Journal of
Official journal of the: ® Association of
Neuromuscular Therapists, Ireland ® Australian Pilates Method Association ® Hands On Seminars, USA ® National Association of Myofascial Trigger Point Therapists, USA ® Pilates Foundation, UK Volume 15 Number 1 2011
Bodywork and Movement Therapies EDITOR-IN-CHIEF
Leon Chaitow ND, DO
c/o School of Integrated Health, University of Westminster, 115 New Cavendish Street, London W1M 8JS, UK Preferred mailing address: P.O.Box 41, Corfu, Greece 49100 (
[email protected])
ASSOCIATE EDITORS Geoff Bove DC, PhD Kennebunkport, ME, USA (
[email protected]) John Hannon DC San Luis Obispo, CA, USA (
[email protected]) Glenn M. Hymel EdD, LMT Department of Psychology, Loyola University, New Orleans, LA, USA (
[email protected])
Dimitrios Kostopoulos PhD, DSc, PT Hands-on Physical Therapy, New York, NY, USA (
[email protected]) Craig Liebenson DC Los Angeles, CA, USA (
[email protected])
ASSOCIATE EDITORS: PREVENTION & REHABILITATION Warrick McNeill MCSP London, UK (
[email protected])
Matt Wallden MSc, Ost, Med, DO, ND London, UK (
[email protected]) International Advisory Board
D. Beales MD (Cirencester, UK) C. Bron PT (Groningen, The Netherlands) I. Burman LMT (Miami, FL, USA) J. Carleton PhD (New York, USA) F. P. Carpes PhD (Uruguaiana, RS, Brazil) Z. Comeaux DO FAAO (Lewisburg, WV, USA) P. Davies PhD (London, UK) J. P. (Walker) DeLany LMT (St Petersburg, FL, USA) M. Diego PhD (Florida, USA) J. Dommerholt PT, MS, DPT, DAAPM (Bethesda, MD, USA) J. Downes DC (Marietta, GA, USA) C. Fernandez de las Peñas PT, DO, PhD (Madrid, Spain) T. M. Field PhD (Miami, FL, USA) P. Finch PhD (Toronto, ON, Canada) T. Findley MD, PhD (New Jersey, USA) D. D. FitzGerald DIP ENG, MISCP, MCSP (Dublin, Ireland) S. Fritz LMT (Lapeer, MI, USA)
G. Fryer PhD. BSc., (Osteopath), ND (Melbourne City, Australia) C. Gilbert PhD (San Francisco, USA) C. H. Goldsmith PhD (Hamilton, ON, Canada) S. Goossen BA LMT CMTPT (Jacksonville, FL, USA) S. Gracovetsky PhD (Ocracoke, NC, USA) M. Hernandez-Reif PhD (Tuscaloosa, AL, USA) P. Hodges BPhty, PhD, MedDr (Brisbane, Australia) B. Ingram-Rice OTRLMT (Sarasota, FL, USA) J. Kahn PhD (Burlington, VT, USA) R. Lardner PT (Chicago, IL, USA) P. J. M. Latey APMA (Sydney, Australia) E. Lederman DO PhD (London, UK) D. Lee BSR, FCAMT, CGIMS (Canada) D. Lewis ND (Seattle, WA, USA) W. W. Lowe LMT (Bend, OR, USA) J. McEvoy PT MSC DPT MISCP MCSP (Limerick, Ireland) L. McLaughlin DSc PT (Ontario, Canada) C. McMakin MA DC (Portland, OR, USA) J. M. McPartland DO (Middleburg, VT, USA)
C. Moyer PhD (Menomonie, WI, USA) D. R. Murphy DC (Providence, RI, USA) T. Myers (Walpole, ME, USA) C. Norris MSc CBA MCSP SRP (Sale, UK) N. Osborne BSc DC FCC (Orth.), FRSH, ILTM (Bournemouth, UK) B. O’Neill MD (North Wales, PA, USA) J. L. Oschman PhD (Dover, NH, USA) D. Peters MB CHB DO (London, UK) M. M. Reinold PT, DPT, ATC, CSCS (Boston, MA, MD, USA) G. Rich PhD (Juneau, AK, USA) C. Rosenholtz MA, RMT (Boulder, CO, USA) R. Schleip MA, PT (Munich, Germany) J. Sharkey MSc, NMT (Dublin, Ireland) D. Thompson LMP (Seattle, WA, USA) C. Traole MCSP, SRP, MAACP (London, UK) P. W. Tunnell DC, DACRB (Ridgefield, CT, USA) E. Wilson BA MCSP SRP (York, UK) A. Vleeming PhD (Rotterdam, The Netherlands)
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Journal of Bodywork & Movement Therapies (2011) 15, 1e2
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EDITORIAL
Learning about fascia When I was reminded that the 3rd Fascia Conference is just over a year away (March 2012), I reflected on just how much we now know about fascial structure and function e as well as on the large gaps in our knowledge, that remain. Hopefully many of these gaps will be filled when this gathering takes place next year. When I was studying osteopathy, many years ago, fascia entered into the lessons and lectures as a somewhat mysterious (and seemingly unimportant in clinical terms) part of the economy of the body. Certainly it featured large in the historical aspects of osteopathy’s evolution, with early pioneers referring to its all-pervading nature. Fascia was everywhere, and there were theories and assertions as to its relevance, but there was a very little that was rooted in science. (Still, 1902) So, the question remained e what did fascia do? What was fascia for? As my studies progressed, and as the years went by, it became ever clearer that fascia was not just a background material, with little function apart from its obvious supporting role, but rather a widespread, tenacious, connective tissue involved deeply in almost all of the fundamental processes of the body’s structure, function and metabolism. For example, in therapeutic terms, as well as anatomically, there is little logic in trying to consider muscles and joints as separate structures from fascia, because they are so intimately related. Remove connective tissue from the scene and any muscle left would be a jelly-like structure without form or functional ability, and joints would quite simply fall apart. We also now know that there exists a tensegrity-like state of structural and functional continuity between all of the body’s hard and soft tissues, with fascia being the ubiquitous elastic e plastic, gluey, component that invests, supports and separates, connects and divides, wraps and gives cohesion, to the rest of the body e the fascial, connective tissue network. Any tendency to think of a local dysfunction, as existing in isolation should be discouraged as we try to visualize a complex, interrelated, symbiotically functioning assortment of tissues, comprising skin, muscles, ligaments, tendons and bone, as well as the neural structures, blood and lymph channels, and vessels that bisect and invest these 1360-8592/$36 ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.10.002
tissues e all given shape, form and functional ability by the fascia (Schleip et al., 2006; Ingber, 2008; Solomonow, 2009; Myers, 2009). And what has emerged from the first two Fascia conferences e Boston 2007 and Amsterdam 2009 e suggests that there is far more to learn. These conferences brought clinicians of all schools, together with scientific researchers, in the hope and expectation that this would lead to a cross-fertilization, in which the clinical needs, confusions and questions of practitioners and therapists would inform researchers, who in turn would help clinicians to better understand the real nature of fascia in relation to their therapeutic efforts. It was further hoped that researchers would be spurred to new directions of study of fascia. And this has happened, and continues, with studies emerging at a remarkable pace, that have clarified the nature and multiple functions and roles of fascia in the body e many of these being reported or published in JBMT e for example the studies by Standley and Meltzer (2008). JBMT has been a supporter of the two previous Fascia Research Conferences, and will actively support the 3rd Fascia Research Congress e that will take place in Vancouver, Canada between 28th and 30th, 2012. The theme of the 3rd congress will be: What Do We Know? What Do We Notice? Continuing the Scientist/Clinician Dialogue The conference proper will be preceded (March 23e27) by a Fascial Dissection Workshop, with a range of additional pre and post-conference workshops, on March 27th and March 31st. At this early stage the planning for the Vancouver conference is already advanced. For example, among the confirmed keynote speakers (note that the topics listed alongside the names are tentative at this stage) are: Cesar Fernandez de las Penas DO PhD: Myofascial Pain Al Banes PhD: Mechanical loading and fascial changes e tendon focus Karen Sherman PhD: Existing trials on fascia in the context of manual therapies
2
Editorial Carla Stecco MD: Fascial anatomy overview Dr. Rolf K. Reed: Fluid dynamics (lymph, circulation etc) Mary Francis Barbe PhD: Changes in fascia related to repetitive motion disorders
A number of panel sessions are also in the planning stage that will highlight the needs and interests of all clinicians. The conference website is http://www.fasciacongress. org/2012/. There has been a call for Abstracts e and guidelines are to be found on the website. As the organising committee have said “The 2012 Fascia Congress will centre on the latest and best research on human fasciae. Additionally‑and recognizing the interests of clinicians in gaining insights that will bear on practical applications‑the program will be designed to include more presentation time to relating the research findings to clinical issues.” JBMT will carry regularly updated advertisements for the Vancouver event, and intends to publish review papers on their keynote topics, by a number of presenters.
References Ingber, D., 2008. Tensegrity and mechanotransduction. Journal of Bodywork and Movement Therapies 12 (3), 198e200. Myers, T., 2009. Anatomy Trains, second ed. Churchill Livingstone, Edinburgh. Schleip, R., Naylor, I., Ursu, D., et al., 2006. Passive muscle stiffness may be influenced by active contractility of intramuscular connective tissue. Medical Hypotheses 66 (1), 71. Solomonow, M., 2009. Ligaments: a source of musculoskeletal disorders. Journal of Bodywork and Movement Therapies 13 (2), 136e154. Standley, P.R., Meltzer, K.R., 2008. In vitro modelling of repetitive motion strain and manual medicine treatments: potential roles for pro- and anti-inflammatory cytokines. Journal of Bodywork and Movement Therapies 12, 201e203. Still, A.T., 1902. Philosophy and Mechanical Principles of Osteopathy. Hudson-Kimberly Pub. Co., Kansas City, MO.
Leon Chaitow, N.D., D.O. 144 Harley Street, London W1G 7LE, United Kingdom E-mail address:
[email protected]
Journal of Bodywork & Movement Therapies (2011) 15, 3e14
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journal homepage: www.elsevier.com/jbmt
Does massage therapy reduce cortisol? A comprehensive quantitative review Christopher A. Moyer, Ph.D*, Lacey Seefeldt, B.A., Eric S. Mann, B.A., Lauren M. Jackley, undergraduate senior University of Wisconsin-Stout, USA Received 15 March 2010; received in revised form 22 May 2010; accepted 31 May 2010
KEYWORDS Massage; Cortisol; Anxiety; Depression; Pain; Effect size; Randomized controlled trial
Summary Objectives: It is frequently asserted that massage therapy (MT) reduces cortisol levels, and that this mechanism is the cause of MT benefits including relief from anxiety, depression, and pain, but reviews of MT research are not in agreement on the existence or magnitude of such a cortisol reduction effect, or the likelihood that it plays such a causative role. A definitive quantitative review of MT’s effect on cortisol would be of value to MT research and practice. Methods: After first performing a comprehensive literature search and retrieval, we use rigorous and conventional meta-analytic methods for calculating between-groups effect sizes. As a point of comparison, we also replicate an unconventional approach taken by other reviewers, in which MT recipients’ within-group cortisol reductions are quantified as a percentage of change, despite the fact that this introduces numerous confounds not addressed by the first approach. Results: Resultant between-groups effect sizes are almost all small (ds Z 0.05e0.30) and nonsignificant. The lone exception is MT’s multiple-dose effect in children, which is larger (d Z 0.52) and statistically significant, but which is based on only three studies and vulnerable to the file-drawer threat. Within-group percentage reductions of cortisol in MT recipients are generally smaller than those found by other reviewers, and are generally inconsistent with the more rigorous between-groups results, which illustrates the unsuitability of this unconventional approach to assessment of treatment effects. Conclusions: MT’s effect on cortisol is generally very small and, in most cases, not statistically distinguishable from zero. As such, it cannot be the cause of MT’s well-established and statistically larger beneficial effects on anxiety, depression, and pain. We conclude that other causal mechanisms, which are still to be identified, must be responsible for MT’s clinical benefits. ª 2010 Elsevier Ltd. All rights reserved.
* Corresponding author at: Psychology, 307 McCalmont Hall, University of Wisconsin-Stout, Menomonie, WI 54751, USA. Tel.: þ1 715 232 1621; fax: þ1 715 232 5303. E-mail address:
[email protected] (C.A. Moyer). 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.06.001
4
C.A. Moyer et al.
Massage therapy (MT), the manual manipulation of soft tissue to promote health and wellness, has several beneficial effects validated by research. Researchers generally agree that MT can lessen the pain associated with some specific conditions (e.g., low back pain, Furlan et al., 2008; arthritis, Beider and Moyer, 2007) and reduce anxiety and depression (Moyer et al., 2004; Field, 1998). Some evidence also suggests that MT may promote weight gain in premature infants (Field, 1998; Field et al., 2007; Scafidi et al., 1990), though more evidence is needed to establish cost-effectiveness (Vickers et al., 2004). But despite the general consensus for these MT effects, there is much less consensus on their underlying causal mechanisms. This is especially true for the assertion that MT reduces bodily levels of cortisol, a hormone regulated by the hypothalamic-pituitary-adrenocortical axis that is associated with psychological, physiological, and physical health functioning. The possibility that MT’s clinical benefits are brought about by the treatment’s ability to reduce cortisol is frequently reported as established fact in the research literature (e.g., Field et al., 2005; Field, 1998), in the popular press (e.g., Lewis, 2007; Ehrenfeld, 2008; Gupta, 2008; Westlake, 2009; Yorio, 2009), and by professional MT organizations (e.g., American Massage Therapy Association, 2009), even though this assertion is contentious. Six previous reviews have examined MT’s effect on cortisol. These reviews, some narrative and some quantitative, are not in agreement despite the fact they Table 1
draw on many of the same individual studies. We summarize their findings in the following paragraphs and in Table 1.
Field, 1998 This seminal article is the first attempt to comprehensively review MT effects in human recipients of all ages, and the theories that might explain those effects. Studies conducted by Field’s Touch Research Institute (TRI) are emphasized, though some other studies are also included in support of MT’s potential to facilitate growth, reduce pain, increase alertness, reduce depression, and enhance immune function. MT’s effect on human cortisol levels is reported to be consistent across the range of studies reviewed, and is strongly asserted as a precursor to its beneficial effects. The assertion that cortisol reductions underlie MT’s effects in human recipients is offered in conjunction with the observation that massagelike procedures performed on mammalian laboratory animals, especially procedures that apply firm rather than soft pressure, reduce the animals’ stress hormone levels. With regard to human recipients, Field states that firmpressure MT “may increase vagal activity, which in turn lowers physiological arousal and stress hormones (cortisol levels)” (p. 1278). This review is limited by its strictly narrative format, which does not quantify the magnitude, consistency, or statistical significance of the effects it describes, and by its emphasis on the findings of a single laboratory, which leaves open the possibility that other MT studies with contradictory findings have been omitted.
Summary of previous reviews concerned with MT and cortisol reduction.
Review
Participant age range
Quantification of effect
Effect size
Conclusion
Field (1998)
All
None
n/a
"Across studies, decreases were noted in. stress hormones (cortisol)" (p. 1278).
Moyer et al. (2004)
Non-infant
Between-groups standardized mean difference
g Z 0.14 (95% CI Z 0.10, 0.38)
"Cortisol. was not significantly reduced, a finding that contrasts with the conclusion previously reached by Field (1998)" (p. 13).
Field et al. (2005)
All
Within-group percentage of change
31% mean decrease
"Positive changes have been noted in biochemistry following massage therapy including reduced cortisol" (p. 1411).
Beider and Moyer (2007)
Pediatric
Between-groups standardized mean difference
g Z 0.28 (95% CI Z 0.27, 0.84)
"There is currently scant evidence that MT provides benefits by first reducing cortisol, as MT’s effect on this stress hormone is seen to be small when analyzed correctly" (p. 33).
Field et al. (2007)
All
None
n/a
"To date, we can confidently say that stimulating pressure receptors under the skin leads to a cascade of events including. decreasing cortisol" (p. 85).
Moraska et al. (2008)
Adult
None
n/a
"A reduction in salivary cortisol was evident following a single massage treatment, yet salivary cortisol returns to initial values when assessed at a later time point, even if massage therapy was administered during the interim timeframe." (p. 8).
Note. CI Z Confidence interval.
Does massage therapy reduce cortisol?
5
Moyer et al., 2004
Beider and Moyer, 2007
This article is the first wide-ranging meta-analysis of MT effects in human recipients other than infants. The authors conducted a systematic search of the MT research literature, converted the results of randomized controlled trials into standardized mean difference effect sizes that objectively compare the effect of MT against control treatments, and applied a trim and fill procedure (Duval and Tweedie, 2000) to explore the possibility that significant results were influenced by publication bias. These steps improve upon narrative review techniques by producing results that are objective, replicable, and quantifiable. Only seven studies that assessed the effect of MT on cortisol with data sufficient for meta-analysis were located; six of these seven studies were from TRI. Meta-analytic results indicate that MT recipients, on average, had cortisol levels that were only 0.14 standard deviations lower than recipients who had experienced a wait-list condition or a comparison treatment (e.g., engaging in progressive muscle relaxation), a small and nonsignificant (95% CI Z 0.10, 0.38) effect. The authors concluded that cortisol levels were not significantly reduced by MT, and noted that this conclusion differs markedly from that reached by Field (1998).
This review examines several MT effects in pediatric samples. The authors located only two studies that assessed the effect of MT on salivary cortisol with sufficient data to permit effect size calculation. Results indicated that MT recipients, on average, had posttest cortisol levels only 0.28 standard deviations lower than control participants, a small and nonsignificant (95% CI Z 0.27, 0.84) effect that parallels the result for adults in Moyer et al. (2004). In addition, the authors found no evidence of an MT effect on immune system functioning in pediatric participants, an effect that other researchers do claim and ascribe directly to MT’s cortisol reducing effect (Diego et al., 2001). A limitation of this pediatric review is its reliance on a very small number of studies.
Field et al., 2005 This article reviews the effects of MT on biochemistry, including cortisol levels. The authors identify 17 TRI studies that have examined the effect of MT on cortisol, and calculate the average percentage decrease in cortisol levels that were experienced by MT recipients during the treatment period. Combining these, they conclude that MT decreases cortisol levels an average of 31%. Limitations of this review are numerous and include (a) restriction to TRI studies; (b) equal weighting of all studies, despite the fact that they contain different numbers of participants; (c) using percentage of change as the measure of effect, instead of conventional and more rigorous meta-analytic effect sizes; and (d), omitting control group data from studies that randomized participants to both treatment and control groups. Each of these limitations has the potential to bias or invalidate the final conclusion, especially the last two. Total reliance on percentage of change as a measure of effect is potentially misleading, given this form of quantification presumes that zero is a realistic value for cortisol level, when it almost certainly is not. Further, no source that we know of advocates percentage of change as a statistically valid measure of effect. More egregious, however, is the decision to omit control group data from controlled studies. Possibly, the cortisol levels of control group participants decreased a similar amount, which would mean MT had no unique effect on cortisol. Alternately, if control participants’ cortisol levels tended to increase, omitting these data would mean that MT’s effect on cortisol would be significantly underestimated as a result. In addition, eliminating all control group data introduces numerous wellknown threats to validity, including time, spontaneous remission, attention and placebo effects, and regression to the mean. Because all control group data has been omitted from this review, its potential to inform us of the effect of MT on cortisol is extremely limited.
Field et al., 2007 The authors of this narrative review state that it is an update of Field’s 1998 narrative review (1998), and conclude that "we can confidently say that stimulating pressure receptors under the skin leads to a cascade of events including. decreasing cortisol, which may facilitate immune function" (p. 85). The limitations of this review are the same as those discussed in reference to the 1998 narrative review, and no mention of other researchers’ contradictory findings is made.
Moraska et al., 2008 This review examines stress-related physiological adjustments resulting from MT, including cortisol changes. A strength of this review is its systematic literature search. Because the review is not limited to studies that provide sufficient data for effect size calculation, the authors were able to include a larger sample of studies than some previous reviews. They located four studies that assessed only salivary cortisol, five studies that assessed only urinary cortisol, and four studies that assessed cortisol in both these ways. Based on these studies, they conclude that “hormonal variables associated with stress were largely unaffected by multiple massage treatments,” but go on to note that “a reduction in salivary cortisol was evident following a single massage treatment. [however] salivary cortisol returns to initial values when assessed at a later time point, even if massage therapy was administered during the interim timeframe” (p. 8). This review is limited by its dependence on analyses and conclusions presented in the original studies, as opposed to conducting a systematic, quantitative analysis based on the original data. This is problematic because the quality of MT research varies greatly, and it is not unusual for original study authors to perform unsuitable analyses (e.g., pre-post within-group analyses that do not match a study’s between-groups design) and, subsequently, to reach conclusions that are not supported by the data collected (Moyer, 2009). Six reviews, then, which draw on an overlapping set of original studies, reach quite different conclusions. The aim of the current review is to address this controversy by rigorously and comprehensively quantifying the effect of MT on recipients’ cortisol levels. Given the recent and rapid
6 increase in MT research (Moyer et al., 2009), we expect to improve on the number of studies that were able to be included in previous quantitative reviews. Further, we improve on narrative reviews, including the most recent ones, by (a) conducting a wide-ranging literature search to obtain the largest and least-biased possible sample of suitable studies; (b) objectively quantifying effects, as opposed to relying on a narrative format; (c) presenting the results of controlled, between-groups standardized mean difference effect sizes alongside the corresponding withingroup percentage reductions of cortisol that were experienced by MT participants; and (d) transparently reporting whether cortisol was assessed via blood, saliva, or urine.
Methods Operational definition MT can take various forms and can be applied to various anatomical sites. In addition, it is not established that commonly used MT terms (e.g., Swedish) have precise or universally agreed upon meanings. The present review operationalizes MT as the manual manipulation of soft tissue to promote health and wellness. We systematically exclude selfmassage and specific medical interventions (e.g., cardiac massage). Also excluded are combination treatments in which research participants receive MT in conjunction with some other form of treatment other than standard care. Use of lubricating oils or lotions and exposure to music are not considered part of combination treatment when used with MT, as these are commonly part of MT in ordinary practice.
Literature search and inclusion criteria A search concluded on January 6, 2010, using the keywords massage and cortisol, yielded the indicated number of articles in the following databases: CINAHL, 28; Dissertation Abstracts, 5; Google Scholar, 1997; PsycINFO, 168; and PubMed, 86. The abstract of each article was examined to determine possible relevance, and only articles that were clearly irrelevant were discarded, which resulted in an initial database of 173 articles requiring closer inspection. These 173 articles were scrutinized to determine if they (a) examined a treatment that fit our operational definition of MT, (b) provided graphical and/or numerical data on the effect of MT on cortisol levels in human recipients, (c) used random assignment of participants to an MT condition and one or more control conditions, and (d) reported results not duplicated in another retrieved article. This yielded 18 articles, containing 19 studies, that met all three criteria. The following information was then extracted, independently by two different raters, from those 18 articles and entered into a database: publication year, type of MT performed, site to which MT was administered, training of person(s) who administered MT, age of participants, duration of individual MT sessions, number of MT sessions, study duration, type of control(s) used, number of participants receiving MT or control treatment(s), form of cortisol assessment, and all relevant cortisol data. In cases where an article was suitable for inclusion but did not include sufficient data for effect size calculation (e.g., means are
C.A. Moyer et al. provided but standard deviations or standard errors are not), attempts were made to contact article authors to determine if the necessary data was available, but in no case was this effort fruitful.
