outside of the box to recognize it.