Study details and data Study coding All data was coded by two raters independently. The lead author (C.A.M.) coded all studies, and three students (L.S., E.S.M., and L.M.J.) who received prior training from the lead author each coded a portion of the studies. Agreement rates (AR) were >92% for most categories; lower but acceptable agreement rates were attained for study ns (AR Z 85%) and therapist training (AR Z 82%). Discrepancies were resolved by first checking for coding or data entry errors, which were subsequently corrected. In the smaller number of instances where discrepancies represented a difference in judgment among coders, the first author (C.A.M.) conferred with the other rater before making a final determination. Types of effects MT effects can logically be divided into single-dose effects, which may result from a single session of treatment, and multiple-dose effects, which may result from a series of treatments (Moyer et al., 2004). MT’s effect on cortisol has been researched in both of these ways, sometimes simultaneously, as illustrated by a study of MT for infants of depressed mothers (Field, Grizzle, et al., 1996). In that study, infant subjects were randomly assigned to receive twice-weekly 15-minute sessions of MT, or to be held and rocked in a rocking chair according to the same schedule, across a period of six weeks. Single-dose effects were examined by pretest and posttest assessments of salivary cortisol performed at the first session of MT or rocking. Multiple-dose effects were examined by assessments of urinary cortisol prior to the first session, and following the twelfth and final session, for both groups. In some studies, the single-dose effect is examined twice; once at the first session in a series of treatments, and again at the last session in a series of treatments. This pattern makes it practical to separately examine the single-dose effects of a first session versus those of a last session. Beider and Moyer (2007) discovered that, for pediatric samples, the single-dose effect of a first MT session and those of a last MT session in a series are significantly different for state anxiety; both are effective, but the effect from the last session in a series is significantly larger. This suggests that there may be adaptive processes involved in receiving MT. For this reason, we examine the single-dose cortisol reducing effects of a first MT session in a series, and those of a last MT session in a series, separately. When primary studies administered only a single session of MT, as many do, we treat that single session as a first session in the current review. In all studies we examined, MT’s single-dose effect on cortisol is assessed by means of a blood draw or a saliva sample, both of which are suitable for capturing a shortterm change in cortisol (Lovallo and Thomas, 2000). Occasionally, the multiple-dose effect of MT on cortisol assessed in a specific study could be quantified in at least two ways. Urinary assessment of cortisol is most often used
Does massage therapy reduce cortisol? across a series of treatments, but selective use of salivary assessments taken at the corresponding times might also be used to capture the multiple-dose effect. Using assessments of cortisol in blood and saliva in this way allows inclusion of a greater number of studies to examine the multiple-dose effect in the current review, because there are some studies that administer a series of treatments without assessing urinary cortisol. The decision to proceed in this manner is supported by findings in recent large scale quantitative reviews concerned with cortisol that find no effect related to method of assessment (Meewisse et al., 2007; Michaud et al., 2008). Nevertheless, we include information on the method of cortisol assessment for each individual study and also conduct a separate analysis of multiple-dose effects based only on the results of urinary cortisol assessments. Multiple studies in a single document In all but one case, each MT research document includes a single study. The exception is the study by Olney (2007) in which two different MT treatment groups are included. In this case, we treated those results as separate independent studies in the current review because we wished to retain the unique information provided by two different MT conditions (one which delivers a series of five 10 m sessions of MT, and one which delivers a series of ten 10 m sessions of MT) even though this violates the condition that individual study effect sizes should be statistically independent (Lipsey and Wilson, 2001). We also check the influence of this decision on our results by conducting secondary analyses in which the two study results from Olney (2007) are averaged to yield a single study result. We also attempted to extract the following pieces of information from every study, as presented in Table 2. Exceptions were made when a category did not apply to a particular study. Anatomical site to which MT was applied Studies vary in the anatomical sites to which MT is applied. In some the site for MT is very limited and specific, while in others MT may be applied to the entire body. Based on our familiarity with the individual studies, we settled on the following descriptors: full body, upper body, back, neck and shoulders, feet. MT type We attempted to record information on the type of MT used in each study. However, at the conclusion of coding, we had to acknowledge that the MT terminology and methods of description in use to date are insufficient to yield usable information for this category. Eventually, the recent development and implementation of valid MT taxonomies (e.g., Sherman et al., 2006) may address this problem. Therapist training Most studies report having used a professional massage therapist for provision of treatment, while other studies report having used a layperson with only minimal MT training or provide no information on therapist training. We coded studies for therapist training in three ways; those that clearly used a professional massage therapist, those that used a minimally trained layperson, and those that provided no information on
7 therapist training. In cases where it was difficult to distinguish whether the person providing MT was professionally or minimally trained, we coded the study as having used a person with minimal training. Description of sample This indicates important characteristics of the participants, including clinical conditions. Sample age Almost all studies provide information on the age of participants. Most often this is expressed as a mean, but occasionally a range is provided. This data permits us to calculate results separately for children and adult recipients. In separate analyses, we considered studies in which the mean age of participants was less than 18 years of age to be a study of MT for children. Treatment minutes per dose This is the duration of each individual MT treatment administered in the study. Number of doses This is the number of MT treatments administered to a participant during the course of the study. Study duration This is the interval of time across which multiple MT treatments were administered. This category does not apply to studies that examine the effect of a single MT treatment. Description of control This indicates the form of time-matched treatment or attention that control participants received. MT and control N These are the number of participants who received MT or a control treatment. These groups are exclusive. Method of cortisol assessment This indicates if cortisol levels were assessed in blood, saliva, or urine. Quantification of effect Between-groups comparisons of cortisol levels were converted to Cohen’s d effect size. Cohen’s d, calculated as (Group Mean 1 e Group Mean 2)/pooled standard deviation, estimates the number of standard deviations by which the average member of a treatment group differs from the average member of a control group for a given outcome. Individual study effect sizes were subjected to a correction for small sample bias, then weighted by their inverse variance and averaged to generate a mean effect size for each outcome variable. Positive values represent a more desirable effect (i.e., a lower cortisol level) for participants who received MT. Homogeneity analyses were performed on each mean effect size by calculation of the Q statistic, to determine if the dispersion of the individual effect sizes around their mean is greater than that expected due to sampling error alone (Lipsey and Wilson, 2001). Statistical significance of the mean effect sizes was assessed by
8
Table 2
Individual study details.
Study
Site Train? Sample
Age
Mns/ #sess Pd sess
Ctrl
Ns
Arroyo-Morales et al. (2009)
FB
e
University students completing Wingate tests
21 yrs
40
1
Chin (1999)
B
e
Gynecologic surgery patients
42 yrs
10
Ditzen et al. (2007)
NS
e
Heterosexual partnered women
26 yrs
Field, Grizzle, et al. (1996)
FB
e
Infants of depressed mothers
Field, Ironson, et al. (1996) Field et al. (1997)
UB
Y
FB
Field et al. (2009)
Cort Between-groups Effect Sizes (d ) MT Ctrl asmt SD, first SD, last MD
e
Sham electrotherapy
32
2
2d
Attn
10
1
e
Attn (n Z 22), no treatment (n Z 25)
39w
15
12
Medical staff
26 yrs
15
N
Children with juvenile rheumatoid arthritis
10 yrs
FB
Y
Depressed pregnant women
Hernandez-Reif et al. (2000)
FB
Y
Hernandez-Reif et al. (2001)
FB
Hernandez-Reif et al. (2002)
0.13
e
e
34a 29b
B
0.13
0.00
0.00
20
47
S
0.11
e
e
6w
Held þ Rocking 20
20
S, U
0.20
e
0.82
10
5w
PMR
26
24
S
0.72
0.18
0.18
15
30
30d RT
10
10
S
0.70
0.55
0.55
25 yrs
20
6
6w
SC
22
21
S
e
0.18
0.18
Hypertensive adults
52 yrs
30
10
5w
PMR
15
15
S, U
0.00
0.35
0.35
Y
Adults with low back pain
40 yrs
30
10
5w
RT
12
12
U
e
e
0.38
FB
Y
Parkinson’s patients
58 yrs
30
10
5w
PMR
8
8
U
e
e
0.41
Hernandez-Reif et al. (2004)
FB
Y
Postsurgery breast cancer patients
53 yrs
30
15
5w
SC
18
16
U
e
e
0.08
Khilnani et al. (2003)
FB
Y
Children and adolescents with ADHD
13 yrs
20
9
4w
WL
15
15
S
0.00
0.14
0.14
Leivadi et al. (1999)
UB
Y
Female university dance students
20 yrs
30
10
5w
RT
15
15
S
0.15
0.11
0.11
Mackereth et al. (2009) F
e
Multiple sclerosis patients
50 yrs
40
6
6w
PMR
25
25
U
0.04
0.00
0.00
McVicar et al. (2007)
F
e
Healthy individuals
16e59 yrs 60
1
e
Attn
10
10
S
0.17
e
e
Menard (1995)
FB
Y
Gynecologic oncology patients 52 yrs
45
5
5d
SC
15
15
U
e
e
0.74
Olney (2007)
B
Y
Hypertensive and prehypertensive adults
10
5
2w
RT
13
14
S
e
e
0.24
49 yrs
C.A. Moyer et al.
S
28
Note. Dashes indicate that data were not reported, are not relevant, or could not be calculated. Site Z Anatomical site to which massage therapy was applied; FB Z Full body; B Z Back; NS Z Neck and shoulders; UB Z Upper body; F Z Feet. Train? Z Use of professionally trained massage therapist; Y Z Yes; N Z No. Mns/sess Z Length, in minutes, of individual massage therapy and control sessions. #sess Z Total number of massage therapy and control sessions administered. Pd Z Time period across which multiple sessions of treatment were distributed. Cort asmt Z Method of cortisol assessment; B Z In blood; S Z In saliva; U Z In urine. SD Z Single-dose; MD Z Multiple-dose; d Z Days; w Z Weeks; m Z Months; SC Z Standard care; Attn Z Attention; RT Z Relaxation therapy; PMR Z Progressive muscle relaxation. ADHD Z Attention-deficit hyperactivity disorder. Ns in italics indicate the original study reported only total N, and in these cases we assumed even distribution among massage therapy and control groups. a Zthis N was only 31 at the last session of massage therapy. b Zthis N was only 23 at the last control session. Effect sizes are recorded such that positive values indicate a lower level of cortisol for the massage therapy group compared to controls.
0.16 e e U 3 Y Taylor et al. (2003)
FB
Abdominal postsurgery women 56 yrs
45
3d
SC
34
36
e e 10 Y Olney (2007)
B
Hypertensive and prehypertensive adults
49 yrs
10
4w
RT
15
14
S
0.11
Does massage therapy reduce cortisol?
9 calculating the 95% confidence interval (CI) for the population parameter. A significance level of 0.05 or better is inferred when zero is not contained within the CI. A random-effects model was used for the calculation of all between-groups mean effects. As a supplement to the calculation of between-groups effects, and based on the same set of studies, we also present the within-group percentage-point reduction in cortisol level exhibited by MT recipients, which replicates the unconventional approach used in Field et al. (2005). This is calculated as (pretest cortisol value e posttest cortisol value)/pretest cortisol value, corresponding to the time interval of interest. Individual study’s percentage-point reductions were then weighted by study size (N of MT recipients) and averaged to yield mean percentage-point reductions.
Results Table 2 summarizes 19 studies, extracted from 18 reports, that provide quantifiable between-groups data on MT’s cortisol effect. The present dataset comprises 704 individuals (614 adults), 359 of whom were randomized to an MT condition (including 314 adults). As predicted, this is considerably more (over two-and-a-half times as many studies, and participants) than were able to be included in a quantitative analysis of cortisol effects published in 2004 (Moyer et al., 2004). The average session length for MT, across all participants in the current dataset, was 26 and-ahalf minutes (range 10e60 m). Table 3 summarizes all of the following between-groups effects as well as the supplementary analysis of withingroup percentage-point reductions of cortisol exhibited by MT recipients.
Between-groups effect sizes Single-dose, first session There were 460 participants across eleven studies who were randomly assigned to receive either a single-dose of MT that could be considered the first in a series of treatments, or a time-matched control treatment. Comparison of MT versus control posttest values indicates that MT did not reduce cortisol significantly more than control treatments (d Z 0.15, 95% CI Z 0.04, 0.34). These results are displayed graphically in Figure 1. Examined separately, children’s (N Z 90) and adults’ (N Z 370) effect sizes were also both nonsignificant (d Z 0.23, 95% CI Z 0.19, 0.65; and d Z 0.13, 95% CI Z 0.08, 0.34, respectively). Homogeneity analyses for all three of these effects were nonsignificant (all three ps > 0.49), which suggests there is no more variability around these effects than that expected from sampling error. Single-dose, last session There were 307 participants across eight studies who were randomly assigned to receive either a single-dose of MT that could be considered the last in a series of treatments, or a time-matched control treatment. Comparison of MT versus control posttest values indicates that MT did not reduce cortisol more than control treatments (d Z 0.15, 95% CI Z 0.08, 0.37). These results are displayed graphically in Figure 2.
10
C.A. Moyer et al.
Table 3
Mean cortisol reductions across massage therapy studies. Between-groups effect sizes
Within-group reductions for MT
d
95% CI
N
Study entries
Single-dose, first in series Children Adults
0.15 0.23 0.13
0.04, 0.34 0.19, 0.65 0.08, 0.34
460 90 370
11 3 8
7.12 1.41 5.51
12.8 20.7 10.8
Single-dose, last in series Children Adults
0.15 0.30 0.12
0.08, 0.37 0.27, 0.87 0.13, 0.37
307 50 257
8 2 6
1.67 0.48 0.86
18.6 18.5 18.6
Multiple-dose Children Adults
0.12 0.52a 0.05
0.05, 0.28 0.09, 0.95 0.13, 0.22
598 90 508
16 3 13
13.84 1.88 7.88
22.1 35.0 19.8
a
Q
%
p < 0.05.
Examined separately, children’s (N Z 50) and adults’ (N Z 257) effect sizes were also both nonsignificant (d Z 0.30, 95% CI Z 0.27, 0.87; and d Z 0.12, 95% CI Z 0.13, 0.37, respectively). Homogeneity analyses for these three mean effects were nonsignificant (all three ps > 0.49), which suggests there is no more variability around these effects than that expected from sampling error. Multiple-dose There were 598 participants across sixteen studies who were randomly assigned to receive either a multiple-dose
Figure 1
series of MT treatments or a time-matched control treatment. Comparison of MT versus control posttest values indicates that, across all participants, MT did not reduce cortisol more than control treatments (d Z 0.12, 95% CI Z 0.05, 0.28). These results are displayed graphically in Figure 3. Averaging the results of the two studies contained in Olney (2007) as a single study, as opposed to treating them as statistically independent studies, has little influence on this result (d Z 0.13, 95% CI Z 0.04, 0.29). We also conducted a supplementary analysis of multipledose effects based only on the results of urinary cortisol
Single-dose, first in series effect sizes and 95% confidence intervals.
Does massage therapy reduce cortisol?
Figure 2
11
Single-dose, last in series effect sizes and 95% confidence intervals.
assessments. The result from this smaller subset of six studies and 249 participants is essentially the same mean effect bracketed by a wider confidence interval (d Z 0.15, 95% CI Z 0.11, 0.41). When multiple-dose effects are examined individually according to the age range of participants, results diverge. The result for adults (N Z 508) is very small and nonsignificant regardless of whether the results from Olney (2007) are treated as two independent studies (d Z 0.05, 95% CI Z 0.13, 0.22) or averaged as a single study (d Z 0.06, 95% CI Z 0.12, 0.23). In contrast, children’s (N Z 90) cortisol was reduced significantly more by multiple doses of MT than by control treatments (d Z 0.52, 95% CI Z 0.09, 0.95, p < 0.05). Homogeneity analyses for all three multiple-dose effects were nonsignificant (all three ps > 0.39), which suggests there is no more variability around these effects than that expected from sampling error.
Within-group percentage reductions of cortisol exhibited by MT participants Though we do not wish to emphasize them as our primary findings, we also calculated the within-group effect on cortisol evidenced by massage therapy participants, expressed as percentage-point reductions. Our motivation for doing this was to permit direct comparisons with the results of Field et al. (2005), and with the current betweengroups results. MT recipients in these between-groups studies exhibit mean reductions of cortisol that range from 10.8% (single-dose reduction from a first treatment in adults) to 35.0% (multiple-dose reduction in children). Eight of these nine means are lower than the 31% mean cortisol reduction reported by Field et al. (2005), a difference that
is probably attributable to using an overlapping but not identical set of studies, and to our decision to weight these reductions by sample size prior to averaging. There are numerous discrepancies between the between-groups and within-group results. For example, most of the within-group reductions cluster near a 20% reduction (six of them are between 18.5% and 22.1%), but the corresponding between-groups effects for these studies exhibit a six-fold range (d Z 0.05e0.30). Further, the correlations between individual studies’ between-groups effect sizes and their within-group percentage-point reductions do not attain values indicative of good reliability (r Z 0.42 for single-dose, first session; r Z 0.25 for singledose, last session; r Z 0.73 for multiple-dose). Because the meta-analytic procedures for calculating standardized mean effects such as d have been widely used and refined, and are recommended by many methodologists (Lipsey and Wilson, 2001; Hunter and Schmidt, 2004; Rosenthal, 1998), and also because quantifying treatment effects only from the treatment group data collected in controlled trials introduces numerous well-known confounds (e.g., time, spontaneous remission, attention and placebo effects, and regression to the mean), we conclude that the general lack of correspondence between the between-groups and within-group effects demonstrates the latter’s unsuitability as an index of treatment effectiveness.
Discussion The assertion that MT significantly reduces cortisol levels is refuted by the results of this review. These results are highly consistent with the results of prior quantitative reviews, and the methods by which they have been reached
12
C.A. Moyer et al.
Figure 3
Multiple-dose effect sizes and 95% confidence intervals.
are transparent and much less prone to bias than those of narrative reviews. As such, we confidently recommend that the current results, and the conclusions to which they lead, should replace those reached in narrative reviews concerned with the effect of MT on cortisol. MT’s mean effect on cortisol is very small and, in most cases, not statistically distinguishable from zero. The exception to this is the multiple-dose effect of MT on the cortisol levels of children. This effect does reach statistical significance, though we hasten to add that it is based on a very small number of studies and participants, and so is vulnerable to the file-drawer threat (the likelihood that even a small number of relevant but unpublished, and therefore irretrievable, studies with null findings are languishing in the desk drawers of the researchers who conducted them). In addition, this effect combines the results of an infant study (mean subject age 39 weeks) with those of two studies on
more developed children (mean participant ages 10 and 13 years), and the effect contributed by the infant study is the largest by a considerable margin. It is possible that MTs effect on the cortisol levels of infants is distinct from its effect on other age populations, but currently available data do not permit this possibility to be examined further. The results of studies conducted with adults, on the other hand, are based on larger numbers of studies and participants, are highly uniform, and have reasonably narrow confidence intervals. In addition, the homogeneity analyses for these effects indicate that there is no more variability among the individual study effects than that expected from sampling error, which gives little reason to believe that some sizable cortisol reduction associated with MT performed for a certain duration, in a certain way, to a certain anatomical site, or under certain conditions, is being washed out by other forms of MT that do not reduce cortisol. In other words, the various
Does massage therapy reduce cortisol? forms of MT being combined in these analyses appear to be equally ineffective in reducing cortisol levels. However, it should not be concluded from this that MT is ineffective. MT has already been shown to have some significant and sizable clinical effects, especially for reducing anxiety, which may prove to be its most useful clinical effect and the basis of several of its other effects (Moyer, 2008). Rather, what the results of this review make apparent is that MT cannot be generating its sizable and proven reductions of state and trait anxiety, depression, and some types of pain by first reducing cortisol. Indeed, it is likely that the very small mean effect that MT has on cortisol e in most cases a reduction only 0.15 standard deviations better than control e is a clinically insignificant downstream effect, not the fundamental upstream cause, of MT’s large effect on anxiety.
How does MT actually provide its verified clinical benefits? While this review answers the question “does MT reduce cortisol?’ e to which the answer is “very little, if at all” e in other ways it raises more questions than it answers. If MT does not provide its proven clinical benefits by first impacting the endocrine system in this way, how then does it work? Does it work primarily in one way, perhaps by first reducing anxiety, which carries over to other outcome categories, such as depression and pain, or is there a unique MT mechanism for reducing each of these? Will it be more fruitful to examine the impact of MT on the relatively faster-acting branches of the nervous system, as opposed to the relatively slower-acting endocrine system, to determine the biological underpinnings of MT benefits? Does it make sense to search for uniform biological mechanisms enacted by MT, or will it be necessary to construct explanatory models that emphasize the interaction of biological processes with psychological phenomena and social contexts that are associated with MT? We do not yet know the answers to these questions. But we do know that they need to be researched, and we are concerned that they tend to be ignored when a competing explanation has been repeatedly and overconfidently asserted without supporting evidence, as has been the case with MT and cortisol reduction. We hope that the current review might stimulate other researchers’ interest in the unknown causal mechanisms of MT’s clinical effects, as it has for us.
Funding This project was not supported by any outside funding.
Conflict of interest The authors have no conflict of interests to declare.
Author Note We thank Ralph R. Hoffman, Hong-Youn Kim, Jessica E. Moyer, Rebekah Mroz, Joel Schwartz, and Karen Sinz for their assistance in the completion of this study.
13
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Journal of Bodywork & Movement Therapies (2011) 15, 15e23
available at www.sciencedirect.com
journal homepage: www.elsevier.com/jbmt
RANDOMIZED CONTROLLED COMPARATIVE STUDY
The immediate effects of traditional Thai massage on heart rate variability and stress-related parameters in patients with back pain associated with myofascial trigger points Vitsarut Buttagat, B.Sc., M.Sc., PhD candidate a,*, Wichai Eungpinichpong, B.Sc., M.Sc., PhD a, Uraiwon Chatchawan, B.Sc., M.PH., PhD a, Samerduen Kharmwan, MD b a b
Division of Physical Therapy, Faculty of Associated Medical Sciences, Khon Kaen University, Khon Kaen 40002, Thailand Department of Rehabilitation Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand
Received 29 December 2008; received in revised form 13 June 2009; accepted 16 June 2009
KEYWORDS Massage; Traditional Thai massage; Myofascial trigger point; Back pain; Randomized control trial
Summary The purpose of this study was to investigate the immediate effects of traditional Thai massage (TTM) on stress-related parameters including heart rate variability (HRV), anxiety, muscle tension, pain intensity, pressure pain threshold, and body flexibility in patients with back pain associated with myofascial trigger points. Thirty-six patients were randomly allocated to receive a 30-min session of either TTM or control (rest on bed) for one session. Results indicated that TTM was associated with significant increases in HRV (increased total power frequency (TPF) and high frequency (HF)), pressure pain threshold (PPT) and body flexibility (p < 0.05) and significant decreases in self-reported pain intensity, anxiety and muscle tension (p < 0.001). For all outcomes, similar changes were not observed in the control group. The adjusted post-test mean values for TPF, HF, PPT and body flexibility were significantly higher in the TTM group when compared with the control group (p < 0.01) and the values for pain intensity, anxiety and muscle tension were significantly lower. We conclude that TTM can increase HRV and improve stress-related parameters in this patient population. ª 2009 Elsevier Ltd. All rights reserved.
* Corresponding author. Tel./fax: þ66 43 202 085. E-mail address:
[email protected] (V. Buttagat). 1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.06.005
16
Background Myofascial pain syndrome (MPS) has been defined as musculoskeletal pain arising from one or several hyperirritable spots within the belly of muscle(s) called myofascial trigger points (MTrPs) (Fricton and Awad, 1989). MPS is associated with many musculoskeletal conditions. A Thai study found that MPS was the primary diagnosis in 36% of 431 patients with musculoskeletal disorders (Chaiamnuay et al., 1998) and a study at a pain clinic reported that MPS was cited as the most common cause of pain; occurring in 85% of people with back pain (Fishbain et al., 1986). The pathophysiology of MPS is largely unknown making it difficult to design effective approaches for its treatment, although numerous therapeutic approaches, both pharmological and non-pharmalogical, have been tried with varying success rates. Massage therapy is now one of the most frequently used alternative treatments for back pain (Eisenberg et al., 1998). Traditional Thai massage (TTM) is a form of deep massage with brief sustained pressure on the muscles. Pressure point massage along the body’s hypothesised 10 major energy channels or ‘‘Sen Sib’’ is believed to release blocked energy and to increase awareness and vitality. Gentle stretching of the muscles relieves tension, enhances flexibility, and induces a deep state of tranquility (Tapanya, 1993). The report by Chaithavuthi and Muangsiri (2005) suggests that TTM also increases blood circulation, lowers heart rate, reduces pain, improves the depth of breathing and promotes relaxation. However, controlled studies to support the effectiveness of TTM for the treatment of different conditions are limited (Chatchawan et al., 2005). There is no published research that objectively assesses the physiological changes involved with the reported relaxation response following TTM, which could be done using methods such as evaluation of heart rate variability. Heart rate variability (HRV) is controlled by the autonomic nervous system. Generally, sympathetic nervous system (SNS) activity increases heart rate (decreases HRV) and parasympathetic nervous system (PNS) activity decreases heart rate (increases HRV). Observed HRV is believed to be an indicator of the dynamic interaction and balance between the SNS and the PNS (Terathongkum and Pickler, 2004; Task Force of The European Society of Cardiology and The North American Society of Pacing and Electrophysiology, 1996). There is evidence to suggest that the balance between SNS and PNS is affected by MPS. This is supported by Perry et al. (1989) who report patients with chronic MPS and with arthritis had decreased parasympathetic activity and increased sympathetic activity, and by Delaney et al. (2002) who found that myofascial trigger point massage therapy (MTPT) decreased heart rate, systolic blood pressure and diastolic blood pressure and increased parasympathetic activity. The later study also found a related self-perceived reduction in muscle tension when compared to the baseline. Regional and/or referred pain are characteristic of MPS, which can lead to anxiety and depression and reduced HRV if not effectively treated (Carney et al., 1995; Stauss, 2003; Terathongkum and Pickler, 2004; Tousignant-Laflamme and Marchand, 2006; Hummel and van Dijk, 2006).
V. Buttagat et al. Measurement of HRV to investigate autonomic influence on the cardiovascular system can be done using a simple, sensitive and non-invasive technique. This technique is increasingly being used as a powerful predictor of hypertension in patients (Terathongkum and Pickler, 2004; Delaney et al., 2002). One of the conventional methods for analyzing HRV is the frequency domain method that uses spectral analysis to quantify the frequency content of the ECG signals. This analysis has been used to determine the total power frequency and power of high and low frequencies, data that can then be used to determine the contribution of the sympathetic and parasympathetic nervous system to the variability in heart rate. It is generally accepted that vagal activity is the major contributor to the high frequency (HF) component of the spectral analysis, thus an increase in HF power (as well as an increase in total power) reflects increased parasympathetic activity. Interpretation of increased LF power is still unclear and depends to some extent on the unit of measure used. An increase in absolute value of power (ms2) of the LF component may reflect both sympathetic and parasympathetic activity. The LF/HF ratio is considered to be an index of sympathetic/vagal balance with an increase in the ratio suggesting either an increase in sympathetic cardiac modulation or a decrease in parasympathetic modulation, or both (Task Force of The European Society of Cardiology and The North American Society of Pacing and Electrophysiology, 1996; Terathongkum and Pickler, 2004). HRV analysis has also been used to evaluate changes in sympathovagal tone during various emotional states (such as stress and anxiety) and pain (Carney et al., 1995; Stauss, 2003; Terathongkum and Pickler, 2004; TousignantLaflamme and Marchand, 2006; Hummel and van Dijk, 2006). Current literature suggests that the relaxation response, meditation, prayer, yoga and therapeutic touch have each been associated with physiologic changes indicating decreased emotional stress and increased parasympathetic activity, which were measurable by HRV (Terathongkum and Pickler, 2004; Benson et al., 1974). In addition, Diego et al. (2005) reported that massage therapy increased the cardiac vagal index (CVI), vagal tone, gastric motility and decreased tachygastria in a group of preterm neonates when compared with sham massage in a control group. Given the value of HRV as a measure of PNS activity and the lack of evidence about the effect of TTM on the autonomic nervous system we investigated the effects of TTM on HRV and other stress-related parameters in patients with back pain associated with MTrPs.
Methods Design and setting A randomized control trial was conducted in the Division of Physical Therapy, Faculty of Associated Medical Sciences, Khon Kaen University, Thailand. The study was approved by the ethical committee of Khon Kaen University.
Thai massage in patients with back pain
Participants Patients with back pain associated with MTrPs were recruited from Khon Kaen province using bulletin boards and oral requests for participants during a 7-month period between September 2007 and March 2008. The clinical criteria for the diagnosis of MTrPs in this study were adapted from those specified by Travell and Simons (1983). Participants were included if they presented with chronic back pain, which had lasted longer than 12 weeks, and had at least one trigger point in the upper and/or lower back region. Trigger points were diagnosed as the presence of spot tenderness in areas that the patient identified as painful. The criteria for exclusion from the study was based on any history of disease or other disorder, which may affect heart rate variability (HRV); such as myocardial infarction, hypertension, neuropathy diabetes mellitus, fever, a history of acute trauma, spinal fracture, inflammatory arthritis (rheumatoid arthritis or gout), muscle diseases, evidence of neurological deficits, and/or skin diseases. Each patient signed an informed consent form prior to the baseline examination. Estimation of the sample size was based on a pilot study (n Z 7) that compared the immediate effect of TTM (four patients) with that of control treatment (three patients) for subjects with back pain associated with MTrPs. Based on data of the pilot study, a standard deviation (of HF power) of 919.7 was used to calculate the sample size needed to detect a 866.1 ms2 change in HF power (based on the post-test mean differences between groups) which was considered as the level to accept clinical significance of the results with 80% power and 5% significance. In addition, a drop-out rate of 20% was allowed for in estimating the total sample size. According to these criteria, 36 patients were recruited.
Procedure Randomization The 36 patients who met the above inclusion criteria were randomly assigned to either the treatment (TTM) group or
17 the control group using block randomized allocation with block sizes of 2, 4, and 6. Groups were assigned using a pre-generated random assignment scheme enclosed in envelopes (STATA Version 9), which resulted in a total of 18 patients per group.
Treatment Treatment group (traditional Thai massage e TTM) Participants received one 30-min session of TTM onto the back muscles while lying in the prone position during the period between 10.00 and 13.00 h on the day of the study. Based on the experience of the first three authors who work as both physiotherapists and massage therapists, plus the outcome of the pilot study, a 30-min session was considered appropriate for an effective impact of massage when confined to the back area only. All TTM in this study was conducted by a well-trained massage therapist, according to the system of royal Thai massage, which applies the theory of ‘‘Sen Sib’’ or the 10 meridian lines. Massage points included in this method are located along two lines and at an additional, single, point along the paravertebral muscles on each side of the spine (Chatchawan et al., 2005). The two lines on the left side of participants are called Ittha and the two lines on the right side of participants are called Pingkhala (Figure 1). The pressing technique employed in TTM uses the body weight of the massage therapist to apply gentle, gradually increasing, pressure through the therapist’s thumb, fingers, or palm. Pressure is applied until the patient starts to feel slight discomfort after which this pressure is maintained for 5e10 s at a time. This sequence can be repeated several times for each massage point (Chatchawan et al., 2005). Control group The control group relaxed by lying prone quietly in the same environment and for the same period of time as the treatment group. After the study period had ended and all data were collected, the control group were offered a session of TTM for their back. The same pre- and posttreatment assessments were conducted on both groups.
Figure 1 The massage points, along the two meridian lines running from thoraco-cervical junction or C7 to posterior superior iliac spine (PSIS).
18 At the end of the study, all participants in both groups were given the opportunity for instruction in a series of back exercises to conduct at home.
V. Buttagat et al. feel confused’, are answered in terms of severity (not at all, a little, somewhat and very much so). The STAI score has a high correlation with stress (r Z 0.93) (Thai version) (Lertluechachai, 1989).
Outcome measures All outcome measures were assessed before and after the TTM and control sessions. Details of outcome measures and how they were assessed is described below. Heart rate variability (HRV) Participants were requested not to eat, drink or smoke for 4 h before the measurements and during the measurement they were asked to refrain from talking, falling asleep, making exaggerated body movements, and/or intentionally altering their respiration. Before HRV measurement, participants rested in a prone position at room temperature (25 C) for 20 min. HRV was assessed before and immediately after the treatment/control period. Analysis was based on a 10 min period of ECG signal acquisition, followed by computerized Fourier analysis of the ECG waves, using the BIOPAC system. Participants were carefully monitored using the BIOPAC Respiratory Transducer SS5LB to ensure there were no significant respiratory pattern changes during the ECG measurement. HRV was then calculated manually using the power spectral analysis method (frequency domain method). The parameters used were set as follows: total power frequency (TPF) (0.00e0.40 Hz), low frequency (LF) power (0.04e0.15 Hz), high frequency (HF) power (0.15e0.40 Hz). The low frequency to high frequency ratio (LF/HF ratio) was calculated based on the outcome of the power spectral analysis. HF power was the main parameter of interest in this study. Pain intensity and muscle tension Pain intensity and muscle tension were assessed using separate 10-cm visual analogue scales (VAS). The intensity of pain and feeling of muscle tension were reported by the participants using numerical analog scales ranging from 0 to 10 on which 0 indicated no pain or no muscle tension, respectively, and 10 indicated the most pain ever and the tensest ever experienced. Reliability of data obtained with these VAS is reported to be high (r Z 0.99) (Scott and Huskisson, 1979), with high construct validity (Wilkie et al., 1990). Pressure pain threshold (PPT) The pressure pain threshold was measured using the pressure algometry technique recommend by Fisher (1986, 1988) and evaluated by Reeves et al. (1986). The participant was asked to signal when he or she began to feel pain or any discomfort, at which point the compression was stopped (Esenyel et al., 2000). Each trigger point was measured three times and the average was taken for analysis. Results of the pressure measurements were expressed in kg/cm2. The precision of measurement was 0.1 kg/cm2. State anxiety inventory (STAI) The state anxiety inventory (Thai version), is a 20-item inventory on how the participant feels at the moment. Characteristic items, which include ‘I feel at ease’ and ‘I
Body flexibility A sit-and-reach box was used to measure body flexibility. Body flexibility was measured three times and the average was computed for inclusion in the analysis reported here. Reliability of data obtained with the sit-and-reach box is reported to be high (r Z 0.97) (Chatchawan, 2005).
Statistical analyses Data were analyzed using STATA Version 9. Descriptive statistics were used to describe the continuous and categorical data including number of participants, age, weight, sex, etc. Mean and standard deviations of the values were calculated for each variable. Paired t-tests were used to compare outcome variables at baseline with outcome measures immediately after the treatment or control period within each respective group. An analysis of covariance (ANCOVA) was used to compare the difference in post-test values between the control and treatment groups after adjusting for differences in baseline values, for each outcome measure. A difference at the level of p < 0.05 was considered statistically significant.
Results Demographic and baseline clinical characteristic Demographic data and baseline clinical characteristics of the patients are presented in Table 1. Of the 36 patients enrolled in this study, 20 were female and 16 were male. Their mean age was 22.6 2.9 years. Eighty-three percent of the patients were students. In more than 88% of all cases, the most painful trigger point of each patient was found in the lower part of the back. Baseline results for HRV and other outcomes measured pre- and post-treatment are shown in Table 2. Most baseline characteristics were equally balanced between the two groups except that the TTM group had a higher high frequency (HF) heart rate variability measurement and had greater body flexibility.
Immediate effects of traditional Thai massage on heart rate variability Table 2 shows that immediately after receiving TTM; the TPF, LF power and HF power components of HRV were significantly increased when compared with pre-treatment values (t Z 4.2, p < 0.001; t Z 3.7, p Z 0.002; and t Z 4.7, p < 0.001, respectively) and the LF/HF ratio was significantly decreased (t Z 2.3, p Z 0.032). In contrast, no statistically significant difference was found in the control group except for LF/HF ratio, which increased following the control period. When comparing between the two groups (Table 3), it was found that, after adjustment for baseline levels, the post-test values for TPF and HF power among the TTM group were significantly higher than those found
Thai massage in patients with back pain Table 1
19
Demographic and baseline clinical characteristics of patients with back pain associated with MTrP.
Characteristics Number of patients Demographic data Age (years); mean (SD) Gender; n (%) of female Weight (kg); mean (SD) Height (cm); mean (SD) Body mass index; n (%) <18.5 18.5e22.9 23e24.9 25e29.9 Occupation or study, n (%) Student Physical therapist Teacher Police inspector Back pain with MTrP area; n (%) Upper part of the back Lower part of the back Severity of back pain: by pain scale; mean (SD) Severity of back pain: by muscle tension scale; mean (SD) Duration of back pain episode (month)
TTM
Control 18
18
Total 36
22.9 11 54.72 164.28
(3.4) (61.1) (7.7) (7.7)
22.3 9 54.89 163.44
(2.6) (50.0) (10.3) (7.6)
22.64 20 54.81 163.86
(2.9) (55.6) (8.9) (7.6)
4 12 2 0
(2.2) (66.7) (11.1) (0.0)
6 10 1 1
(33.3) (55.6) (5.6) (5.6)
10 22 3 1
(27.8) (61.1) (8.3) (2.8)
16 1 0 1
(88.9) (5.6) (0.0) (5.6)
14 3 1 0
(77.8) (16.7) (5.6) (0.0)
30 4 1 1
(83.3) (11.1) (2.8) (2.8)
1 (5.6) 17 (94.4) 5.2 (2.0)
2 (11.1) 16 (88.9) 4.6 (1.4)
3 (8.3) 33 (91.7) 4.9 (1.7)
4.7 (1.7)
4.1 (1.8)
4.4 (1.8)
19.1 (16.1)
14.1 (16.6)
17.0 (16.2)
Note: TTM is traditional Thai massage.
among the control group (F Z 23.55, p Z 0.006 and F Z 36.24, p < 0.001, respectively) whereas the post-test LF/HF ratio was lower in the treatment group than the control group (F Z 25.89, p < 0.001). There was no significant difference in the post-test LF power values between the two groups.
Immediate effects of traditional Thai massage on other parameters The pain intensity (VAS), pressure pain threshold, muscle tension (VAS), body flexibility and state anxiety inventory (STAI) all showed significant improvements with TTM treatment (t Z 9.4, p < 0.001; t Z 10.8, p < 0.001; t Z 7.0, p < 0.001; t Z 4.7, p < 0.001; and t Z 6.6, p < 0.001, respectively). No statistically significant differences were found in these five parameters pre- to post-test among the control group except for a negative change in body flexibility (Table 2). A comparison of the adjusted post-test values for the five non-HRV related outcome measures between the TTM and control groups indicated a significant improvement in these parameters in the TTM group (F Z 45.57, p < 0.001; F Z 106.75, p < 0.001; F Z 20.67, p < 0.001; F Z 250.86, p < 0.001; and F Z 10.19, p Z 0.026, respectively) (Table 3).
Discussion The outcomes of this study support that theory of Moyer et al. (2004) that massage has an effect on the PNS. Findings from this present study suggest that TTM onto the back
muscle of patients with back pain associated with MTrP is effective in increasing cardiac parasympathetic activity and decreasing sympathetic activity. The consequences of these changes to the autonomic system manifest as: increased TPF and HF power and a decrease in LF/HF ratio. Associated effects of these changes, as observed in this study, are: decreased pain and related increased pressure pain threshold, and decreased muscle tension and feeling of stress (Tables 1 and 2). These findings are in accordance with those of Delaney et al. (2002) and Diego et al. (2005), as described in the background section of this paper. However, it should be noted that some aspects of these studies differ from the present study, which include underlying condition, the body area treated, the position of patients during treatment, the massage technique and the duration of treatment. An increase in LF power after receiving TTM was found in this study (Table 2). This finding of increased LF power is in accordance with the study of Delaney et al. (2002) which showed a trend toward increase of LF power but did not show a statistically significant increase following treatment by MTPT (the LF power in the MTPT group at baseline was 910 ms2 and this was increased to 1390 ms2 after treatment). However, interpretation of increased LF power is still unclear. From comparison of results between the treatment and control groups we can conclude that treatment by TTM among patients with back pain associated with MTrP is superior to the control condition of rest in the prone position. The mechanisms by which TTM may enhance heart rate variability and cardiac parasympathetic activity and the
20
Table 2
Comparison of the outcome measures between baseline (pre-test) and post-test assessments in the TTM and control groups (paired t-tests).
Parameter
TTM (n Z 18)
CONTROL (n Z 18)
Baseline (mean (SD))
Post-test (mean (SD))
Difference (95% CI)
Heart rate variability (HRV) Total power frequency (TPF): ms2 Low frequency (LF): ms2
1264.4 (910.8)
2066.9 (1346.8)
281.3 (253.9)
496.7 (313.1)
High frequency (HF): ms2
478.7 (520.5)
1012 (763.5)
0.87 (0.53)
0.66 (0.35)
5.2 (1.9)
2.6 (1.9)
3.0 (0.95)
4.4 (1.1)
802.5 (395.1 to 1209.9) 215.4 (93.4 to 337.3) 533.3 (294.9 to 771.7) 0.21 (0.40 to 0.02) 2.6 (3.2 to 2.0) 1.4 (1.1 to 1.7)
4.7 (1.7)
2.3 (1.9)
2.6 (7.4)
4.9 (7.1)
40.1 (9.4)
31.4 (7.4)
Low frequency to high frequency (LF/HF) Other parameters: pain scale (VAS) Pressure pain threshold (PPT) Muscle tension (VAS) Body flexibility State anxiety inventory (STAI)
2.5 ( 3.2 to 1.7) 2.4 (1.3 to 3.4) 8.7 (11.4 to 5.9)
t value
p value
Baseline (mean (SD))
Post-test (mean (SD))
Difference (95% CI)
t value
4.2
<0.001
1211.3 (933.4)
1249.6 (857.5)
0.2
0.828
3.7
0.002
305.2 (276.4)
428.2 (360.6)
1.7
0.101
4.7
<0.001
405.1 (220.1)
340.5 (209.1)
1.3
0.198
2.3
0.032
0.71 (0.39)
1.2 (0.68)
5.6
<0.001
9.4
<0.001
4.6 (1.4)
4.8 (1.4)
0.9
0.407
10.8
<0.001
2.7 (1.0)
2.7 (1.0)
0.3
0.791
7.0
<0.001
4.1 (1.8)
4.5 (2.1)
0.9
0.375
4.7
<0.001
1.3 (8.5)
3.9 (9.2)
4.4
<0.001
6.6
<0.001
38.3 (328.6 to 405.3) 123 (26.5 to 272.5) 64.6 (166.5 to 37.2) 0.53 (0.33 to 0.74) 0.2 (0.31 to 0.72) 0.0 (0.26 to 0.20) 0.4 (0.48 to 1.2) 2.6 (3.9 to 1.37) 2.3 (2.5 to 7.2)
1.0
0.325
39 (5.7)
36.7 (10.7)
p value
Note: TTM is traditional Thai massage. A difference at the level of P < 0.05 is considered statistically significant. ms2 Z millisecond square.
V. Buttagat et al.
Thai massage in patients with back pain
21
Table 3 Comparison of mean post-test measures between the treatment and control groups after adjustment for differences in baseline values (ANCOVA). Parameter Heart rate variability (HRV) Total power frequency (TPF): ms2 Low frequency (LF): ms2 High frequency (HF): ms2 Low frequency to high frequency ratio (LF/HF ratio) Other parameters Pain scale (VAS) Pressure pain threshold (PPT) Muscle tension (VAS) Body flexibility State anxiety inventory (STAI)
TTM (n Z 18)
Control (n Z 18)
Difference (95% CI)
2043.2
1273.3
769.9 (237.4e1302.4)
23.55
0.006
418.9 379.3 1.3
87.0 (97.5e271.6) 593.9 (339.5e848.2) 0.72 (0.45e0.9)
10.02 36.24 25.89
0.344 <0.001 <0.001
2.7 (1.9e3.4) 1.5 (1.1e1.8)
45.57 106.75
<0.001 <0.001
2.7 (1.6e3.7) 5.0 (3.3e6.7) 5.9 (0.8e11.1)
20.67 250.86 10.19
<0.001 <0.001 0.026
505.9 973.2 0.59
2.4 4.3
5.1 2.8
2.0 3.0 31.1
4.7 2.0 37.0
F value
P value
Note: TTM is traditional Thai massage; a difference at the level of p < 0.05 is considered statistically significant. ms2 Z millisecond square.
associated perception of pain, muscle tension and stress is discussed in more detail as follows. (a) Increased HRV and relaxation. TTM is known to promote relaxation and decrease stress and anxiety (Chaithavuthi and Muangsiri, 2005; Cowen et al., 2006). Delaney et al. (2002) and Benson et al. (1974; Benson, 1983) suggest that these findings are probably the result of an increased relaxation response and an overall reduction in the defence-arousal (stress) response as a result of TTM, possibly mediated by increased parasympathetic and decreased sympathetic activity. Other studies report an association between massage and increased levels of serotonin (5HIAA) and dopamine, again indicating modulation of the autonomic nervous system and expected decreased anxiety (Field et al., 2007; Carney et al., 1995). Our study verified these findings of decreased perceived stress and anxiety, while also providing evidence for the physiological mechanism behind these outcomes, i.e., enhanced PNS activity and increased HRV. (b) Decreased pain and PNS activity. Mackawan et al. (2007) showed that TTM onto low back muscle for 10 min can temporarily relieve pain in patients with non-specific low back pain and proposed that this may be explained by gate-control theory. The study reported in this paper demonstrated that self-reported pain intensity was reduced after TTM treatment and that the pain pressure threshold (PPT) correspondingly increased. Increased PPT after TTM is consistent with findings by Chatchawan et al. (2005) and with the theory proposed by Simons (2002) that local pressure may normalize the length of sarcomeres by stretching the involved muscle fiber, consequently increasing the energy supply to the area and decreasing MTrP
sensitivity. Decreased pain has been shown to increase cardiac parasympathetic activity and decrease sympathetic activity (Tousignant-Laflamme and Marchand, 2006; Hummel and van Dijk, 2006), a relationship supported by our study. (c) Patient position and PNS activity. TTM onto back muscle in prone position may stimulate the parasympathetic nervous system by increasing regional cerebral blood flow (rCBF). Ouchi et al. (2006) reported that pressure stimulation by massage onto the back muscles in the prone position increased rCBF in the parietal (precuneus) and occipital cortices, which leads to greater activity in this area and stimulates an increase in parasympathetic activity. It is, therefore, feasible that the position of the treatment group when receiving TTM in our study assisted in increasing HRV. (d) Pressure massage and HRV. Moderate pressure massage may involve stimulation of pressure receptors, which has been shown in animal studies to activate the vagus, leading to increased heart rate variability (UvnasMoberg, 1994). Since TTM is a type of pressure massage it is feasible that the same mechanism was at least partly responsible for the increase in HRV observed in our study. Immediately after treatment, the TTM group showed an improvement in body flexibility. A previous study showed that TTM could increase body flexibility in patients with back pain associated with myofascial trigger point (Chatchawan et al., 2005). The potential mechanism proposed was that TTM might stimulate proprioceptors (spindle cell and Golgi tendon organs) in targeted muscles, resulting in reduced muscle spasm and adhesion in tissue (Chatchawan, 2005). In the control group, body flexibility reduced after the control session. Lying prone for
22 a reasonably long time (30 min) can, thus, be proposed to exacerbate the stiffness of the involved muscle.
Limitations of the study The present study has some limitations as follows. The respiratory rates of participants in this study were monitored using the BIOPAC Respiratory Transducer SS5LB, which might have caused some discomfort to the participants due to the fairly constrictive chest band. In future studies, a more comfortable method for assessing respiratory rate should be found. The present study only evaluated the immediate effect of TTM, which may not correlate with a longer term effect. However, studies by Chatchawan et al. (2005) found that pain intensity and PPT were still significantly improved 3 weeks after TTM and Cowen et al. (2006) established that STAI improvements remained for up to 48 h, which was the limit of follow-up in that study.
Conclusion The results of this study suggest that TTM onto the back muscle for 30 min in the prone position is effective in increasing cardiac parasympathetic activity, reducing sympathetic activity and reducing pain and stress in patients with back pain associated with myofascial trigger point (MTrP). This treatment technique is a non-pharmacologic intervention with no side effects. Since, this massage technique can be easily taught to partners or family members of patients, we suggest that TTM should be considered as one of the alternative treatments for MTrP.
Acknowledgements We wish to thank all the patients who participated in the present study and also Dr Jacqueline Knowles for her work in reviewing and editing this paper. This study was supported by The Khon Kaen University’s Graduate Research Fund Academic Year 2007.
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V. Buttagat et al. health]. The Graduate School, Khon Kaen University, Khon Kaen, Thailand. Chatchawan, U., Thinkhamrop, B., Kharmwan, S., Knowles, J., Eungpinichpong, W., 2005. Effectiveness of traditional Thai massage versus Swedish massage among patients with back pain associated with myofascial trigger points. Journal of Bodywork and Movement Therapies 9, 298e309. Cowen, V.S., Burkett, L., Bredimus, J., Evans, D.R., Lamey, S., Neuhauser, T., Shojaee, L., 2006. A comparative study of Thai massage and Swedish massage relative to physiological and psychological measures. Journal of Bodywork and Movement Therapies 10, 266e275. Delaney, J.P.A., Leong, K.S., Watkins, A., Brodie, D., 2002. The short-term effects of myofascial trigger point massage therapy on cardiac autonomic tone in healthy subjects. Journal of Advanced Nursing 37, 364e371. Diego, M.A., Field, T., Hernandez-Reif, M., 2005. Vagal activity, gastric motility and weight gain in massaged preterm neonates. The Journal of Pediatrics 147, 50e55. Eisenberg, D.M., Davis, R.B., Ettner, S.L., Appel, S., Wilkey, S., Van Rompay, M., et al., 1998. Trends in alternative medicine use in the United Stated, 1990e1997: results of a follow-up national survey. Journal of the American Medical Association 280, 1569e1575. Esenyel, M., Caglar, N., Aldemir, T., 2000. Treatment of myofascial pain. American Journal of Physical Medicine and Rehabilitation 79, 48e52. Field, T., Diego, M., Hernandez-Reif, M., 2007. Massage therapy research. Developmental Review 27, 75e89. Fishbain, D.A., Goldberg, M., Meagher, B.R., et al., 1986. Male and female chronic pain patients categorized by DSM III psychiatric diagnostic criteria. Pain 26, 181e197. Fisher, A.A., 1986. Pressure threshold meter: its use for quantification of tender spots. Archives of Physical Medicine and Rehabilitation 67, 836e838. Fisher, A.A., 1988. Documentation of myofascial trigger points. Archives of Physical Medicine and Rehabilitation 69, 286e291. Fricton, J.R., Awad, E.A., 1989. Advances in Pain Research and Therapy, Vol. 17: Myofascial Pain and Fibromyalgia. Reven Press, pp. 44, 110. Hummel, P., van Dijk, M., 2006. Pain assessment: current status and challenges. Seminars in Fetal & Neonatal Medicine 11, 237e245. Lertluechachai, N., 1989. Effects of Rational Emotive Therapy on Test Anxiety of Secretarial Students. [Master of Education Thesis in Education]. The Graduate School, Chulalongkorn University, Bangkok, Thailand. Mackawan, S., Eungpinichpong, W., Pantumethakul, R., Chatchawan, U., Hunsawong, T., Arayawichanon, P., 2007. Effects of traditional Thai massage versus joint mobilization on substance P and pain perception in patients with non-specific low back pain. Journal of Bodywork and Movement Therapies 11, 9e16. Moyer, C.A., Rounds, J., Hannum, J.W., 2004. A meta-analysis of massage therapy research. Psychological Bulletin 130, 3e18. Ouchi, Y., Kanno, T., Okada, H., Yoshikawa, E., Shinke, T., Nagasawa, S., Minoda, K., Doi, H., 2006. Changes in cerebral blood flow under the prone condition with and without massage. Neuroscience Letters 407, 131e135. Perry, F., Heller, P.H., Kamiya, J., Levine, J.D., 1989. Altered autonomic function in patients with arthritis or with chronic myofascial pain. Pain 39, 77e84. Scott, J., Huskisson, E.C., 1979. Vertical and horizontal visual analog scales. Annals of the Rheumatic Diseases 38, 560. Simons, D.G., 2002. Understanding effective treatments of myofascial trigger points. Journal of Bodywork and Movement Therapies 6, 81e88. Stauss, H.M., 2003. Heart rate variability. American Journal of Physiology, Regulatory. Integrative and Comparative Physiology 285, R927eR931.
Thai massage in patients with back pain Tapanya, S., 1993. Traditional Thai Massage. Duang Kamol, Bangkok, pp. 1e3. Task Force of The European Society of Cardiology and The North American Society of Pacing and Electrophysiology, 1996. Heart rate variability: standards of measurement, physiological interpretation, and clinical use. European Heart Journal 17, 354e381. Terathongkum, S., Pickler, R.H., 2004. Relationships among heart rate variability, hypertension, and relaxation techniques. Journal of Vascular Nursing 22, 78e82. Tousignant-Laflamme, Y., Marchand, S., 2006. Sex differences in cardiac and autonomic response to clinical and
23 experimental pain in LBP patients. European Journal of Pain 10, 603e614. Travell, J.G., Simons, D.G., 1983. Myofascial Pain and Dysfunction. The Trigger Point Manual. Williams & Wilkins, Baltimore, pp. 45e54. Uvnas-Moberg, K., 1994. Role of efferent and afferent vagal nerve activity during reproduction: integrating function of oxytocin on metabolism and behavior. Psychoneuroendocrinology 19, 687e695. Wilkie, D., Lovejoy, N., Dodd, M., Tesler, M., 1990. Cancer pain intensity measurement: concurrent validity of three toolsdfinger dynamometer, pain intensity number scale, visual analogue scale. The Hospice Journal 6, 1e13.
Journal of Bodywork & Movement Therapies (2011) 15, 24e34
available at www.sciencedirect.com
journal homepage: www.elsevier.com/jbmt
BREATHING DYSFUNCTION
Relationships between measures of dysfunctional breathing in a population with concerns about their breathing Rosalba Courtney, DO*, Kenneth Mark Greenwood, PhD, Marc Cohen, MBBS PhD Royal Melbourne Institute of Technology (RMIT) University, School of Health Science, Melbourne, Australia Received 22 December 2009; received in revised form 9 June 2010; accepted 12 June 2010
KEYWORDS Hyperventilation; Breathing assessment; Breathing pattern; Breathing disorders
Summary Background: Dysfunctional breathing (DB) is implicated in physical and psychological health, however evaluation is hampered by lack of rigorous definition and clearly defined measures. Screening tools for DB include biochemical measures such as end-tidal CO2, biomechanical measures such assessments of breathing pattern, breathing symptom questionnaires and tests of breathing function such as breath holding time. Aim: This study investigates whether screening tools for dysfunctional breathing measure distinct or associated aspects of breathing functionality. Method: 84 self-referred or practitioner-referred individuals with concerns about their breathing were assessed using screening tools proposed to identify DB. Correlations between these measures were determined. Results: Significant correlations where found within categories of measures however ccorrelations between variables in different categories were generally not significant. No measures were found to correlate with carbon dioxide levels. Conclusion: DB cannot be simply defined. For practical purposes DB is probably best characterised as a multi-dimensional construct with at least 3 dimensions, biochemical, biomechanical and breathing related symptoms. Comprehensive evaluation of breathing dysfunction should include measures of breathing symptoms, breathing pattern, resting CO2 and also include functional measures such a breath holding time and response of breathing to physical and psychological challenges including stress testing with CO2 monitoring. ª 2010 Elsevier Ltd. All rights reserved.
* Corresponding author. 11 Binburra Ave, Avalon, NSW 2107, Australia. Tel.: þ61 2 99183460. E-mail address:
[email protected] (R. Courtney). 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.06.004
Relationships between measures of dysfunctional breathing
Introduction Dysfunctional Breathing (DB) is commonly used to describe disturbances in breathing functionality that impacts on health (Dixhoorn, 1997, 2004; Morgan, 2002; Thomas, McKinley et al., 2005; Prys-Picard and Niven, 2008; Stanton, Vaughn et al., 2008). The definition of DB however is unclear and no gold standards exist to define it. Dysfunctional breathing includes hyperventilation or breathing in excess of metabolic needs but also refers to breathing pattern abnormalities, poor breathing control and presence of breathing symptoms (Dixhoorn, 1997; Morgan, 2002; Warburton and Jack, 2006). Scientists have until recently focused their attention on hyperventilation, which is defined as breathing in excess of metabolic requirements that results in depletion of carbon dioxide (Comroe, 1974). However the importance of hyperventilation and hypocapnia in producing all symptoms associated with DB is disputed (Hornsveld, Garsson et al., 1996; Hornsveld and Garsson, 1997). It has been proposed that DB symptoms may arise as a result of non biochemical breathing dysfunctions or have neurological causes (Howell, 1997). A broader definition of dysfunctional breathing, that considers the multiple functions of breathing may be a more useful way to characterise DB and to determine its prevalence and impact (Dixhoorn, 1997). Maintenance of normal levels of blood gases such as carbon dioxide is an important, if not the key function of breathing; however breathing has other important functions. Breathing functions in posture and motor control (Lewitt, 1980; McGill, Sharratt et al., 1995; Hodges, Heijnen et al., 2001). It is a key influence on oscillating rhythms that are important for homeostasis, autonomic nervous system regulation and efficient interaction between body systems (Giardino, Lehrer et al., 2000; Bernardi, 2001; Song and Lehrer, 2003). Normal and precisely controlled breathing is also important for voice production and regulation of speech (MacLarnon and Hewitt, 1999; Sivasankar and Erickson, 2009). Biomechanical, neurological and psychological aspects of breathing are not always tightly linked to biochemical parameters and their other relationships are complex and not adequately understood (Han, Stegen et al., 1996a,b). Attempts to tie the symptoms associated with dysfunctional breathing to only the biochemical dimension i.e., hyperventilation and hypocapnia have not been successful (Burton, 1993; Hornsveld and Garsson, 1997). Physical and psychological causes of breathing dysfunction are often interwoven and can be difficult to separate, however DB is thought to contribute to additional symptoms not adequately explained by the main presenting complaint (Han, Zhu et al., 2004). Research has shown that symptoms associated with dysfunctional breathing are strongly influenced by anxiety and other emotional states and in some cases the psychological influences are primary (Wientjes and Grossman, 1994; Han, Zhu et al., 2004). Other symptoms, particularly various qualities of dyspnea have been linked to breathing pattern abnormalities and poor neuromechanical coupling during breathing (O’Donnell, 2006; Prys-Picard and Niven, 2008). Muscular skeletal dysfunctions, speech and voice problems appear to be predominately linked with dysfunctions of
25 breathing pattern and neural control of respiration rather than to the body’s carbon dioxide status (McGill, Sharratt et al., 1995; Gandevia, Butler et al., 2002). The accumulation of studies showing the presence of breathing disturbances in highly symptomatic patients and results of research showing that patients with a range of symptoms and medical conditions improve after breathing therapy (Lum, 1975; Grossman et al., 1984; Tweedale, Rowbottom et al., 1994; Han, Stegen, et al., 1996a; Meuret, Rosenfield et al., 2009) lends weight to the importance of assessment and optimisation of breathing functionality in patient care. However, evaluation of dysfunctional breathing is currently hampered by lack of clear measurement guidelines. Measures used by practitioners as screening tools to identify dysfunctional breathing include biochemical measures such as end-tidal CO2 (Hardonk and Beumer, 1979; McLaughlin, 2009), biomechanical measures such assessments of breathing pattern (Prys-Picard, Kellett et al., 2004), breathing symptom questionnaires (Thomas, McKinley et al., 2005; Courtney and Greenwood, 2009) and tests of breathing function such as breath holding time (Courtney and Cohen, 2008).
Symptom questionnaires used to evaluate DB The Nijmegen is the most commonly used questionnaire used to identify DB. (see Figure 1). The 16 item NQ was originally devised to test for HVS and includes 4 questions on respiratory symptoms and the other 12 items on peripheral and central neurovascular or general tension related symptoms (Dixhoorn and Duivenvoorden, 1985a,b). A questionnaire called the Self Evaluation of Breathing Questionnaire (SEBQ) has also been devised to specifically assess respiratory symptoms and breathing behaviours reported to be associated with DB. The SEBQ includes a larger number of respiratory items than the NQ and can differentiate 2 distinct dimensions of breathing discomfort “lack of air” probably related to chemoreceptor derived sensations and “perception of inappropriate or restricted breathing” probably related to the biomechanics of breathing and breathing perception (Courtney and Greenwood, 2009). Normal values for the SEBQ have not been established as yet and this questionnaire is only useful at present for assessing change in breathing symptoms in individuals after treatment. However, it does have potential as a screening tool for DB once further studies are done to validate this instrument. Normal values for the NQ in European studies are generally around a sum score of 10 (Han, Stegen et al., 1996a,b; Han, Stegen et al., 1998; Thomas, McKinley et al., 2005) whereas in China values are lower and average around 5 (Han, Zhu et al., 2004). In categorising individuals as having DB, cut-offs of both 20 and 22 have been found useful (Doorn, Folgering et al., 1982; Dixhoorn and Duivenvoorden, 1985a; Dixhoorn and Hoefman, 1985b).
Clinical measures of dysfunctional breathing pattern Clinicians usually assess breathing pattern using observation and palpation and historically have used a range of techniques most of which have not been validated (Pryor and Prasad, 2002; Perri, 2007). One component of
26
R. Courtney et al. Nijmegen Questionnaire Please tick how often you suffer from the symptoms listed. Never 0
Rare 1
Sometimes 2
Often 3
Very often 4
Chest pain Feeling tense Blurred vision Dizzy spells Feeling confused Faster & deeper breathing Short of breath Tight feelings in chest Bloated feeling in stomach Tingling fingers Unable to breathe deeply Stiff fingers or arms Tight feelings round mouth Cold hands or feet Palpitations Feelings of anxiety
Figure 1
Nijmegen Questionnaire. A score of 23/64, or more, is suggestive of hyperventilation. (Vansteenkiste et al., 1991).
breathing pattern that is considered dysfunctional is chronic thoracic dominant breathing at rest. Recently a technique called the Manual Assessment of Respiratory Motion (MARM), which can quantify extent of thoracic dominant breathing as well as other aspects of breathing pattern, has been found to have high levels of interexaminer reliability and to agree with measures made simultaneously with Respiratory Induction Plethysmography (Courtney, van Dixhoorn et al., 2008). Normal healthy individuals appear to have balanced breathing with relatively equal motion of upper rib cage to lower rib cage abdominal motion. Perfectly balanced breathing gives a MARM value of 0. Normal values for the MARM in this study of 12 yoga teachers and breathing therapy practitioners were around 6. MARM values above 30 can be considered dysfunctional, as they are at least 2 standard deviations above the mean values found in normal healthy individuals (Courtney, van Dixhoorn et al., 2008). Another aspect of breathing pattern considered dysfunctional is the presence of paradoxical or asynchronous breathing (Prys-Picard, Kellett et al., 2004). In paradoxical breathing the belly is drawn in and lower rib cage narrows rather than expands during inhalation. Practitioners generally assess presence of paradoxical breathing simply by asking the patient to breathe in gently, slightly deeply and into the belly while they observe the respiratory phase relationship of chest and belly motion. If the belly moves inward, decreasing its dimensions during inhalation, the breathing is considered to be paradoxical. This simple observation by the practitioner of chest and belly motion sometimes called the Hi Lo breathing assessment has been found to be reasonably accurate for determining different types of simulated breathing patterns including paradoxical breathing (Courtney and Reece, 2009).
Cabon dioxide levels and DB Persistent low levels of resting carbon dioxide might be expected in individuals with dysfunctional breathing as
evidenced by chronic persistent hyperventilation. However there is considerable argument about what parameters constitute normal values of resting CO2 and the usefulness of resting CO2 as a means of identifying individuals with hyperventilation tendencies because the tendency to symptom producing hyperventilation can be intermittent rather than chronic and only become apparent in response to physical or psychological challenge testing (Hardonk and Beumer, 1979; Warburton and Jack, 2006). Some older texts state that levels of carbon dioxide below 37 mmHg indicate hyperventilation (Comroe, 1974) and more recent texts place normal CO2 levels as above 35 mmHg (Levitsky, 1995). Gardener found that many individuals had CO2 levels chronically below 35 mmHg with no apparent symptoms until levels were taken below 30 mmHg (Gardner, 1995). In fact he found that mean levels of CO2 in healthy individuals were around 36.2 mmHg with 2 standard deviations below this level being 32.2 (Gardner, 1995). Regardless of arguments over CO2 cut-offs it can be concluded that persistently low CO2 and low CO2 in response to challenge testing is an aspect of dysfunctional breathing worthy of measurement, particularly as end-tidal CO2 which fairly accurately represents arterial CO2 can be easily measured with modern capnometry equipment (McLaughlin, 2009).
Breath holding time and dysfunctional breathing Breath holding ability is an aspect of breathing functionality that is commonly disturbed in individuals with tendencies to hyperventilation and to dysfunctional breathing (Jack, Darke et al., 1998; Warburton and Jack, 2006). Breath holding time in individuals with chronic idiopathic hyperventilation has been reported to be only 20 s, when held at the end of inhalation, in comparison to normal individuals whose breath holding time is around 60 s when performed according to the same instructions (Jack, Rossiter et al., 2004). Breath holding time differs markedly depending on how it is performed, being affected by whether the hold occurs after inhalation or exhalation and
Relationships between measures of dysfunctional breathing by the size of the breath taken at the beginning of the breath hold (Mithoefer, 1965). One breath holding time protocol, which uses a somewhat standardized procedure and is used for evaluating and monitoring dysfunctional breathing, is the Buteyko Method technique of the Control Pause. The Control Pause is a post expiratory breath hold and is performed with 2 slight variations. In one variation the breath is held until the first urge to breathe and in another variation until the first involuntary motion of the respiratory muscles (Courtney and Cohen, 2008). Control Pause levels of below 20 are proposed to indicate the presence of DB and to correlate with resting carbon dioxide levels (Stalmatski, 1999; Stark and Stark, 2002). Little research has systematically investigated the relationships between biochemical, biomechanical and symptomatic measures of dysfunctional breathing commonly used by clinicians and therapists to evaluate their patients. The small amount of research that does exist tends to suggest that biochemical, symptomatic and breathing pattern aspects of breathing dysfunction do not necessarily co-exist in individuals suspected of having some type of DB. For example disturbances in breathing pattern are not always associated with chronically decreased baseline levels of CO2 (Han, Stegen et al., 1996a,b; Pine, Coplan et al., 1998; Caldirola, 2004) and changes in breathing pattern and symptoms after breathing therapy may not be accompanied by changes in CO2 (Han, Stegen, et al., 1996a). In a recent study Meuret found that changes in CO2 mediate symptoms in patients with panic disorder (Meuret, Rosenfield et al., 2009), however other studies have found that general symptoms believed to be characteristic of dysfunctional breathing may be only mildly related to chronic CO2 levels or even acute changes in CO2 (Burton, 1993; Hornsveld and Garsson, 1997). It has been previously reported that Buteyko’s Control Pause does not correlate with resting CO2 levels (Courtney and Cohen, 2008). These observations could imply that breathing pattern, symptoms and carbon dioxide levels reflect distinct aspects of breathing functionality and that dysfunctional breathing might best be characterised as a complex condition with multiple dimensions. While a combination of measurement tools is sometimes used to evaluate dysfunctional breathing and establish its prevalence in particular populations (Stanton, Vaughn et al., 2008), researchers and practitioners of different breathing therapies may for historical or convenience reasons evaluate only one aspect of breathing function. A number of studies have determined prevalence of DB on the basis of symptom questionnaires alone (Thomas, McKinley et al., 2001; Humphriss, Baguley et al., 2004; Thomas, McKinley et al., 2005) or have emphasized the measurement of carbon dioxide levels (McLaughlin, 2009) or breathing pattern (Perri and Halford, 2004). If measurement in one dimension of breathing functionality proves not to be highly correlated with measurement in other dimension, this may result in incorrect assumptions about prevalence. Research into the relationships between measure of DB will help to clarify what range of measures are needed for comprehensive evaluation of DB. This type of research would help to determine what minimum requirements are needed for comprehensive evaluation of the various aspects breathing dysfunction in the clinical
27 environment. It would also assist understanding of how best to characterise DB. Aims of this study 1. To compare prevalence of DB on the basis of a range of measures 2. To evaluate relationships and correlations between various measures of DB Given the difficulties and lack of consensus on gold standard definitions of DB, we have chosen a pragmatic study design and applied a range of clinically used measures of DB to a population with concerns about their breathing rather than attempting to test a population fitting any particular definition of DB. We believe this approach has greater external validity and applicability for practitioners as it more closely mimics what occurs in “real life” clinical situations.
Method Participants Participants were recruited from general practices and complementary medicine clinics in Sydney, Australia. Flyers and brochures were placed in waiting rooms and practitioners received a letter about the study that was described as an investigation into the measurement of “incorrect” and dysfunctional breathing and that it presented an opportunity for individuals to have their breathing assessed. This attracted individuals with a range of mild medical conditions who had concerns or curiosity about their breathing or who wished to improve their breathing. They had not been comprehensively assessed for presence of dysfunctional breathing, however most subjects came to the study because they were referred or self referred for investigation of dysfunctional breathing. As people generally self refer or are referred for breathing therapies to improve a range of health problems as well as for health optimisation, this sample represents the types of individuals who might use breathing therapies or go to see a therapist for assessment of their breathing. The 83 individuals who participated in this study were 29 males and 54 females, whose average age was 49 years. They were either healthy or suffered from mild medical conditions including mild asthma. Twenty-nine of these subjects were found to have abnormal spirometry defined by either Forced Expiratory Volume at 1 s (FEV1) or Forced Vital Capacity (FVC) > 15% below predicted. Descriptive statistics and mean values for the various measures used can be seen in Table 1.Of the 83 participants, 63 (75.9%) had dysfunctional breathing according to at least one measure if the most conservative cut-off for this measure is applied. Number of participants with DB according to each of the individual measures are shown in Table 2.
Measures Spirometry Spirometry was performed using a laptop-based spirometer (Spirocard, QRS Diagnostics, Plymouth, MN). The variables
28 Table 1
R. Courtney et al. Descriptive statistics for all variables (n Z 83).
FEV1 (% predicted) Av. SPO2 (% Hb Sat) Av. ETCO2 (mmHg) Respiration rate MARM (% RC) MARM Balance Av. BHT-DD (s) Av. BHT-IRM (s) Nijmegen Questionnaire SEBQ
M
SD
Min
Max
93 96 38 16 73 19 26 30 18 13
13 2 4 4 27 18 12 12 10 8
58 91 26 7 33 20 11 13 0 0
121 100 48 26 178 75 68 72 51 32
used were Forced Expiratory Volume in 1 s (FEV1) and Forced Vital Capacity (FVC). Individuals with FEV1 or FVC < 15% below predicted were classified as having abnormal spirometry. Oxygen and end-tidal carbon dioxide measurement End-tidal carbon dioxide (ETCO2) levels were sampled with a two-pronged nasal canula, and readings were taken with a combined oxymeter and capnometer (BCI, Capnocheck, Waukesha, WI). The equipment was calibrated and checked for accuracy with a known gas mixture. ETCO2, along with O2 saturation (SPO2), respiratory rate, and heart rate, were measured continuously for about 25 min while the person filled out various questionnaires including several that were not related to this study but were used for distraction purposes. The filling out of questionnaire was used to distract participants from excessive attention on their breathing, a source of error that tends to alter breathing rate, volume and pattern. They were advised not to speak and to breath nasally at all times. After excluding data from
Table 2
the first 2 min to allow for the subject settling in, the average ETCO2 was calculated and used in determining correlation coefficients with other variables. In classifying individuals as having DB based on low resting ETCO2, 2 cutoffs were used, 35 mmHg and also 32 mmHg.
The manual assessment of respiratory motion The Manual Assessment of Respiratory Motion (MARM) is a clinical tool used to assess breathing pattern that has been shown to have clinical utility and validity (Courtney, van Dixhoorn et al., 2008; Courtney and Reece, 2009). This palpatory technique permits the examiner to assess the relative contribution of upper thoracic to lower thoracic and abdominal compartments during breathing and calculate quantitative measures of the balance between these two compartments in breathing. A number of variables can be derived from the MARM procedure, and two of these were used in this study. The first of these is % rib cage motion (MARM % RC) and the second is MARM balance. The examiner using the MARM places their open hands over the subject’s back at the region of the lower four to six ribs. The examiner’s thumbs are about 1 inch from the spine and oriented vertically. The examiner’s hands are spread so that the lower three fingers are oriented in a transverse direction. This hand placement makes it possible for the examiner to feel lateral and vertical motion of the rib cage and assess relative contribution from the upper rib cage and the lower rib cage/ abdomen. The examiner draws a diagram with an upper line to represent extent of the upper rib cage and vertical motion and a lower line to represent extent of lower rib cage/abdomen motion. Calculations are then made for thoracic diaphragm “balance” and % rib cage motion (Courtney, van Dixhoorn et al., 2008). Mean measures for
Individuals classified as having dysfunctional breathing according to a single measures.
Type of measure
Number in whole sample
% of whole sample (n Z 83)
Number in abnormal spirometry group
% of abnormal spirometry group (n Z 29) 100%
Spirometry measures FEV1 or FVC < 15% below predicted
29
34.1%
29
Nijmegen Questionnaire (NQ) NQ 20 or above NQ 23 or above SEBQ 11 or above
29 23 48
34.1% 27.1% 56.5%
11 9 21
37.9% 31% 72.4%
Capnometry ETCO2-32 mmHg or below ETCO2-below 35 mmHg
8 22
9.4% 26%
0 5
0 17.2%
Breath holding time BHT-DD-20 or below BHT-DD-30 or below BHT-IRM-20 or below BHT-IRM-30 or below
35 61 14 45
41.2% 71.8% 16.5% 52.9%
21 25 11 23
72.4% 86% 37.9% 79%
Breathing pattern MARM % rib cage >70% MARM balance > 30 Paradoxical breathing
36 26 8
42.4% 30.6% 9.4%
15 11 3
51.7% 37.9% 10%
Relationships between measures of dysfunctional breathing the MARM balance measure were found in this previous study to be around 6 (12 Cut-offs of 30 were used to classify individuals with DB on the basis of the MARM balance measure). For the MARM % RC measure, where normals had mean levels of 56 (8) a cut-off of 70 was used.
The Hi Lo breathing assessment This technique involves simple observation by the practitioner of chest and belly motion. The Hi Lo breathing assessment has been found to be reasonably accurate for determining various types of breathing patterns including simulated paradoxical breathing (Courtney and Reece, 2009). In this study patients were asked to slowly and a little bit deeply “breathe into the belly” while the Hi Lo was used to assess the presence of paradoxical breathing. During the Hi Lo, the examiners hands were placed on the anterior central upper chest and clavicular area (Hi) and the anterior upper abdomen (Lo). From this hand position the examiner determined whether abdominal motion was “paradoxical”, i.e., whether it moved inward towards the spine, during inspiration despite the patients attempt to breathe into and expand their belly.
Breath holding time tests Due to different views on the exact procedure for the Buteyko Control Pause, two breath holding tests were performed (Courtney and Cohen, 2008). In the first, participants held their breath until they experienced a definite sensation of discomfort or recognizable difficulty in holding the breath (BHT-DD). The second involved the time until the first involuntary movement of the respiratory muscles (BHT-IRM). Participants were instructed to sit quietly and breathe normally. They were then asked to breathe gently and at the end of a normal exhalation to pinch their noses and hold the breath. Of these 2 breath holding procedure, the BHT-IRM is likely to be the most reproducible and physiologically stable because involuntary motion of the respiratory muscles has been found to be a more consistent measure of breaking point of breath holding than subjective sensation of the urge to breath (Lin et al., 1974). Measurement was done with a stopwatch that measured to .01 of a second. This number was rounded to .1 of a second. All breath holding procedures were repeated three times. As the procedure did not require complex learning and all participants were able to master this procedure easily, the mean rather than the best result was used in calculating correlations. Prolongation of breath holding time, which can occur when subjects are asked to hold their breath to maximal breaking point (Heath, 1968), did not occur with either of breath holding procedure used in this study. We presume this was because subjects did not hold their breath “as long as they could” and instead followed instructions to only hold until the first muscular impulse (BHT-IRM) or intensification of dyspnea (BHT-DD). Cut-offs of 20 and 30 were used to classify people as having dysfunctional breathing for both these 2 breath hold protocols. These cut-offs were based on Buteyko Method claims that BHT less than 30 indicated mild dysfunctional breathing (and correlated with resting ETCO2 of 36 mmHg) and less than 20 indicated more severe dysfunctional
29 breathing (and correlated with resting ETCO2 of approximately 32 mmHg) (Buteyko, 1990; Novozhilov, 2010). The following series of questionnaires were administered and measurements taken.
The Nijmegen questionnaire The Nijmegen Questionnaire (NQ) is a checklist of symptoms initially believed to reflect hyperventilation syndrome (HVS). It was first developed by van Doorn and colleagues who demonstrated that the testeretest reliability was valid (r Z ..87) (van Doorn, Folgering et al., 1982). The NQ has been demonstrated as able to identify patients (identified by clinicians on the basis of symptoms and observation of breathing behaviours) as suffering from HVS (Dixhoorn and Duivenvoorden, 1985a). Subsequent studies have also shown that the symptoms of the NQ are reproducible by voluntary hyperventilation (Vansteenkiste et al., 1991). In recent years, studies have used the NQ to identify DB as well as hyperventilation syndrome (Thomas, McKinley et al., 2001; Thomas, McKinley et al., 2005). According to van Dixhoorn the mean score for the healthy population is around 11.0 (SD 7.6) (Dixhoorn, 2008). Other studies have found mean NQ scores vary around 5e10 in healthy individuals without DB (Han, Stegen, et al., 1996a; Han, Stegen et al., 1998; Han, Zhu et al., 2004; Thomas, McKinley et al., 2005). Values for the Nijmegen Questionnaire greater than 23 are commonly used to signify DB (Dixhoorn and Duivenvoorden, 1985a). However in one study in a physiotherapy practice comparing patients with a clear musculoskeletal diagnosis with those with dysfunctional breathing, a cut-off score of 20 proved adequate to classify 88% of patients (Dixhoorn and Hoefman, 1985).
The self evaluation of breathing questionnaire (SEBQ) This questionnaire was compiled from various sources. Its items were derived after considering symptoms proposed by Burton, Howell, Fried and other literature to be discriminative for DB, discussion with colleagues, relevant clinical experience of the author and from a public domain Internet questionnaire titled ‘‘How Good is your Breathing Test, Take our Free Breathing Test and See’’ (HGYB)(White, 2005). No item of the SEBQ was taken directly from any single source, most items were included because they were suggested by several sources and appeared plausible (Courtney and Greenwood, 2009) (Figure 2). Procedure The Human Research Ethics Committee of RMIT University approved the study. All data collection was completed within a single two-hour visit. The participants were given the series of questionnaires to fill out while attached to a capnometer and pulse oxymeter. While the participants were either reading or filling out the questionnaires the following respiratory parameters were measured, end-tidal CO2, oxygen saturation, respiratory rate and heart rate. These respiratory parameters were measured over approximately 25 min. A single examiner (RC) then assessed breathing pattern by performing the Manual Assessment of
30
R. Courtney et al.
Self Evaluation of Breathing Questionnaire 0 Never or
1
not true at
occasionally frequently
frequently –
all
a bit true
mostly true
very true
I get easily breathless on physical exertion out of proportion to my fitness
0
1
2
3
I get breathless even when resting
0
1
2
3
I get breathless when I am anxious
0
1
2
3
I get short of breath or very tired when reading out loud or talking a lot
0
1
2
3
I feel breathlessness in association with other physical symptoms
0
1
2
3
I feel that the air is stuffy, as if there is not enough air in the room.
0
1
2
3
I feel I cannot get a deep or satisfying breath
0
1
2
3
I can’t catch my breath
0
1
2
3
My breathing feels stuck, restricted
0
1
2
3
I Feel that my ribcage is tight and can’t expand.
0
1
2
3
My clothing often feels too tight or uncomfortable around my chest.
0
1
2
3
I sigh, yawn or gasp.
0
1
2
3
I find myself holding my breath at various times
0
1
2
3
I notice myself breathing shallowly using my upper chest and shoulders.
0
1
2
3
I notice myself breathing quickly.
0
1
2
3
I notice myself mouth breathing
0
1
2
3
I have trouble co-ordinating my breathing when I am speaking
0
1
2
3
I notice myself breathing irregularly.
0
1
2
3
Figure 2
2
3 very
Breathing self-evaluation questionnaire.
Respiratory Motion (MARM) (Courtney, van Dixhoorn et al., 2008). Following assessment of breathing pattern, breath holding times were tested. The final procedure performed was spirometry with participants asked to perform three forced respiratory manoeuvres and the best result used to minimize effects of technique error.
Results As can be seen in Table 1, the mean levels for all dysfunctional breathing measures are not particularly high for this group, however means for the NQ, (18) and the
MARM (19) are higher and more dysfunctional than those found in studies of normal individuals. In individuals with normal breathing, mean values for sum scores of the NQ are around 10 (Han, Stegen, et al., 1996a; Han, Stegen et al., 1998; Thomas, McKinley et al., 2001) and for the MARM are around 6 (Courtney, van Dixhoorn et al., 2008). The majority of individuals fit criteria of having dysfunctional breathing on the basis of at least one proposed DB measure. Of the 83 participants, 63 (75.9%) had dysfunctional breathing according to at least one measure using the most conservative cut-off criteria for measures such as the NQ, BHT and ETCO2 that had 2 possible cut-offs. Using the less stringent cut-offs for the
Relationships between measures of dysfunctional breathing Table 3
31
Descriptive statistics and differences between the normal and abnormal spirometry groups.
Males Females Average age (years) FEV1 (% predicted) Av. ETCO2 (mmHg) Av. BHT-DD (s) Av. BHT-IRM (s) Av. SPO2 (% Hb Sat) Resp. Rate Nijmegen Questionnaire MARM (% RC) MARM Bal. SEBQ-total
Normal spirometry (n Z 54)
Abnormal spirometry (n Z 29)
Mean difference
P Values
17 37 49(13) 99(10) 37(4) 28(12) 33(11) 96(2) 16(4) 17(9) 70(21) 19(16) 12(7)
12 17 48 (14) 82(11) 39(4) 20(8) 24(10) 95(2) 17(4) 19(11) 77(35) (1918) 16(8)
17 2 7.8 9 1 1 2 7 .9 4.5
.0001 .01 .0001 .0001 .04 .79 .35 .29 .82 .008
measures. Scores for the two questionnaires, the NQ and the SEBQ, were strongly correlated. The two types of breath holding, BHT-DD and BHT-IRM, were also strongly correlated. The two MARM variables, MARM balance and % RC were also correlated. Correlations between variables in different categories were generally not significant. The only significant correlation was between BHT-IRM and MARM % rib cage motion. And also FEV1 levels and SEBQ sum scores were correlated. Carbon dioxide, measured in this study by end-tidal CO2, did not correlate significantly with symptom questionnaires, breathing pattern, PO2 or FEV1. A statistically significant, but weak, correlation was found with one type of breathing holding, BHT-DD. It should be noted that this correlation was negative, opposite to the expected direction. There was a correlation between BHT-DD and SpO2 levels. The SEBQ was negatively correlated with FEV1. FEV1 also correlated with both types of breath holding time.
NQ, (>20) and the two types of BHT (<30), 66 of the 83 participants (79.5%) might have been classified by some practitioners as having dysfunctional breathing. This is illustrated in Table 2. There were 29 individuals who had FEV1 or FVC < 15% below predicted. Mean values of the proposed DB measures were compared between the group with normal spirometry and those with normal spirometry; these are shown in Table 3. The group with abnormal spirometry had higher CO2 level and lower O2 levels, and therefore were not more prone to hyperventilation. NQ, MARM values and respiratory rates were approximately equal in normal and abnormal spirometry groups. The only increased signs of DB in the abnormal spirometry group were, shorter BHT and increased SEBQ scores. Correlations between measures are shown in Table 4. As can be seen, significant correlations where found within the following categories of measures. 1. Symptom questionnaires; 2. Breath holding times; and, 3. Breathing pattern
Table 4
FEV1 PO2 ETCO2 RR MARM% RC MARM bal. BHT-DD BHT-IRM NQ
Correlation matrix. Biochemical measures
Biomechanical measures
Breath holding time
Symptom questionnaires
PO2
ETCO2
RR
MARM % RC
MARM bal.
BHT-DD
BHT-IRM
NQ
SEBQ
.10 p Z .38 1
.08 p Z .47 0.23 p Z .84 1
.09 p Z .44 .10 p Z .10 .14 p Z .20 1
.19 p Z .09 .14 p Z .22 .02 p Z .82 .09 p Z .40 1
.08 p Z .43 .12 p Z .26 .136 p Z .221 .07 p Z .55 .82 p Z .0001 1
.31 p Z .004 .24 p Z .03 .241 p Z .03 .18 p Z .11 .090 p Z .42 .07 p Z .54 1
.31 p Z .005 .186 p Z .09 .198 p Z .07 .16 p Z .14 .25 p Z .02 .204 p Z .06 .84 p Z .0001 1
.133 p Z .23 .11 p Z .26 .12 p Z .27 .20 p Z .08 .04 p Z .70 .01 p Z .90 .20 p Z .07 .18 p Z .10 1
.264 p Z .02 .02 p Z .80 .01 p Z .96 .14 p Z .22 .11 p Z .31 .14 p Z .20 .17 p Z .12 .20 p Z .07 .75 p Z .0001
32
Discussion Strict definitions of DB are not possible at present, but for practical purposes it is probably most useful not to think of DB as single entity limited to the biochemical dimension of breathing functionality (as in Hyperventilation Syndrome) but to consider breathing symptoms and breathing pattern as potentially separate aspects of DB which need to be measured in their own right. This study found that significant correlations exist only within categories of breathing measures but not between categories, showing there was no consistent linear relationship between categories of measures. The two symptoms questionnaires investigated in this study, the NQ and the SEBQ were found to correlate, as did the 2 measures of breath holding time and the 2 similar MARM measures of breathing pattern. Biochemical measures, oxygen and carbon dioxide, were not related. Therefore the clinician who wishes to do a comprehensive evaluation of breathing functionality should consider using a range of measurement tools, including breathing symptom questionnaires, breathing pattern evaluation and CO2 measurement. In this sample of people, which on average had only mild dysfunctional breathing, there was very little relationship between the categories of measures. The only significant correlation between categories found, was between one type of breath holding, (BHT-IRM) where breath was held until first involuntary motion of the respiratory muscles and extent of thoracic dominant breathing pattern, represented as percentage of upper rib cage contribution to breathing motion (MARM % rib cage). No measures were found to correlate with end-tidal CO2. This indicates that individuals with dysfunctions in one aspect of breathing functionality do not necessarily have dysfunctions in other aspects, particularly if the breathing dysfunction is not severe. The most well recognised form of dysfunctional breathing is hyperventilation which is strictly defined by a biochemical definition i.e., breathing in excess of metabolic requirements so that a depletion of carbon dioxide occurs. Despite its biochemical criteria, hyperventilation is sometimes presumed to exist on the basis of symptoms, on findings of abnormal breathing patterns or length of breath holding time (Lum, 1976a,b; Dixhoorn and Duivenvoorden, 1985a; Stark and Stark, 2002). This study suggests that dysfunctions of breathing pattern, shortened breath holding time and DB symptoms can exist without chronic hypocapnia. This is consistent with previously published studies that have also found that baseline CO2 does not always relate to symptoms of dysfunctional breathing (Folgering and Colla, 1978; Vansteenkiste et al., 1991). However the literature also shows that individuals with high levels of hyperventilation type symptoms do have depressed levels of CO2 when compared to symptom free controls (Gardner et al., 1986). So while it cannot be presumed that there is no association between symptoms of DB and resting CO2, it should be recognised that the relationship is complex and can be influenced by other moderating factors such as anxiety.. This was demonstrated by Wintjes and Grossman who showed that in a group of 83 healthy individuals CO2 contributed only 4% of the variance in HV symptoms (Wientjes and Grossman, 1994). Our finding that dysfunctional breathing pattern is not
R. Courtney et al. necessarily associated with low resting CO2 levels is also consistent with the literature as other studies have also found that symptomatic individuals with disturbed breathing pattern often have normal levels of CO2 (Han, Stegen et al., 1996a,b). Again it cannot be presumed that there is no association between breathing pattern and CO2 levels, as many clinicians and researchers have observed abnormal breathing pattern in individuals with hyperventilation (Lum, 1976a,b). However it can be concluded that the level of resting CO2 cannot be presumed from presence of symptoms commonly thought to be associated with dysfunctional breathing, from breath holding time or from breathing pattern. The clinician can only be certain of CO2 levels if these are specifically measured. It should also be noted that measurement of resting CO2 might not identify individuals who hyperventilate in response to psychological stress or physical exercise or whose CO2 regulating capacitates are compromised. This is done variously through capnometry combined with exercise or psychological challenge or the Hyperventilation Provocation Test (Hardonk and Beumer, 1979; Warburton and Jack, 2006). In this study the MARM measures reflecting thoracic dominance in breathing shown a small degree of correlation with breath holding till first desire to breathe (BHT-DD). It seems reasonable to hypothesise that this may be because both these measures reflect respiratory drive, with increased respiratory drive increasing extent of thoracic breathing and decreasing breath holding time. It is also possible that thoracic breathing patterns themselves affect perception of dyspnea sensations related to the breaking point of breath holding. This study did not show an association between general symptoms of dysfunctional breathing, as measured by the SEBQ or the NQ and breathing pattern. These findings are unexpected and not consistent with clinicians observations that individuals with high levels of symptoms associated with DB tend to have breathing pattern disturbances (Lum, 1976a,b; Howell, 1997). And that specific qualities of breathing discomfort or dyspnea are affected by patterns of respiratory muscle use (Simon and Schwartzstein, 1990; Altose, 1992; O’Donnell, 2006). The lack of relationship in this current study may be due to the fact that the sample used tended to represent individuals with only mild signs of dysfunctional breathing. Correlations not evident in this sample with mild DB might be stronger in individuals with more severe DB. Also relationships that do exist between breathing pattern and symptoms may be non-linear. Another factor contributing to the poor correlation found between symptoms and actual physiological and biomechanical aspects of breathing, such as end-tidal CO2 breathing pattern and FEV1 might be the individuality of cognitive processes involved in recognizing, attending to, and then evaluating physical symptoms. Certain individuals show persistent tendencies to over-perceive or underperceive symptoms related to breathing function (Teeter and Bleeker, 1998; Klein, Walders et al., 2004). Thus, while the findings of this study suggest that symptoms do not necessarily correlate with biochemical or biomechanical or breath holding measures across individuals, they do not diminish possibility or importance of relationships between symptoms and breathing functions within individuals.
Relationships between measures of dysfunctional breathing
Limitations of this study Not all ways of measuring DB were assessed in this study. For example measurement of carbon dioxide at rest, as was undertaken during this study, will only reveal chronic persistent hyperventilation and may not be adequate for revealing which individuals are prone to intermittent hyperventilation in response to physical or psychological stress (Hardonk and Beumer, 1979). The interpretation of these results is limited to their use as general screening tools, as the patient population used in this study was not representative of individuals with pronounced breathing dysfunction. Relationships not evident in this population might be evident in a sample more representative of individuals with hypocapnia, markedly disturbed breathing pattern or abnormal Nijmegen Questionnaire scores. Representation from patients in disease categories thought to be affected by dysfunctional breathing is needed to make more robust assumptions.
Future research Further Research is required to investigate the presence of more complex relationships between the various dimensions of breathing dysfunction. Research should also target individuals with stronger evidence of breathing dysfunction or with specific ailments.
Conclusion For practical purposes DB is probably best characterised as multi-dimensional. DB can occur in at least 3 dimensions: biochemical, breathing pattern and breathing related symptoms and these might not co-exist. Screening for DB with measures representing only one of these dimension may not lead to realistic estimations of the prevalence and impact of the various types of breathing dysfunctions. Comprehensive evaluation of breathing dysfunction should include measures of breathing symptoms, breathing pattern, resting CO2 and also include functional measures such a breath holding time and response of breathing to physical and psychological challenges.
Conflict of interest statement None of the authors of this manuscript shall derive any personal profit or gain, directly or indirectly, by reason of his or her authorship of this manuscript.
Acknowledgments We would like to acknowledge the Australian Osteopathic Association for funding and administrative assistance.
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Journal of Bodywork & Movement Therapies (2011) 15, 35e41
available at www.sciencedirect.com
journal homepage: www.elsevier.com/jbmt
TOOL ASSISTED CLINICAL METHODS
Dynamic fascial release and the role of mechanical/ vibrational assist devices in manual therapies Zachary Comeaux, DO, FAAO* West Virginia School of Osteopathic Medicine, Division of Osteopathic Principles and Practice, 400 N. Lee Street, Lewisburg, WV 24901, United States Received 19 October 2009; received in revised form 15 February 2010; accepted 17 February 2010
KEYWORDS Vibration; Percussion vibration; Tonic vibratory reflex; Fascia; Connective tissue; Deep oscillation; Energetic; Vibratory platforms
Summary Machine-assisted vibrational devices have a following in current and historical approaches to bodywork. This article reviews several such devices, including the percussion vibrator, vibrational platforms, and deep tissue oscillation. The percussion vibrator, reintroduced by Robert Fulford, reflecting the author’s practice style and is addressed in more detail. Usage, conceptualization of goals as well as possible mechanisms of effect on the fascial and neuromuscular system are discussed. Special attention is given to the physiologic phenomenon of tonic vibratory reflex. ª 2010 Elsevier Ltd. All rights reserved.
Introduction The term fascia is often reserved for the thicker portions of connective tissue which are easily identified and cleared away to examine more important structures. In doing so, the role of connective tissue is underappreciated. Given its proper significance, fascia, and connective tissue more generally, represents a continuum of mesodermally derived connective tissue (van der Wal, 2009). As such, it serves a role in creating form and transmitting the force of intended action. But equally important, fascia plays a key role in the maintenance of readiness for further action, as well as in coordination of motion itself.
* Tel.: þ1 304 647 6369; fax: þ1 304 647 6304. E-mail address:
[email protected].
Combined with the neural system, fascia participates in a functional neuromyofascial syncytium in which the connective tissue component serves the role of form integrity, force distribution, and reactivity (van der Wal, 2009). The continuously connected universal distribution of connective tissue from the intracellular microtubules to the epidermis has been described elsewhere (Chen and Ingber, 2007). Since form is commonly coupled to function, this structural hierarchy suggests a corresponding functional hierarchy. The classical view of fascia ascribes it the role of passive transmission force, as an element in engineering design (Huijing, 2007). However fascia has more recently been described as an integral part of the self-regulatory coordination of muscle movement (van der Wal, 2009). Spindles and other mechanoreceptors found in the aponeurotic arrangement of fibrin at myotendinous junctions in a parallel, not series arrangement imply a role in regulation
1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.02.006
36
Z. Comeaux
(van der Wal, 2009). Additionally, the recent identification of alpha smooth muscle actin in fascia (Schleip et al., 2005) reinforces the concept of fascial reactivity. Historically, some practitioners have intuited the importance of fascia and the relevance of mechanical vibration in correcting restrictions (Comeaux, 2002). This functional relationship of vibration and oscillation to physiology will be reviewed below. Empirically, externally applied oscillation has been shown to interact with the neuro-coordinative process of proprioception and its relationship to locomotor function (Hagbarth and Eklund, 1966). This article explores that relationship and its relevance to the historical and current usage of mechanical vibration. The data is not conclusive in supporting a translational application to clinical practice however the hope is that this discussion will stimulate further research. Furthermore, although vibration had been used historically in light therapy, music and tone therapies, homeopathy, radionics as well as conventional radiation therapy (Abrams, 1922; Vithoulkas, 1980; Kruser, 1937), this chapter focuses on therapies using vibration in the range of 1e100 Hz.
Historic use of vibration in neuro/fascial regulation The literature of early American manual medicine, notably osteopathy, cites the primacy of motion is assessing the quality of life and the importance of fascial function in this regard (Still, 1892). Wernham, a student of J.M. Littlejohn (who introduced osteopathic education to England), attests that rhythm has been part of osteopathy since its inception in the late nineteenth century (Wernham, 2003). In the US, in this era, the introduction of machine assist devices in manual therapy sparked debate regarding the use of manually applied techniques versus mechanically applied vibration, and its relevance to physiologic wellness. A perspective from that time can be obtained by comparing the work of Snow (1912) and articles in the Journal of Osteopathy from the same period contesting this approach (Bower, 1904; Sullivan, 1904) (Figure 1). Robert Fulford reintroduced mechanical vibration into the context of osteopathic bodywork in the 1950s using a percussion vibrator treatment (Comeaux, 2002). Simultaneous to these developments, oscillation evolved in purely manual techniques as in Wernham’s General Osteopathic Treatment (GOT) and in the derived Harmonic Technique (Hartman, 2001; Lederman, 1997). In America, T.J. Ruddy used patient activated rhythmic motions to induce localized relaxation (Comeaux, 2000). This became the basis for Mitchell’s neuro-coordinative techniques termed Muscle Energy Technique and Vibratory Isolytic Technique (Mitchell, 1998).
Current use of vibration in neuro/fascial regulation Osteopathic manipulation Some osteopaths, in treating somatic dysfunction in the fascial component, continue to use the percussion vibrator
Figure 1 Contemporary version of Foredom percussor used by Dr. Fulford.
(or percussion hammer), as introduced by Fulford. The technique is cited in the Glossary of Osteopathic Terminology (American Association of Colleges of Osteopathic Medicine, 2009). Fulford’s use of the device relied heavily on the practitioner’s perception and intention. This rationale will be discussed later in this article under explanatory mechanisms since his approach presumed a redefinition of the patient, the practitioner and their interaction. After multiple trials of available devices, Fulford used a Foredom model percussor (Comeaux, 2002). This device consists of a standard induction motor with a variable running speed from 0 to 4000 rpm or 66 Hz. The motor’s rotational force is conveyed by means of a shielded flexible cable to a hand piece. Within the hand piece the rotary force is converted by a cam to reciprocal motion, driving a piston at the end of which is a padded applicator head. The applicator conveys the therapeutic force to the patient as it is applied over a bony prominence to disseminate force optimally through the fascial matrix. More recently the author has used a device introduced in the chiropractic community namely, the VibraCussor to be an improvement. The motor of the Vibracussor is in the hand piece which is connected only by a flexible coiled wire to the transformer which allows more freedom of movement. Additionally, the direct proximity of the motor to the point of application creates a more forceful, though gentle, corrective force (Figure 2). The percussor may be been used in general treatment or for specifically targeted local effects. In the general technique, vibration is applied over bony prominences (to
Dynamic fascial release and the role of mechanical/vibrational devices
Figure 2 Vibracussor, a contemporary alternative preferred by the author.
maximally disseminate vibratory force through the fascial matrix) in a pattern from feet to shoulders. The organization was derived according to a conception of the distribution of the body’s energy field, as described by Stone, as well as from experience working with residual birth trauma, even in adult patients (Stone, 1986; Comeaux, 2002) (Figures 3 and 4). Specific, focal treatment may be applied anywhere that a decrease in vital resonance is detected. This lack of resonance relies on refined palpation to complement the more conventional parameters for defining dysfunction. Considering matter, including the body, as fundamentally an expression of vibrating energy, Fulford saw somatic dysfunction, the result of trauma and strain underlying complaints of pain, as a dysrhythmia. He referred to the residual tension in fascia as an ‘‘energy sink’’, or drain, by which the natural vibratory capacity of tissue was restrained from healthy resonance (Comeaux, 2002).
Chiropractic Within the chiropractic field, vibration has been introduced in the current generation of computer assisted thrust
37
Figure 4 Percussion vibrator, application in a limb. May be applied over bony prominence or directly over tissue you intend to release.
devices which use frequency modulated repetitive thrusts. This is a succession to the spring loaded devices for controlling force in spinal manipulation. They function within the range of 6e12 Hz based on empiric testing of spinal compliance in animal models (Keller et al., 2007; Colloca and Keller, 2001). Two well advertised formats include Arthro stim and Impulse IQ referenced below. Although the stated focus in validation and effectiveness research is on the role of non-osseous components of the spine (Colloca, 2001), implications for connective tissue involvement are inevitable given the role of ligaments in arthrodial stabilization. The case for more refined or specific tissue effects is not made. Likewise, because of the size of the applicator tip, extension to the broader field of fascia or muscle is impractical. At the other end of the application scale is whole body vibration. In chiropractic this is used as a tone building application and for pre-treatment muscle relaxation. As in use in sports physiology and weight loss, described in the next paragraph, the effect is attributed in a general way to tonic vibratory reflex without more detailed investigation of actual benefit. In addition, research remains mixed as far as confirming attributed benefits.
Sports physiology and fitness
Figure 3 Percussion vibrator, spinal application. Applicator may be advanced over each segment both to diagnoses and treat.
In the area of sports fitness training, whole body mechanical vibration using a variety of vibrating platforms has emerged as a popular means of improving muscle tone and therefore increasing strength (Cardinale and Lim, 2003; Delecluse et al., 2003). Other benefits described are weight loss and increased lean body mass. The effects are attributed generally to the involvement of tonic vibratory reflex in place of arduous resistance training. Obviously, there are a variety of issues in selecting this therapy including variation in effect with different training schedules, inconsistent demonstration of strength/power with use of vibration, as well as lack of clarity as to optimal amplitude to engage natural dampening in the musculature (Cardinale and Wakeling, 2005). In ascribing the effectiveness specifically to engagement of tonic vibratory reflex, detail is lacking. Tonic vibratory
38 reflex (TVR) involves an observed physiologic set of responses that are not easily characterized; as will be discussed later in the article, various researchers have described different aspects of the phenomenon with varied results, reflecting that the processes are not yet completely understood. TVR is discussed later in this article in the context of the population coding model of neuromuscular coordination. The scientific relevance of this explanation will be discussed below.
Deep oscillation A further technology marketed as Hivamat 200 (Jahr et al., 2008), claims to create fascial change by applying an intermittent electrostatic charge to the collagen matrix. This is described as creates cyclic movement in the deep tissues leading to mechanical pumping and the redistribution of fluids. The modality is marketed as an adjunct to surgical or other wound healing, sports medicine and respiratory diseases (Seffinger, 2009). Reference data regarding mechanisms is limited but outcome studies after treatment of acute sports injuries report decreased edema, pain reduction, and enhanced healing with limited fibrosis (Aliyev, 2009).
Scientific conceptual basis e tonic vibratory reflex (TVR) In order to understand the attributions of these therapies to TVR, a background in the development of the population coding model of neurocoordination is helpful. The contemporary view of population coding derives from Donald Hebb’s attempts in neurophysiology to reconcile the spatial limitation with the extensive functions of the brain (Spatz, 1996). Hebb proposed an encoding process sensory interpretation, memory, and action execution since the skull could not contain enough space for task-dedicated tissue for these tasks. In essence, it emphasizes that neuronal coordination involves patterns of rhythmic activity, not just dedicated cells and pathways in binding of stimuli into meaningful experience. Functionality would result from phasic relationships and patterns of depolarization besides sheer connectivity. Individual neurons could participate synchronously in several operations simultaneously. Despite limitations to the theory, the theme of rhythmic depolarization and phase synchrony presents a defensible model of neural coordination applicable on a peripheral as well as central level (Windhorst, 1996). Neural coordination, in this model, is rhythmic and the controlling feature is phase synchrony across and between cell populations constituting different functional tissues. Both reflex and voluntary movements have been shown to demonstrate periodic rather than constant depolarization. Gross voluntary motion, muscle tone, and posture (including the cerebellar component) are composites of cyclic depolarization rather than a linear process (Windhorst, 1996; Farmer, 1998; Zedka and Prochazka, 1997). This is similar to the experience of appreciating a constant object on a video screen which actually represents a signal refreshed at a rate of 24 cycles per second.
Z. Comeaux One realizes from this that muscle tone, with its adaptive tendon and epimesial/perimesial (connective tissue) tension is a function of rhythmic activity (McAuley et al., 1997). This tension from posture, movement has a reciprocal relationship with fascial tension. Fascia either directly or indirectly participates in the balance of tensions coordinated by the neural or neuromuscular system. Population coding is a concept which complements the system of coordinative reflexes traditionally viewed as a primary means of neural and neuromuscular coordination. The applicable point to bodywork is that neuromuscular activity, both afferent and efferent, is rhythmic. Physical tone of structural tissue, including that occurring after trauma or strain, is determined by states of phasic depolarization.
Rhythmic reflexes e Tonic Vibratory Reflex (TVR) and related effects If neurocoordination in general is rhythmic in character, reflexes involve a phasic component. TVR is a complex phenomenon that was originally described by Hagbarth and involves the contraction of muscle in response to vibration in the range 0e100 Hz (Hagbarth and Eklund, 1966). Martin and Park note a frequency dependent excitationecontraction coupling leading to muscle fatigue (Martin and Park, 1997). Many others show altered performance, notably blindfolded subjects typically misperceive the extent of their intended action during voluntary movement, representing a kinesthetic illusion (Cody et al., 1990). Changes in muscle spindle activity betray involvement of discoordination of gamma-alpha motor neuron coordination controlling muscle tone (Vallbo and Al-Falahe, 1990; Burke et al., 1976). In composite, these effects describe TVR as a discoordination or confusion of proprioception. But proprioception is a coordination of vestibular, ocular, cerebellar, cortical and alpha gamma reflex effects. As a result, tonic vibratory reflex involves a complex of interactions. Curiously, locally applied vibrations cause reflexively coordinated movements of other body parts (Zedka and Prochazka, 1997; Han and Lennerstrand, 1999; Rossi et al., 1985). Additionally, spino-cerebellar disease or degeneration diminishes this effect (Abbruzzese et al., 1982). The application of rhythmic afferent input can have intriguing effects. A most dramatic application of the principles described under TVR occurs in the work of microneurographic pioneer, Schalow and Blank (1996). Beginning with work in open spinal surgical fields in partially cord-transected patient in hopes of reestablishing bladder control, Schalow developed a means of identifying pools of homologous nerve types, functional populations. He demonstrated that there was a distinctive difference in patterns of phasic synchrony in the firing of homologous muscles of the lower extremity between his paretic patients and normal controls. In application Schalow was able to show patient recovery of spontaneous movement and limited gait by suspending subjects in harness over a spring board. Initially subjects were raised and lowered passively to simulate bouncing. Progressively limbs would reflexively respond.
Dynamic fascial release and the role of mechanical/vibrational devices During this protocol, it was observed that the natural phasic character of rhythmic depolarization of neuromuscular firing gradually returned to postural muscles and the patients began spontaneous gait-associated movements. This activity involved progressive challenge of the patient to initiate synergistic contraction of the limb muscles. This research does not directly demonstrate the application of vibration in the modalities cited in this article. However since it also involved externally applied rhythmic pressure to the limbs, possibly it entrained, by rhythmic afferent input, the natural protogenic pattern involved in gait. It is hoped that the current article will contribute toward precipitating such research. The extension of the relevance of these reflexes in the context of inappropriate muscle tone, including that underlying joint restriction seems plausible. As such, TVR could explain a large part of the effect of the percussion vibrator, as well as the repetitive thrust devices. The attribution to the broad range of effects of the vibrating platforms is plausible but only in a general, non-specific sense. When one factors in the presence of spindles in the myotendinous junctions (van der Wal, 2009) and the alteration of spindle reflexes with TVR (Vallbo and Al-Falahe, 1990) a picture of relevance emerges. Although these neuroreflexive relationships pertain to the special connective tissue identified as striated muscle, the recent identification of adaptive actin fibers in fascial tissue make this line of thought worth pursuing (Schleip et al., 2005). Empiric use of the procedures and devices described next underscores this relevance.
Table 1
39
Application to clinical use of mechanical devices As noted above, TVR is an intervention with complex results. A summary of effects should support the following conclusions. The excitationecontraction uncoupling that occurs leads to a derecruitment of some fibers as well as requiring the remaining fibers to work harder to maintain posture increasing the rate of fatigue. To remain standing, subjects are obliged to activate their postural or antigravity muscles in an uncoordinated and inefficient manner. The engaged fibers are therefore receiving resistance training by another method. They are selectively overused to ensure body posture in their compromised state. In essence, it would appear that this is resistance training, only under conditions in which the gross muscle is operating in a state of disorganization. See Table 1 for further suggested mechanism.
Scientific conceptual basis e energetic phase coherence or the ‘‘energy body’’ Although operating in the same frequency range as TVR, Robert Fulford conceptualized the application of oscillatory force in a different way. Considering matter on all levels of organization, including the body, as fundamentally an expression of vibrating energy, he saw somatic dysfunction, the result of trauma and strain underlying complaints of pain, as a dysrhythmia. As mentioned above, he referred to the residual tension in fascia resulting from trauma as an
A contemporary list of proposed physiological mechanisms for the effectiveness of vibration.
Contemporary hypothetical explanations of effectiveness of vibration Hypothetical mechanism
Rationale and reference
Cumulative creep through successive cyclic loading of collagen fibers
Mechanical characteristics of collagen and the dynamic reciprocal functional and metabolic role in repetitive motion with muscle (Solomonow, 2009) An extension of the muscle energy model (Mitchell, 1998)
Resetting alphaegamma coordination in muscle activation changing tension patterns distributed by fascia Phase coherence of quantum state of fascia as a tensegrity matrix
Entrainment of endogenous physiologic oscillators
Application of tonic vibratory reflex Metaphysical
Application of the tensegrity structural model to the fascial organization of biologic systems. The fibrin matrix distributes force underlying structure and function (Chen and Ingber, 2007). Fibrous network as a communication grid for coordinating encoded information within the fascial network; involves quantum vibrational energetic phase coherence (harmonics) for health being (Ho, 2008) Population coding model of neuro biologic function underlying recurrent activity (including depolariazation/repolarization cycle of neurons), rhythm of coherent depolarization of cells depicts a functional state. Phasic state changes entrain changes in rhythmic function of a population, resulting in functional change (Windhorst, 1996; Zedka and Prochazka, 1997; Farmer, 1998). Another route to altering tone through muscle spindle reflexes (Comeaux, 2008) Descriptions using the term ‘energy’ as the term ‘ether’ was used in the twentieth century await empiric correlation (Comeaux, 2001)
40 ‘‘energy sink’’, or drain, by which the natural vibratory capacity of tissue was restrained from healthy resonance. The kinetic energy of injury was retained in the tissues. Modeling his thought from that of Walter Russell and Randolph Stone, he considered the fascia to be a medium of transmutation of thought (another form of vibration) to action, in a biophysiologic as well as figurative sense (Stone, 1986; Russell, 1974). Treatment then was aimed at revitalizing, reenergizing tissue to a native state of healthy resonance (Comeaux, 2002). A further element of resonant function, described in these last three sources, is the appreciation of thought and intention as other forms of constitutive vital energy. In this context, the fascia is considered the matrix or conduit for this vital energy. Consistent with the research which claimed to demonstrate the actual, demonstrable effect of thought on physical outcomes (Jahr, 2008), Fulford felt that on a subtle level the practitioner’s intentions and attention altered health outcomes. Prior to the development of functional magnetic resonant imaging, Fulford modeled the patient and their physiologic function around the concept of the etheric or energy body or energy field. Fulford’s terminology derived partly from early neurologic research of Burr’s L-field or life field (Burr, 1972) and partly from the esoteric literature. The concepts and description appear esoteric and beyond the realm of conventional science. However, the phenomena demonstrated on functional MRI and similar technologies associate electromagnetic vibrational activity with cerebral neurologic events in response to stimulus (Friston et al., 1994). These similarities may be interpreted as representing semantic rather than substantive variance of Fulford’s model of the body from conventional scientific view. Additionally, Fulford’s syntheses can be viewed as presaging the integration of quantum physics into bioscience as well as the current quest to understand the physiology of consciousness. Mae-Wan Ho and others have begun to describe the relevance of vibrational phase coherence as an additional physical parameter of the body’s coordinative function (Ho, 2008). Significant progress has also been made to measure the congruence yet independence of mental and spiritual activity from the molecular biology of the brain. The current community of endeavor expressed in Beauregard’s The Spiritual Brain (Beaurgard and O’Leary, 2007), underscores Fulford’s claim that ‘‘thoughts are things’’, that mental life has physical consequence through but not dependent exclusively on physiological processes. Additionally, experiments in the Hearth Math initiative suggest physiologically relevant interpersonal effects of inherent rhythmic function (McCraty and Atkinson, 1999). Vibrational function, both naturally initiated or evoked by application of external vibratory force, begin to appear physiologically relevant.
Summary Vibration and oscillation have been and continue to be a component in the application of force in bodywork. Various mechanical devices are proposed as adjuncts or improvement in the application of manual diagnosis and treatment. Percussion vibration, computer assisted thrust devices, deep oscillation, and whole body vibrating
Z. Comeaux platforms are formats of which this author is aware. The physiological effectiveness of these devices is partially elucidated and currently under debate. Further research into mechanisms and effectiveness is invited.
Disclaimer The description here of the use of any mechanical device is not intended as a suggestion for use beyond a practitioners training and scope of license. Skills development rather than accessibility of a device defines effective and ethical use of any tool in patient care.
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Dynamic fascial release and the role of mechanical/vibrational devices Delecluse, C., Roelants, M., Verschueren, S., 2003. Strength increase after whole body vibration compared to resistance training. Medicine and Science in Sports and Exercise 35, 1033e1041. Farmer, S., 1998. Rhythmicity, synchronization and binding in human and primate motor systems. Journal of Physiology 509 (1), 3e14. Friston, K., Jezzard, P., Turner, R., 1994. Analysis of functional MRI time-series. Human Brain Mapping 1, 153e171. Hagbarth, K., Eklund, G., 1966. Motor effects of vibratory stimulus in man. In: Granit, R. (Ed.), Nobel Symposium 1, Muscle Afferents and Motor Control, pp. 177e186. Stockholm. Han, Y., Lennerstrand, G., 1999. Eye position changes induced by neck muscle vibration in strabismic subjects. Graefe’s Archive for Clinical and Experimental Ophthalmology 237, 21e28. Hartman, L., 2001. Handbook of Osteopathic Technique, third ed. Nelson Thorne Ltd., Cheltenham, UK, p. 34. Ho, M., 2008. The Rainbow and the Worm, third ed. World Scientific Publishing Company, Singapore. Huijing, P., 2007. Muscle as a collagen fiber reinforced composite: a review of force transmission in muscle and whole limb. In: Findley, T., Schleip, R. (Eds.), Fascia Research. Elsevier GmbH, Munich, p. 90. Impulse IQ. http://neuromechanical.com/index.php?optionZ com_content&taskZview&idZ73&ItemidZ110 (accessed 12.07.09). Jahr, S., Schoppe, B., Reisshauer, A., 2008. Effect of treatment with low-intensity and extreme low-frequency electrostatic fields (Deep Oscillation) on breast tissue and pain in patients with secondary breast lymphoedema. Journal of Rehabilitation Medicine 40 (8), 645e650. Keller, T., Colloca, C., Harrison, D., Moore, R., Gunzburg, R., 2007. Muscular contributions to dynamic dorsoventral lumbar spine stiffness. European Spine Journal 16, 245e254. Kruser, F., 1937. Light Therapy. P B Hoeber, Inc., New York, NY. Lederman, E., 1997. Harmonic Technique. Churchill Livingston, Edinburgh. Martin, B., Park, H., 1997. Analysis of the tonic vibration reflex: influence of vibration variables on motor unit synchronization and fatigue. European Journal of Applied Physiology 75, 504e511. McAuley, J., Rothwell, J., Marsden, C., 1997. Frequency peaks of tremor, muscle vibration and electromyographic activity at 10 Hz, 20 Hz, and 40 Hz during human finger muscle contraction may reflect rhythmicities of central neural firing. Experimental Brain Research 114, 525e541. McCraty, R., Atkinson, M., 1999. The role of physiological coherence in the detection and measurement of cardiac energy exchange between people. In: Proceedings of the Tenth international Montreux Congress on Stress, Montreux, Switzerland.
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Mitchell, F., 1998. The Muscle Energy Manual, vol. 2. MET Press, Lansing, MI, p. 94. Rossi, A., Rossi, B., Santarcangelo, E., 1985. Influences of neck muscle vibration on lower limb extensor muscle in man. Archives Italiennes de Biologie 123, 241e253. Russell, W., 1974. The Universal One. University of Science and Philosophy, Schwananoah, VA. Schalow, G., Blank, Y., 1996. Electromyographic identification of spinal oscillator patterns and recoupling in a patient with incomplete spinal lesion: oscillator formation as a method of improving motor activities. General Physiology and Biophysics 15 (10), 121e220. Schleip, R., Klinger, W., Lehman-Horn, F., 2005. Active fascial contractility: fascia may be able to contract in a smooth muscle-like manner and thereby influence musculoskeletal dynamics. Medical Hypotheses 66, 66e71. Seffinger, M., 2009. Supplementing manual therapy for lymphedema. JAOA 109 (4), 214e215. Snow, A., 1912. Mechanical Vibration: its Physiologic Application in Therapeutics. The Scientific Authors’ Publishing Co, New York, NY. Solomonow, M., 2009. Ligaments: a source of musculoskeletal disorders. Journal of Bodywork and Movement Therapy 13 (2), 136e154. Spatz, H., 1996. Hebb’s concept of synaptic plasticity and neuronal cell assemblies. Behavioural Brain Research 78, 3e7. Still, A., 1892. The Philosophy and Mechanical Principles of Osteopathy. Hudson-Kimberly Publishing CO, Kansas City, MO, p. 60, 250. Stone, R., 1986. Polarity Therapy, vols. I and II. CRCS Publishing, Sabistopol, CA. Sullivan, J., 1904. Vibrators. JO, May: 201e203. Vallbo, A., Al-Falahe, N., 1990. Human muscle spindle response in a motor learning task. Journal of Physiology 421, 553e568. van der Wal, J., 2009. The architecture of the connective tissue in the musculoskeletal system e an often overlooked functional parameter as to proprioception in the locomotor apparatus. In: Findley, T., Schleip, R. (Eds.), Fascia Research II. Elsevier GmbH, Munich, pp. 21e23. Vithoulkas, G., 1980. The Science of Homeopathy. Grove/Atlantic Press, New York, NY. Wernham, J., 2003. Rhythm in Osteopathy. By author, Maidstone, Kent. Windhorst, U., 1996. The spinal cord and its brain: representations and models e to what extent do forebrain mechanisms appear at the brainstem spinal cord levels. Progress in Neurobiology 49, 381e414. Zedka, M., Prochazka, A., 1997. Phasic activity in the human erector spinae during repetitive hand movements. Journal of Physiology 504 (3), 727e734.
Journal of Bodywork & Movement Therapies (2011) 15, 42e49
available at www.sciencedirect.com
journal homepage: www.elsevier.com/jbmt
MYOFASCIAL TRIGGER POINT THERAPY
The immediate effect of soleus trigger point pressure release on restricted ankle joint dorsiflexion: A pilot randomised controlled trial Rob Grieve, MSc, MCSP*, Jonathan Clark, BSc, MCSP 1, Elizabeth Pearson, BSc, MCSP 1, Samantha Bullock, BSc, MCSP 1, Charlotte Boyer, BSc, MCSP 1, Annika Jarrett, BSc, MCSP 1 Department of Allied Health Professions, School of Health and Social Care, Faculty of Health and Life Sciences, University of the West of England (UWE), Glenside Campus, Blackberry Hill, Bristol BS16 1DD, UK Received 31 August 2009; received in revised form 9 December 2009; accepted 17 February 2010
KEYWORDS Myofascial trigger points; Range of motion; Latent trigger points; Goniometry; Myofascial pain syndrome
Summary Objectives: The primary aim of this study was to investigate the immediate effect on restricted active ankle joint dorsiflexion range of motion (ROM), after a single intervention of trigger point (TrP) pressure release on latent soleus myofascial trigger points (MTrPs). The secondary aim was to assess aspects of the methodological design quality, identify limitations and propose areas for improvement in future research. Design: A pilot randomised control trial. Participants: Twenty healthy volunteers (5 men and 15 women; mean age 21.7 2.1 years) with a restricted active ankle joint dorsiflexion. Intervention: Participants underwent a screening process to establish both a restriction in active ankle dorsiflexion and the presence of active and latent MTrPs in the soleus muscle. Participants were then randomly allocated to an intervention group (TrP pressure release) or control group (no therapy). Results: The results showed a statistically significant (p Z 0.03) increase of ankle ROM in the intervention compared to the control group. Conclusion: This study identified an immediate significant improvement in ankle ROM after a single intervention of TrP pressure release on latent soleus MTrPS. These findings are
* Corresponding author. E-mail address:
[email protected] (R. Grieve). 1 Final year physiotherapy students at time of data collection. 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.02.005
The immediate effect of soleus trigger point pressure release
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clinically relevant, although the treatment effect on ankle ROM is smaller than a clinical significant ROM (5 ). Suggestions for methodological improvements may inform future MTrP research and ultimately benefit clinical practice in this under investigated area. ª 2010 Elsevier Ltd. All rights reserved.
Introduction An adequate ankle range of motion (ROM) is considered a necessary component for functional activities such as running, ascending and descending stairs and normal gait (Cavanagh, 1990; Donatelli, 1996; Brukner and Khan, 2006). A disturbance of ankle ROM, resulting from muscle tightness during gait, may affect not only the ankle-foot complex, but also the remaining joints of the lower extremities (You et al., 2009). Chronic myofascial pain in the calf muscles has been documented to cause a biomechanical abnormality of gait, resulting in an excessive knee flexion angle during the stance phase of gait (Wu et al., 2005). Adequate ankle dorsiflexion (>10 ) is required in midistance for the tibia to advance over the foot and allow forward body movement (Norkin and White, 2003). If this ankle ROM is restricted by tight musculature, compensation may occur in the form of genu recurvatum, early knee flexion, early heel lift or excessive pronation at the subtalar joint (Prior, 1999). These compensatory mechanisms put undue stresses on structures and may lead to foot pathologies such as plantar fasciitis, achilles tendonitis and metatarsalgia (Hill, 1995). Increased subtalar joint pronation has also been identified as a ‘‘remote’’ contributing factor in patellofemoral pain (Crossley et al., 2006). A commonly used description of myofascial trigger points is that by Travell and Simons (1992) and Simons et al. (1999), who define MTrPs as hyperirritable areas within taut bands of skeletal muscle or fascia. Within the literature, MTrPs have been classified as active or latent. Active MTrPs refer pain at rest or with muscular activity, whereas latent MTrPs are normally pain free unless direct pressure is applied to them (Travell and Simons, 1992; Simons et al., 1999). Latent MTrPs often cause stiffness and restricted ROM without pain and are far more common that active MTrPs (Simons et al., 1999). MTrPs refer pain along a limb or body part and are found regionally, for example the neck, back, shoulder and lower limb. This muscular pain disorder is termed a myofascial pain syndrome (MPS) (Simons et al., 1999). MTrPs are considered a hallmark finding of MPS and within clinical practice are claimed to be a common source of musculoskeletal pain and dysfunction, in people presenting for manual therapy (Friction, 1990; Blanco et al., 2006). Travell and Simons (1983) originally termed compression of a MTrP as ‘‘ischaemic compression’’. Clinical evidence and the nature of MTrPs indicate that when applying digital pressure to inactivate a MTrP there is no need to exert sufficient pressure to produce ischaemia, as the core of the MTrP is already suffering from severe hypoxia (Travell and Simons, 1999). Therefore ‘‘ischaemic compression’’ has been replaced by ‘‘trigger point pressure release’’ which, according to Simons et al. (1999) is less vigorous, equally or more clinically effective and employs the barrier release
concept advocated by Lewit (1999). TrP pressure release applied downward on a MTrP tends to lengthen sarcomeres and can be effective in increasing ROM and reducing muscle tension (Simons, 2004). The need to include ROM measurements in future studies on the efficacy of manual therapy in MTrPs has been recommended as myofascial pain is characterised by restricted ROM (Ferna ´ndez de las Pen ˜as et al., 2005). Physiotherapists, particularly in orthopaedic practice, have traditionally focused on the measurements of impairments such as pain, range of motion and muscle strength (Abrams et al., 2006). There is limited clinical evidence on the efficacy of manual therapy on MTrPs/MPS in the lower limb. A systematic review of the literature on the effectiveness of non invasive treatments for active MTrP pain, found twenty of the twenty-three included trials assessed the treatment of MTrPs in the neck and/or upper trapezius region (Rickards, 2006). Although the available literature suggests that MTrPs may cause restricted joint ROM (Travell and Simons, 1983; Travell and Simons, 1992; Simons et al., 1999; Lucas et al., 2004; Ferna ´ndez de las Pen ˜as et al., 2005; Blanco et al., 2006), there is a scarcity of research suggesting that TrP pressure release may be an effective intervention for restriction in ankle ROM. It has been proposed that soleus MTrPs specifically relate to a restriction of dorsiflexion of the ankle (Travell and Simons, 1992). The primary aim of this pilot study was to investigate the immediate effect of a single treatment of TrP pressure release of soleus on restricted active ankle dorsiflexion ROM. The secondary aim is to assess the methodological design quality of the pilot study and identify areas for improvement in future research.
Methods Participants Twenty-eight healthy undergraduate physiotherapy and sports therapy students volunteered for this study. During the screening process, 20 participants (5 men and 15 women; mean age 21.7 2.1) were included as they met the inclusion criteria, namely unilateral restriction in active ankle dorsiflexion (<10 ) and at least one identifiable MTrP within the soleus muscle. The exclusion criteria were: under 18 years old, diagnosis of Fibromyalgia Syndrome (FMS), inability to lie prone or flex the knee to 90 , Talipes Equino Varus, previous ankle fractures and/or surgery within last 12 months, manual therapy to the Triceps Surae within last 3 months and any neurological or poor general health that would impair sensory input. Ethical approval for this pilot study was granted by the School of Health and Social Care Ethics Sub-Committee,
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R. Grieve et al.
University of West of England, Bristol. Informed consent was obtained from all participants and any relevant questions answered on data collection.
Research design This pilot randomised controlled trial was designed to investigate the immediate effect of TrP pressure release on restricted active ankle dorsiflexion. After screening, all participants were randomly assigned to the intervention (TrP pressure release) or control group (no intervention).
Randomisation Block randomisation, utilising an online randomisation tool ‘Research Randomizer’ http://www.randomizer.org (Urbaniak and Plous, 2009). This method involved creating a table using two number sets. The randomiser ensured each group appeared an equal number of times whilst simultaneously randomly allocating participants to each group.
Procedure The overall procedure lasted 30 min per participant and is depicted in a flow diagram (Figure 1).
Screening Stage 1: Exclusion criteria
Identification of soleus MTrPs All participants were positioned prone with their knee flexed to 90 for examination and location of TrP1 (Travell and Simons, 1992), but extended for TrP2 and TrP3, Figure 2. The 4 essential diagnostic criteria for identifying a latent or active trigger point were based on the following physical signs and symptoms (Simons et al., 1999). 1. A palpable taut band within the skeletal muscle 2. A hypersensitive tender spot/nodule within a taut band 3. Recognition of current pain complaint by pressure on the tender nodule 4. Painful limit to full stretch range of motion As inclusion into this study included reduced ankle ROM, for positive identification of a soleus MTrP, at least 2 or more of the above essential diagnostic criteria were present on examination. The researcher responsible for MTrP identification attended a seminar with a clinician experienced in MTrP clinical practice, as a training period for identification of MTrPs is essential to achieve accurate and reliable results (Gerwin et al., 1997). If the participant presented with a bilateral restriction in ROM the right leg would be screened initially to standardise the procedure, but only one limb was to be included in the study. All identified soleus MTrPs were marked on the participant’s skin as a cross and if no MTrPs were found in soleus the participant was excluded from the study.
Ankle dorsiflexion measurement Screening Stage 2:
Excluded if any exclusion criteria exhibited
Identification of restricted active ankle dorsiflexion ROM (≤10º)
Screening Stage 3: Identification of ≥1 soleus MTrPs in the limb with restricted ankle dorsiflexion
Randomised Group Assignment
Excluded with >10° active ankle dorsiflexion bilaterally
Active ankle dorsiflexion ROM was the outcome measure for this pilot study. Three measurements were taken to calculate a mean ROM using a two-armed, 360 plastic goniometer (Baseline); the researcher was blinded to the group allocation of each participant. The participant was positioned in prone lying with a 90 knee bend, to reduce the influence of gastrocnemius on ankle dorsiflexion and to accurately determine a restriction purely in soleus (Root et al., 1977; Petty, 2005).
Excluded if no soleus MTrPs identified in the limb with restricted ankle dorsiflexion Identification of
TrP2
TrP3 Intervention Group
TrP3
TrP1
Control Group
Outcome Measure: Active ankle dorsiflexion ROM
Figure 1
Flow diagram of procedure.
Figure 2
Location and pain referral patterns of soleus MTrPs.
The immediate effect of soleus trigger point pressure release
45
The participant was asked to actively maximally dorsiflex their ankle and measurements were taken from plantargrade (0 ) (Rome 1996). If unable to reach plantargrade, then the measurement was taken from the degree of range available and recorded as a negative value. In order to isolate saggittal plane ankle joint dorsiflexion ROM, goniometric measurements were taken in an open chain position (Lang et al., 1997). The position of the goniometer is illustrated in Figure 3 and followed the landmark guidelines suggested by Norkin and White (2003), namely: the fulcrum of the goniometer aligned with the lateral malleolus, proximal arm of the goniometer aligned with the fibula and the distal arm adjacent to the lateral aspect of the 5th metatarsal.
TrP pressure release TrP pressure release was performed according to the technique described by Simons et al. (1999) and employs the barrier release concept (Lewit, 1999). The participant was positioned prone with both legs extended. The researcher would slowly apply increasing pressure with the thumb on the marked soleus MTrP (Figure 4) site until the first increase in tissue resistance was felt (barrier). This point was usually perceived as tender but not painful by the subject. Pressure was maintained until the clinician felt a release in muscle tension under the palpating thumb. This process was repeated for approximately 60 s (Fryer and Hodgson, 2005, although not advocated by Simons et al., 1999) consecutively for each taut band identified, unless the MTrP was deactivated prior to this time or the participant requested the treatment to be discontinued. The intervention was 3 min, if all 3 MTrPs were identified for treatment. The researcher was blind to the results of the pre- and post-intervention goniometric ankle ROM measurements.
Figure 4
TrP pressure release to a Soleus MTrP.
Intervention group Participants in this group received TrP pressure release to the marked soleus MTrPs in numerical order. To standardise the procedure the participant was positioned prone with knees extended bilaterally for 5 min irrespective of the number of MTrPs identified.
Control group Participants in this group received no intervention or sham therapy from the researcher and were positioned prone with knees extended bilaterally for 5 min. This replicated the conditions of the intervention group and enabled concealment of group allocation from the researcher administering the pre- and post-intervention ROM goniometric measurements.
Data analysis
Figure 3 Goniometer position to measure active ankle dorsiflexion (Adapted from Norkin and White, 2003).
Data was analysed with SPSS version 15.0 (SPSS Inc, Chicago, IL). Data analysis was conducted at a 95% confidence interval (CI) and a probability (p) value of <0.5 was considered statistically significant. Descriptive data for the group characteristics were calculated (gender; age) including the mean values and standard deviations (SD) for the pre- and post-ROM data in both groups. The mean change in ankle ROM between the preand post-measurements for both groups was calculated. The ROM quantitative pre- and post-data for both the experimental and control group was normally distributed (ShapiroeWilk test, p > 0.05) and met the criteria for parametric testing therefore the independent t-test was used to analyse statistical significance between groups. In comparison, the data relating to the ages of both groups was not normally distributed (ShapiroeWilk, p < 0.05) and non-parametric analysis was undertaken (ManneWhitney U test). Within group effect sizes were calculated using Cohen’s d coefficient (Cohen, 1992). An effect size greater than 0.8 was considered large, around 0.5 moderate and less than 0.2 small.
46 Table 1
R. Grieve et al. Group characteristics.
Number of participants Gender M/F Age (Median; IQR) Age Range
Control
Intervention
10 5/5 21; 4 19e27
10 0/10 21.5; 1.3 20e22
A retrospective sample size calculation was performed using the power.exe online programme (Machin et al., 1997) on the basis of the post-test standard deviation (3.4); 2 group sample; a Z 0.05; using 80% power and a clinical effect of 5 increase in ankle ROM.
Results The groups appear relatively comparable in age but not gender, with the intervention group bias towards females. Group Characteristics in Table 1 The descriptive data for the pre- and post-ROM measurements, including the mean values and standard deviations (SD) obtained for the control and intervention group are presented in Table 2. The independent t-test at baseline indicates no statistically significant difference between the groups for pre-ROM measurements (p Z 0.93). In relation to ankle ROM it can be assumed that both groups were comparable before the TrP pressure release intervention. The ManneWhitney U test showed no significant difference when comparing baseline age characteristics (p Z 0.85). The mean ankle ROM value in the control group decreased by 0.2 from pre- to post-measurement, whereas the mean change in ROM value for the intervention group improved by 3.3 , with the standard deviation indicating a greater spread of results. The results showed a moderate-large preepost effect size (d Z 0.74) Cohen’s d (Cohen, 1992). The independent t-test showed a statistically significant (p Z 0.03) greater increase of ankle ROM in the experimental compared to the control group. The sample size calculation found that a minimum of 9 participants per group was required to detect a significant increase in ankle ROM.
Discussion The results of this present study demonstrate that statistically a single treatment of TrP pressure release to the soleus has an immediate effect on restricted active ankle dorsiflexion ROM. A moderate treatment effect size was Table 2 Raw score means and standard deviations of pre- and post-ROM measures and difference in scores for ROM (in degrees). Pre
Post
Mean SD
Mean SD
Group 1 (Control) 4.7 Group 2 (Intervention) 4.6
3.5 4.5 3.8 7.9
Difference
3.4 5.7
0.2 3.3
established in the intervention group, suggesting that the results are clinically meaningful. Statistical significance does not necessarily equate to clinical importance (Gemmell et al., 2008). Jacobson and Traux (1991) highlight a limitation in the use of statistical significance tests to evaluate the effects of treatment. They suggest that statistical results fail to provide information on the variability of response to treatment within the sample; yet information regarding variability of outcome is highly important to clinicians. In the intervention group, one participant achieved a 12 improvement and three participants demonstrated an increase of 5 in ankle dorsiflexion ROM. In clinical practice these immediate changes after one treatment are certainly significant. The clinical implications of increased ankle ROM after only one treatment would include cost effectiveness and patient satisfaction. Of further clinical relevance, is the inadequate rehabilitation of dorsiflexion ROM which may lead to long term-term pain and ankle instability (Reid et al., 2007). As this study used goniometric measurements for ankle dorsiflexion ROM outcome values, the results should be interpreted in relation to the findings of Croxford et al. (1998), who suggest that clinicians using goniometry should only assume that a real clinical change in ankle dorsiflexion has occurred when there has been a ROM change of more than 5 . Winter (1992) collected gait laboratory data demonstrating that foot clearance is sensitive to small angular changes ( 2.07 ) at the ankle. As the overall treatment effect in the experimental group was an increased ankle ROM of 3.3 this may be clinically important information for the clinician. A review of the literature indicates that this may be the first study that has specifically analysed the effects of TrP pressure release of soleus on restricted ankle dorsiflexion, although two published case studies in the peer review literature have examined the effectiveness of TrP pressure release in the lower limb on reduced ankle ROM (Wu et al., 2006; Grieve, 2006). Wu et al. (2006) analysed the gait of a woman suffering from MPS and chronic calf tightness. Following an 8-week treatment programme of TrP pressure release, transverse friction massage and proprioceptive neuromuscular facilitation stretches to gastrocnemius; there were significant improvements in ankle dorsiflexion ROM of the affected limb. These findings are of clinical relevance as the premanagement ankle dorsiflexion ROM improved from 10 (pre-intervention) to 18 (post-intervention). Grieve (2006) treated a patient presenting with a proximal hamstring rupture and a chronic restriction in ankle dorsiflexion. An element of the management programme involved TrP pressure release as well as a passive stretch to the gastrocnemius muscle. Grieve (2006) found an immediate increase in dorsiflexion from a value of 0 to 10 following an application of MTrP release followed by a passive stretch. Following four sessions, the patient regained full ankle ROM and long-term efficacy of the intervention was supported on follow-up 7 months later. However, for both of these case studies the overall effect cannot be attributed to a single treatment method as either one of the manual techniques or static stretches may have produced the results independently. Within research hierarchy, case studies may represent the most basic element in research, however this view is
The immediate effect of soleus trigger point pressure release inaccurate as a case study may act as a foundation and alert researchers and health care professionals to critically important trends (Chaitow, 2006). This is particularly true in respect to the dearth of literature in the field of MTrP research on the lower limb and specifically to joint ROM as an outcome measure. The above case studies have alerted and informed the authors of this pilot study to the clinical significance of MTrPs and inspired a more rigorous experimental approach to determine a possible association between TrP pressure release and reduced ankle joint dorsiflexion. The following authors have utilised ROM as an outcome measure in the management of MTrPs (Hanten et al., 2000; Hou et al., 2002; Ferna ´ndez de las Pen ˜as et al., 2004; Chatchawan et al., 2005; Blanco et al., 2006; Gemmell et al., 2008; Buttagat et al., 2010). Although none of these studies have focused on the lower limb, four have investigated the efficacy of MTrP compression (ischaemic or TrP pressure release) on ROM. The remaining authors, have used alternative methods, namely; post-isometric relaxation technique on mouth opening (Blanco et al., 2006); the effectiveness of traditional Thai massage vs Swedish massage on patients with back pain and MTrPs (Chatchawan et al., 2005); the immediate effects of traditional Thai massage on stress related parameters on back pain and MTrPs (Buttagat et al., 2010). Studies after 2005 appear to have responded to recommendations for the inclusion of ROM as an outcome measurement of the efficacy of manual therapy in the management of MTrPs (Ferna ´ndez de las Pen ˜as et al., 2005). Although as previously highlighted (Rickards, 2006), there is still a paucity of research on manual therapy of MTrPs in the lower limb. Rickards (2006) systematic literature review concluded that only a few of the numerous non-invasive physical therapy treatments proposed for MTrP pain may be effective. The review also recommends that future research should address the effect of contributing and perpetuating factors of MTrPs. A recently published systematic review of the literature on the chiropractic management of MTrPs and MPS (Vernon and Schneider, 2009) reviewed 112 publications and came to the recommendation that moderately strong evidence supports some manual therapies (manipulation and ischaemic pressure) for immediate pain relief of MTrPs. However, Vernon and Schneider (2009) conclude that only limited evidence exists for long term pain relief of MTrPs. The search strategy for this review identified only those studies of chiropractic treatments for MPS and MTrPs, no indication of anatomical location or ROM outcomes were made.
Limitations and methodological considerations The secondary aim of this pilot study was to critique aspects of the methodological design quality, identify limitations and propose areas for improvement in future research evidence.
Sampling issues Although a retrospective sampling size calculation was performed and this study was adequately powered, gender was not accounted for and consequently the gender mix between
47 groups was unevenly distributed. Although the male to female ratio of 1:3 may be representative of a student healthcare population, it is possible the results may not be truly representative of a population with ankle joint dysfunction. Some authors have shown that females have a larger ankle ROM than men as a result of gender differences in the visco-elastic properties of the achilles tendon (Kato et al., 2005). Research also suggests that females may have a higher prevalence of MPS and MTrPs (Sola et al., 1955; Drewes and Jennun, 1995). Although internal validity was increased in this study with the random allocation of participants into groups, there was no block randomisation in terms of gender. In order to minimise the effects of such influences on the outcome it is recommended in future that participants are also randomised on gender, in order to ensure any change in ankle ROM is solely a result of the intervention (Polgar and Thomas, 2008). To increase the clinical significance and external validity of any future study on association between TrP pressure release and ankle ROM, participants with an ankle injury or a previous unsuccessful triceps surae stretching programme should also be included. It is important to note that all 28 volunteers were young healthy physiotherapy and sports therapy students, who were easily accessible, active and possibly more health conscious than a potential patient population. This study may therefore be vulnerable to self-selection bias in the form of convenience sampling, which may have introduced a potential source of error (Sim and Wright, 2000).
Outcome measure The Norkin and White (2003) ankle dorsiflexion goniometer protocol used in this study has been demonstrated to have high intrarater reliability (Martin and McPoil, 2005). However, the protocol failed to address the issue of subtalar (STJ) joint pronation as this may compensate for limited dorsiflexion at the ankle joint and encourage dorsiflexion at the STJ or midtarsal (MTJ) joints (Tiberio et al., 1989; Donatelli and Wooden, 1996). This study therefore suggests a method of controlling possible STJ pronation during ankle dorsiflexion measurements. A biplane goniometer may be an option, as it is designed specifically to measure ankle dorsiflexion, prevent pronation and maintain STJ neutral (Donnery and Spencer, 1988).
MTrP diagnosis and TrP pressure release Although the diagnostic criteria of Simons et al. (1999) were used in this study, further research is needed to test the reliability, sensitivity and specificity of the diagnostic criteria currently recommended by authoritative sources (Tough et al., 2007). Quantification of abnormal pressure sensitivity using pressure pain threshold (PPT) has been identified as a useful approach in identifying latent MTrPs (Fischer, 1987; Fryer and Hodgson, 2005). In flat palpation and/or TrP pressure release to soleus TrP 2 in the lateral calf, the researcher may have inadvertently compressed and/or deactivated the corresponding gastrocnemius TrP2 in the belly of the lateral head. Gastrocnemius MTrPs are associated with symptoms of nocturnal calf cramps and not specifically related to restricted ankle dorsiflexion (Travell and Simons, 1992).
48 Apart from palpation and/or TrP pressure release to the soleus, future studies may review the association between the treatment effect observed (increased ankle dorsiflexion ROM) and a similar intervention applied elsewhere on the lower limb and not on a MTrP. The association between increased ankle dorsiflexion ROM and the proprioceptive effect of tactile pressure applied may also be clinically relevant in future clinical trials. It has been suggested that identification of MTrPs via palpation requires skill in the physical examination of muscle (Gerwin et al., 1997). The researcher’s involved in MTrP identification and TrP release, had attended a specific short training seminar and had been taught about the subject at undergraduate level. Although supervised by an experienced clinician, as final year physiotherapy students it may be argued that they lacked clinical expertise and experience in MTrP assessment and treatment. The use of a student clinician for MTrP data collection, with insufficient examination procedure practice may be a possible source of error (Gemmell et al., 2008).
Study design and clinical relevance The inclusion of a passive muscle stretch is an integral part of MTrP treatment (Simons et al., 1999; Blanco et al., 2006). Kostopoulos et al. (2008) support this claim showing the inclusion of a stretch to be more beneficial than MTrP treatment alone. Therefore, a future study may include an additional group with a passive stretching component and/or self-stretch. Apart from a specific intervention group, future designs may include a sham control group, which may strengthen the evidence of clinical effectiveness (Gemmell et al., 2008). Neither anterior impingement (Brukner and Khan, 2006) nor any ankle bony blockage which may account for reduced ankle dorsiflexion were assessed for in this study. The presence of an unaccounted articular joint dysfunction with or without a MPS, may have had a direct result on the efficacy of a primarily soft tissue intervention. As there was no follow up after the initial TrP pressure release intervention, this study was unable to ascertain how long the observed effects of increased ankle dorsiflexion lasted.
Conclusion This study has indicated that a single treatment of TrP pressure release has shown an immediate significant increase in active ankle dorsiflexion. Although the overall treatment effect size of ankle ROM is smaller than may be clinically significant, this study may have clinical relevance to the clinician treating a patient with reduced ankle dorsiflexion. It is hoped that the main findings, including the identified limitations and methodological considerations in this pilot study, will inform future MTrP research and benefit clinical practice in this under investigated area. Previous literature has indicated that future research should also address the effect of contributing and perpetuating factors and the long-term effectiveness of any MTrP intervention.
R. Grieve et al.
Acknowledgements The authors would like to thank Dr Shea Palmer (University of the West of England) for statistical advice.
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Journal of Bodywork & Movement Therapies (2011) 15, 50e56
available at www.sciencedirect.com
journal homepage: www.elsevier.com/jbmt
ASSESSMENT METHODOLOGY
Ultrasonography of longus colli muscle: A reliability study on healthy subjects and patients with chronic neck pain Khodabakhsh Javanshir, Msc PT, PhD candidate of physiotherapy a,b, Mohammad Ali Mohseni-Bandpei, PhD, PT a,*, Asghar Rezasoltani, PhD, PT c, Mohsen Amiri, PhD, PT d, Mehdi Rahgozar, PhD e a Physiotherapy Department, University of Social Welfare and Rehabilitation Sciences, Kodakyar Street, Evin, PO Box 1985713834, Tehran, Iran b Babol University of Medical Sciences, Ganjafrooz Street, Babol, Iran c Physiotherapy Department, Faculty of Rehabilitation, Medical University of Shahid Beheshti, Tehran, Iran d Physiotherapy Department, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran e Biostatistics Department, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
Received 3 February 2009; received in revised form 30 June 2009; accepted 7 July 2009
KEYWORDS Ultrasonography; Longus colli muscle; Chronic neck pain; Muscle size
Summary In this study, the reliability of the longus colli muscle (LCM) size was assessed in a relaxed state by a real time ultrasonography (US) device in a group of healthy subjects and a group of patients with chronic neck pain. Fifteen healthy subjects (19e41 years old) and 10 patients with chronic neck pain (27e44 years old) were recruited for the purpose of this study. LCM size was measured at the level of thyroid cartilage. Two images were taken on the same day with an hour interval to assess the within day reliability and the third image was taken 1 week later to determine between days reliability. Cross sectional area (CSA), anterior posterior dimension (APD), and lateral dimension (LD) were measured each time. The shape ratio was calculated as LD/APD. Intraclass correlation coefficients (ICC) and standard error of measurement (SEM) were computed for data analysis. The ICC of left and right CSA for within day and between days reliability in healthy subjects were (0.90, 0.93) and (0.85, 0.82), respectively. The ICC of left and right CSA for within day and between days reliability
* Corresponding author. Tel./fax: þ98 21 2218 0039. E-mail address:
[email protected] (M.A. Mohseni-Bandpei). 1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.07.005
Ultrasonography of longus colli muscle
51
in patients with neck pain were (0.86, 0.82) and (0.76, 0.81), respectively. The results indicated that US could be used as a reliable tool to measure the LCM dimensions in healthy subjects and patients with chronic neck pain. ª 2009 Elsevier Ltd. All rights reserved.
Introduction
Clinical applications US imaging was shown to be a reliable tool in measuring LCM dimensions. It seems that in clinical practice US imaging can be applied to monitor the effect of a rehabilitation program in the treatment of patients with chronic neck pain.
It has been demonstrated that muscle dimensions including cross sectional area (CSA) can be measured by ultrasonography (US) (Emshoff et al., 1999; Rezasoltani et al., 1999; Rankin et al., 2005; Fernandez-de-las-Penas et al., 2008). US appears to be the most cost effective and feasible method for visual evaluation of muscle tissue. Muscle US provides an opportunity to measure muscle dimensions in a relaxed state and different states of muscle contraction (Rezasoltani et al., 2002; Hodges et al., 2003; Ferreira et al., 2004; McMeeken et al., 2004; Watanabe et al., 2004). Although US technique has been used in the assessment of different cervical muscles (Soltani et al., 1996; Rezasoltani et al., 1998, 1999, 2004; Rankin et al., 2005; Fernandez-delas-Penas et al., 2008; Lee et al., 2007; O’Sullivan et al., in press), there is still a lack of research in the assessment of deep cervical flexor (DCF) muscles. Recent research indicated that the DCF muscles including longus colli muscle (LCM), longus capitis, rectus capitis inferior and rectus capitis lateralis have major roles in maintaining cervical lordosis and providing cervical joint stabilization (Mayoux-Benhamou et al., 1994; Conley et al., 1995; Barton and Hayes, 1996; Vasavada et al., 1998; Boyd-Clark et al., 2001, 2002). The dysfunction of DCF muscles including lack of strength and endurance has been demonstrated in patients with chronic neck pain (Janda, 1994; Barton and Hayes, 1996; Placzek et al., 1999). Also patients with idiopathic neck pain and those with whiplash injury have revealed significantly lower muscle performance in the craniocervical
Table 1
flexion (CCF) test (Jull et al., 1999; Jull, 2000). The CCF test as a low load task is considered to provide an indirect measure of LCM contraction (Mayoux-Benhamou et al., 1994, 1997). The LCM is a deep prevertebral muscle consisting of three parts. The origin of the muscle lies on the anterior aspect of the vertebral bodies from C5 to T3, the anterior tubercle of the transverse processes of C3eC5 and the sides of T1eT3 vertebral bodies (Schuenke et al., 2006). The muscle inserts on the anterior sides of C2eC4 vertebraes, the anterior tubercle of the atlas and the transverse processes of C5 and C6 (Schuenke et al., 2006). Other approaches have been employed to assess cervical flexor muscles including surface electromyography (EMG) (Jull et al., 2002, 2004). More recently a new muscle EMG technique has demonstrated DCF muscle impairment in patients with neck pain (Falla et al., 2003). Because of the deep location of DCF muscles and their close proximity to nearby structures such as the lymphatic chain, vagus nerve and the carotid artery, studying these muscles is difficult. Furthermore, in spite of useful information acquired using new EMG techniques (Falla et al., 2003), the technique is invasive and awkward because the nasopharyngeal electrode must lie directly posterior to the oropharyngeal wall through the nasal septum. As the size of the DCF muscles can be a good indicator of the significant stabilizing function of these muscles, research of the DCF is desirable. The purpose of this study was to assess whether US can reliably measure the size of the LCM in relaxed state of the muscle in healthy subjects and patients with chronic neck pain.
Materials and methods Subjects The participants included 15 healthy subjects aged between 19 and 41, and 10 patients with chronic mechanical neck pain aged between 27 and 44. Table 1 summarizes the demographic characteristics of participants. The healthy subjects were recruited from university students who had no previous history of neck pain or injury. Patients
Characteristics of the participants.
Group
Healthy subjects Patients with neck pain
Mean SD (range) Age (year)
Height (cm)
Weight (kg)
BMI
VAS (mm)
NDI (%)
25.5 5.4 (19e41) 34.3 5.5 (27e44)
170.6 9.8 (155e185) 162.8 6.2 (158e175)
69.7 13.4 (53e94) 64.5 11.6 (51.5e87.5)
23.7 3.1 (20.5e30.3) 24.2 3.9 (20.6e33.7)
41.1 20.5 (7.1e69.6)
30.4 11.2 (16e5)
BMI Z Body Mass Index; VAS Z Visual Analogue Scale; NDI Z Neck Disability Index; SD Z standard deviation.
52
K. Javanshir et al.
with chronic neck pain with bilateral neck symptoms were recruited from an outpatient physiotherapy clinic. All participants were right handed and the duration of neck pain was at least 12 weeks. For the purpose of this study, mechanical neck pain was defined as generalized neck or shoulder symptoms provoked by maintained neck postures, neck movements, or muscle palpation. Patients with unilateral neck pain, fibromyalgia, previous cervical spine surgery severe neck osteoarteritis, cervical rib, previous traumatic or whiplash injury, cervical radiculopathy and myelopathy were excluded. All participants had no previous history of regular training for the cervical region or upper extremities in the previous 3 months. All patients completed the validated Iranian version of Neck Disability Index (NDI) and recorded their pain level on a 100 mm Visual Analogue Scale (VAS) (Mousavi et al., 2007). All participants gave their informed consent, and ethical clearance for the study was obtained from the Medical Ethics Committee of the University of Social Welfare and Rehabilitation Sciences.
Ultrasonography protocol An US device (Ultrasonix, Medical Corp., ES 500, Canada) with a 12.5 MHz linear array and 38 mm foot print probe was used in this study. The subjects were positioned supine on an examination table with both arms lying along the sides of the body and head and neck were in neutral position. A three-folded towel was held under the head so that the head lay 3e4 cm higher than the examination table. To measure the size of LCM the thyroid cartilage was identified by palpation, 2 cm below this level was marked by a marker, and the image was taken at this level in the relaxed state of the muscle. By placing the probe perpendicular to the vertical axis of neck an axial cross sectional image was obtained (Figure 1). B-mode US images were captured and measurement of muscle dimensions was made online using on-screen-calipers. The left and right sides were imaged separately. The outlines of LCM were identified by the following landmarks: inferiorly and medially by the body of the vertebrae, laterally by the carotid artery and superiorly by the retropharyngeal space (Figure 2). The
Figure 1 muscle.
Position of transducer for imaging of longus colli
CSA and the thickness or anterior posterior dimension (APD) and width or lateral dimension (LD) of the LCM were measured as the greatest distance from border to border (facial outline was not included in the measurement) (Soltani et al., 1996). Shape ratio was calculated by the width divided by thickness (LD/APD). Each muscle was scanned three times: two times a day with a minimum of an hour interval (for within day reliability) and the third 1 week later (for between days reliability) (Table 2). A PhD candidate of physiotherapy who was trained by an experienced ultrasonographer for a period of 3 months performed the US measurements. The measurement protocol was designed through several pilot trials and based on a fundamental knowledge of cervical cross sectional anatomy and US.
Data management and analysis The mean and standard deviation (SD) of CSA, APD, LD and shape ratio measurements for the left and right LCMs are presented in Table 2. Intraclass correlation coefficients (ICC) and standard error of measurement (SEM) were used to assess within day (between the first and second measurements) and between days (between the first and third measurements) reliability of measuring LCM dimensions using US imaging (Table 3). The values suggested by Rosner (2006) were used to identify the quality of the reliability coefficients of the results of this study. It was suggested that reliability coefficient values of <0.4 indicates poor reproducibility, 0.4e0.75 indicates fair to good reproducibility, and 0.75 indicates excellent reproducibility. Data were analyzed using SPSS, version 12.
Figure 2 Ultrasonogram of the longus colli muscle cross sectional area in a healthy subject. SCM Z sternoclidomastoid; CA Z carotid artery; RPS Z retropharyingieal space; LC Z longus colli; VB Z vertebral body.
Ultrasonography of longus colli muscle Table 2
53
The mean and standard deviation (SD) of CSA, APD, LD and shape ratio measurements of longus colli muscle. Mean SD
Variable
Healthy 2
CSA (cm ) APD (mm) LD (mm) Shape ratio
Patients
Left
Right
Left
Right
0.87 0.12 8.82 1.42 10.61 1.53 1.23 0.25
0.85 0.21 9.06 1.52 11.71 2.23 1.31 0.28
0.69 0.10 7.83 1.09 12.2 1.90 1.59 0.36
0.78 0.15 8.08 0.93 12.54 1.78 1.56 0.25
CSA Z cross sectional area; APD Z anterior posterior dimension; LD Z lateral dimension; SEM Z standard error of measurements; SD Z standard deviation.
As Bland and Altman (1986) suggested, the high correlation does not mean that the two sets of data agree, as correlation measures the strength of a relation between two data, not the agreement between them. Therefore, an additional method as described was used to demonstrate how closely the measurements agree on different occasions. They recommend use of the 95% confidence interval (95% CI) of the range of differences between the two measurements (Bland and Altman, 1986).
Results The descriptive analysis of the measurements of the LCM in both groups and sides are shown in Table 2. The ICC and SEM values for within day and between days reliability are presented in Table 3 for both groups and sides. A trend towards higher ICC values was observed for within day reliability in both groups compared with between days reliability. The CSA and shape ratio was generally smaller in patients compared with healthy subjects.
Healthy subjects According to the criteria suggested by Rosner (2006), excellent within and between days reliability were observed for CSA of left and right sides with ICC ranging from 0.82 to 0.93. Also excellent within day and between days reliability for APD of left and right sides with ICC ranging from 0.89 to 0.90 and excellent within day with ICC ranging from 0.83 to 0.89 and fair to good between days reliability with ICC ranging from 0.63 to 0.77 for LD were obtained.
Patients group Within day reliability of CSA (ICC Z 0.86 and 0.82) was shown to be excellent for left and right side, respectively. Between days reliability of CSA was good to excellent (ICC Z 0.76 and 0.81) for left and right side, respectively. Also excellent within day (ICC Z 0.86 and 0.80) and good to excellent between days reliability of APD (ICC Z 0.84 and 0.77), were observed for left and right, respectively. For LD, good to excellent within day reliability (ICC Z 0.87 and 0.66) and fair to good between days reliability (ICC Z 0.72 and 0.60) were obtained for left and right side, respectively. Figures 3 and 6 are examples that display an agreement between the measurements for CSA of LCM for both occasions. The limits of agreement were defined as the mean difference of the two measurements 2 standard deviations. The mean difference should be zero or no significant difference between two means. For example, Figures 3 and 4 show a comparison of CSA of LCM between the first and second measurements in healthy subject and patients group. The mean differences were 0.017 with 95% CI of 0.137 to 0.103 cm square and 0.031 with 95% CI of 0.125 to 0.063 cm square for healthy subjects and patients group, respectively, which indicate a good level of agreement between the two measurements. Figures 5 and 6 demonstrate a comparison of CSA of LCM between the first and third measurements in healthy subject and patients group. The mean differences were 0.02 with 95% CI of 0.11 to 0.15 cm square and 0.015 with 95% CI of 0.135 to 0.165 for healthy subjects and patients group, respectively, which indicate a good level of agreement between the two measurements (Bland and Altman, 1986).
Table 3 The results of within and between days reliability for the left and right LCMs sizes in healthy subjects and patients with neck pain (ICC and SEM). Groups
Healthy subjects Patients group
Sessions
Within day Between days Within day Between days
ICC for CSA (SEM)
ICC for APD (SEM)
ICC for LD (SEM)
Left
Right
Left
Right
Left
0.93 0.82 0.82 0.81
0.89 0.89 0.86 0.84
0.90 0.90 0.80 0.77
0.89 0.63 0.87 0.72
0.90 0.85 0.86 0.76
(0.162) (0.173) (0.100) (0.158)
(0.126) (0.158) (0.214) (0.212)
(2.75) (2.00) (2.10) (1.62)
(1.64) (1.65) (1.28) (2.36)
Right (2.90) (2.11) (1.91) (2.68)
0.83 0.77 0.66 0.60
(3.49) (4.38) (3.39) (3.30)
ICC Z intraclass correlation coefficients; CSA Z cross sectional area; APD Z anterior posterior dimension; LD Z lateral dimension.
K. Javanshir et al.
0.30
0.20
Mean + 2SD 0.10
Mean
0.00
Mean - 2SD
-0.10
-0.20
-0.30 0.50
0.60
0.70
0.80
0.90
Differences between first and third measures
Differences between first and second measures
54
0.30 0.20
Mean + 2SD
0.10 Mean
0.00 Mean - 2SD
-0.10 -0.20 -0.30 0.60
1.00
0.70
0.80
0.90
1.00
Average of first and third measures
Average of first and second measures
Figure 5 Differences between pairs of measures plotted against the mean of those pairs of measures for CSA on the left side measured over 1 week in healthy subjects.
Discussion
Jesus and Ferreira (2008) in a preliminary study investigated the changes of DCF muscles thickness associated with changes in muscle recruitment by US. They positioned the US probe longitudinally in the anterior aspect of the neck, in parallel with trachea’s orientation. This method does not allow visualizing and measuring muscle dimensions except for APD. It seemed that in this unique study on DCF using US (Jesus et al., 2008), small sample size (totally 10 healthy subjects) resulted in no significant changes in muscle recruitment of DCF muscles between different phases of the test. It should be noted that the US protocol implemented in the present investigation was different from that used in the above-mentioned study. In the present study the US probe was applied perpendicular to the anterior of the neck so that CSA, APD and LD could be measured and shape ratio could be calculated.
Differences between first and second measures
The results of this study indicated that US protocol used in this research could reliably measure the CSA, APD and LD of LCM in relaxed state, in both symptomatic and asymptomatic subjects. To the best of our knowledge, this is the first study to demonstrate that US imaging provides reliable measurements of CSA and other dimensions of LCM in healthy subjects and patients with chronic neck pain. The results also revealed that CSA of LCM on both sides was smaller in patients with chronic neck pain than that of healthy subjects. The difference of CSA between the two groups may be attributed to the possible atrophy of LCM in patients with neck pain compared with healthy subjects. In addition, the greater values for shape ratio in patients are regarded as flatter muscles and smaller shape ratio in healthy subjects is related to rounder muscles.
0.20
Mean + 2SD 0.10
Mean 0.00
Mean - 2SD -0.10
0.50
0.60
0.70
0.80
0.90
Average of first and second measures
Figure 4 Differences between pairs of measures plotted against the mean of those pairs of measures for CSA on the left side measured on the same day in patients group.
Differences between first and third measures
Figure 3 Differences between pairs of measures plotted against the mean of those pairs of measures for CSA on the left side measured on the same day in healthy subjects.
0.30
0.20
Mean+ 2SD
0.10
Mean 0.00
-0.10
Mean - 2SD
-0.20
0.50
0.60
0.70
0.80
Average of first and third measures
Figure 6 Differences between pairs of measures plotted against the mean of those pairs of measures for CSA on the left side measured over 1 week in patients group.
Ultrasonography of longus colli muscle Cagnie et al. (2009) in a study on LCM size measurement using US and MRI found moderate reliability and questionable validity. It is important to consider that in the present study the LD and APD were measured in addition to CSA, which may need more attention and accuracy. Furthermore, the level of measurement in the present study was 2 cm below the thyroid cartilage at about C6 level whereas in the mentioned study it was at the bottom of the laryngeal prominence of the thyroid cartilage which is at the C5eC6 level. Regarding the origin and closed course of LCM and longus capitis muscle and separation of these muscles at about C5 level, it is considered that there is no overlap at the C6 level. Thus in the present study, clearer images and thus more reliable measurements were obtained. The CSA of LCM reported in the Cagnie et al. (2009) study, was larger than the CSA found in present investigation. The difference might be related to the scanning level. As mentioned earlier in the present study the muscle was measured at C6 level where there is no overlap of the LCM and longus capitis muscle whereas in the Cagnie et al. (2009) study, the measurement level was at C5 level with possible overlap of these muscles which may result in larger CSA measurement and might be a reason for different conclusion. Kristjansson (2004) found a wider limit of agreement for multifidus thickness in a symptomatic group (Kristjansson, 2004). In patients with chronic neck pain, the DCF muscles may be atrophied and this may result in shrinkage of the facial layer and obscuring of muscle outlines especially on the lateral border of the muscle. There is a tendency towards a higher reliability in healthy subjects compared with patients groups (Table 3), which is in agreement with Kristjansson (2004) in terms of cervical multifidus measurement. In another study on the semispinalis capitis muscle, Rezasoltani et al. (1999) stated that the fascia and aponeurotic intersections are clearer in athletes whose muscles are thicker and more hypertrophied than non-athletes. The finding of the current study supports the research carried out by Rezasoltani et al. (1999). If specific exercises result in hypertrophy of the DCF muscles, their facial layers become more visible and clearer images and resultant measurements would be more reliable. With a strict measurement US protocol, researchers can depict the LCM dimensions in healthy subjects and patients with chronic neck pain. However lower reliability for LD in patients in this study may be due to the loss of clarity of the lateral border of the muscle. Using US as a non-invasive and comfortable tool, it is possible to monitor the effect of exercise therapy intervention on muscle dimensions, which is the second target of the present research.
Limitations of the study and recommendation for future research The present study was performed only in a relaxed state of the muscle. Meanwhile, the patients with neck pain on average were 10 years older and lighter (with a higher body mass index), and this might be a threat to between group comparison.
55 However, further research with a larger sample size, measuring muscle dimensions in different stages of muscle contractions at different levels of cervical vertebrae is recommended. In brief, the results of the present study demonstrate that US can be considered as a reliable tool to measure the LCM dimensions in both healthy subjects and patients with chronic neck pain.
Acknowledgments The authors wish to thank the Babol University of Medical Sciences for financial support of this study.
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56 Jull, G., Barrett, C., Magee, R., Ho, P., 1999. Further clinical clarification of the muscle dysfunction in cervical headache. Cephalalgia 19 (3), 179e185. Jull, G., 2000. Deep cervical neck flexor dysfunction in whiplash. Journal of Musculoskeletal Pain 8, 143e154. Jull, G., Trott, P., Potter, H., Zito, G., Niere, K., Shirly, D., 2002. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine 27 (17), 1835e1843. Jull, G., Kristjansson, E., Dall’Alba, P., 2004. Impairment in the cervical flexors: a comparison of whiplash and insidious onset neck pain patients. Manual Therapy 9 (2), 89e94. Kristjansson, E., 2004. Reliability of ultrasonography for the cervical multifidus muscle in asymptomatic and symptomatic subjects. Manual Therapy 9 (2), 83e88. Lee, J.P., Tseng, W.Y., Shau, Y.W., Wang, C.L., Wang, H.K., Wang, S.F., 2007. Measurement of segmental cervical multifidus contraction by ultrasonography in asymptomatic adults. Manual Therapy 12 (3), 286e294. Mayoux-Benhamou, M.A., Revel, M., Vallee, C., Roudier, R., Barbet, J.P., Bargy, F., 1994. Longus colli has a postural function on cervical curvature. Surgical and Radiological Anatomy 16 (4), 367e371. Mayoux-Benhamou, M.A., Revel, M., Vallee, C., 1997. Selective electromyography of dorsal neck muscles in humans. Experimental Brain Research 113 (2), 353e360. McMeeken, J.M., Beith, I.D., Newham, D.J., Milligan, P., Critchley, D.J., 2004. The relationship between EMG and change in thickness of transverses abdominis. Clinical Biomechanics 19 (4), 337e342. Mousavi, S.J., Parnianpour, M., Montazeri, A., Mehdian, H., Karimi, A., Abedi, M., et al., 2007. Translation and validation study of the Iranian version of the Neck Disability Index and the Neck Pain and Disability Scale. Spine 32 (26), E825eE831. O’Sullivan, C., Meaney, J., Boyle, G., Gormley, J., Stokes, M. The validity of rehabilitative ultrasound imaging for measurement of trapezius muscle thickness. Manual Therapy, doi:10.1016/j. math.2008.12.005.
K. Javanshir et al. Placzek, J.D., Pagett, B.T., Roubal, P.J., Jones, B.A., McMichael, H.G., Rozanski, E.A., et al., 1999. The influence of the cervical spine on chronic headache in women: a pilot study. Journal of Manual and Manipulative Therapy 7 (1), 33e39. Rankin, G., Stockes, M., Newham, D.J., 2005. Size and shape of the posterior neck muscles measured by ultrasound imaging: normal values in males and females of different ages. Manual Therapy 10 (2), 108e115. Rezasoltani, A., Kallinen, M., Malkia, E., Vihko, V., 1998. Neck semispinalis capitis muscle size in sitting and prone position measured by real-time ultrasonography. Clinical Rehabilitation 12 (1), 36e44. Rezasoltani, A., Malkia, E., Malkia, E., Vihko, V., 1999. Neck muscle ultrasonography of male weight-lifters, wrestlers and controls. Scandinavian Journal of Medicine and Science in Sports 9 (4), 214e218. Rezasoltani, A., Ylinen, J., Vihko, V., 2002. Isometric cervical extension force and dimensions of semispinalis capitis muscle. Journal of Rehabilitation and Research Development 39 (3), 423e428. Rezasoltani, A., Kauhanen, H., Avikainen, V., 2004. Ultrasonography of neck semispinalis capitis muscle in a case of idiopathic scoliosis. Case Reports and Clinical Practice Review 5, 90e93. Rosner, B., 2006. Fundamental of Biostatistics. Thomson Brooks, Belmont. Schuenke, M., Schults, M., Schumacher, U., 2006. THIEME Atlas of anatomy. Thieme, New York. Soltani, A.R., Kallinen, M., Malkia, E., Vihko, V., 1996. Ultrasonography of the neck splenius capitis muscle. Investigation in a group of young healthy women. Acta Radiologica 37 (5), 647e650. Vasavada, A.N., Li, S., Delp, S.L., 1998. Influence of muscle morphometry and moment arms on the moment-generating capacity of human neck muscles. Spine 23 (4), 412e422. Watanabe, K., Miyamoto, K., Masuda, T., Simizu, K., 2004. Use of ultrasonography to evaluate thickness of the erector spine muscle in maximum flexion and extension of the lumbar spine. Spine 29 (13), 1472e1477.
Journal of Bodywork & Movement Therapies (2011) 15, 57e62
available at www.sciencedirect.com
journal homepage: www.elsevier.com/jbmt
MANUAL THERAPY
Immediate effect on pain thresholds using active release technique on adductor strains: Pilot study Andrew Robb, BA, DC, CSCS a,b,*, Jason Pajaczkowski, Bsc, BS, DC, FCCSS(C), FCCRS(C), CSCS a,c a
Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, Ontario, Canada Division of Graduate Studies, Sports Sciences, Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, Ontario, Canada c Associate Professor, Division of Undergraduate Studies, Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, Ontario, Canada b
Received 15 September 2009; received in revised form 10 February 2010; accepted 10 April 2010
Summary Background: Pain pressure thresholds (PPT) have not been investigated when Active Release Techniques (ART) is directed at treating soft tissue injuries. Aim: To investigate the immediate effects of ART employed in the management of adductor muscle strains to modulate pain threshold. Methods: Patients were administered ART commensurate with the extent and nature of their adductor muscle injury. The outcome measureused was PPT over the adductor muscle strain which was assessed pre-intervention and 2 min post-intervention. Results: Within group effect sizes were calculated using a paired samples t-test to assess clinical effect. The mean pre-intervention and 2 min post-intervention PPT values were 4.2 0.83 and 5.3 0.99 significantly different (p < 0.001). Conclusion: The application of ART to treat groin strains may be of benefit in increasing pain thresholds amongst ice-hockey players. Future research requires sufficient sample sizing, a control group, and correlations with objective outcome measures (VAS and range of motion) to validate the therapeutic effect of ART. Crown Copyright ª 2010 Published by Elsevier Ltd. All rights reserved.
Introduction
* Corresponding author. Tel.: þ1 416 482 2340. E-mail address:
[email protected] (A. Robb).
Adductor strains are a common occurrence among icehockey players. Amongst elite Swedish players adductor strains accounted for 10% of all injuries (Nicholas and Tyler, 2002). Emery and Meeuwisse (2001) evaluated the risk of adductor-related injuries in professional hockey players
1360-8592/$ - see front matter Crown Copyright ª 2010 Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.04.004
58 (NHL) and concluded that of the 1292 potential groin injuries, 82.6% were diagnosed as adductor strains. Adductor strains have been a focus in the clinical setting to determine the successful approach to treatment and return to play. Soft tissue injuries that are managed incorrectly result in a large scar formation with randomly oriented collagen fibres, which may lead to further disability, chronicity, and pain (Jarvinen et al., 2005). A soft tissue technique used in the treatment of a broad pathological spectrum of injuries to the fascia, muscles, tendons, and nerves is Active Release Techniques (ART). ART is a soft tissue technique utilizing compressive, tensile, and shear forces applied by manual (hand) touch to address repetitive strain, cumulative trauma injuries, and constant pressure tension lesions (Figure 1). The literature describing the therapeutic effect of ART contain only case reports outlining anecdotally the effects including increased ranges of motion, early return to work or athletic play, and a reduction in symptomatology associated with soft tissue injuries (Agrios and Crawford, 1999; Baer, 1999; Howitt, 2006; Kazemi, 2000; Pajaczkowski, 2003). Outcomes in pain pressure thresholds (PPT) have not been yielded when ascertaining the therapeutic effect of ART to modulate pain. Various soft tissue techniques have demonstrated therapeutic effects for controlling pain including muscle pressure release (Fryer and Hodgson, 2005; Aguilera et al., 2009), stretching/tension technique (Hanten et al., 2000), and friction massage (Fernandez-delas-Penas et al., 2006). Although these other techniques vary in technique and clinical indication the mechanisms attributed with ART may be borne of these other techniques to modulate pain. These attributes include compression and tensile loading. Therefore research is warranted to ascertain if ART modulates pain. There is a paucity of published studies investigating the therapeutic effects of ART to modulate pain as measured utilizing pain thresholds in patients with muscle injuries. Therefore the objective of this study was to determine whether ART protocol for the groin as treatment for adductor muscle strains among ice-hockey players increase immediate pain pressure thresholds (PPT).
A. Robb, J. Pajaczkowski
Methods
Figure 1 A. Initial contact is made by compressing to the level of the muscle, apply a shear force proximally (taking out tissue slack) with the clinician’s thumb on the proximal tendon of the adductor longus, in the muscle’s shortened position, with the hip in flexion and slight adduction (i.e. site of pain or lesion). B. With the clinician maintaining contact on the adductor longus, the hip is taken into extension and abduction (tension force on the affected muscle tissue).
All eligible subjects signed the required consent before beginning the study. Patients who participated in the study agreed to have ART performed as treatment for their adductor muscle strain. Subjects provided verbal pain threshold feedback during the use of a pressure algometer at the completion of each ART session. Subject eligibility were patients who were at least 18 years of age and played elite level of ice-hockey (AAA, Major Junior A, Ontario Hockey League), presenting with adductor muscle pain and stiffness during ice-hockey participation (games and practices) for at least 2 weeks, and diagnosed with an adductor muscle strain. An adductor muscle strain involved a muscle that is responsible for producing adduction of the hip joint (i.e. gracilius, adductor longus, brevis, magnus, and pectineus). The adductor muscle strain was clinically confirmed with provocation of symptomatology
during active and passive hip abduction, pain and weakness during resisted hip adduction muscle testing, and palpatory findings of pain and altered tissue texture at the pubic insertion or muscle belly of the adductor musculature. For the purposes of this study an adductor muscle strain was defined as disruption of the muscle fibres of adductor complex (pectineus, adductor brevis, adductor longus, adductor magnus, or gracilius). The tissue damage was consistent with a grade one strain. Subject exclusion was determined if any of the following concomitant injuries and/or co-morbidities were present: abdominal muscle tear; avascular necrosis of the femoral head; pelvic fracture; bursitis; conjoined tendon dehiscence; herniated nucleus pulposus; myositisossificans; nerve entrapment; osteitis pubis; osteoarthritis; pubic instability;
Immediate effect on pain thresholds using active release technique seronegative spondyloarthropathy; slipped capital femoral epiphysis; referred pain from the knee or spine due to any of the aforementioned conditions; epididymitis; hydrocele; varicocele; hernia; lymphadenopathy; ovarian cyst; pelvic inflammatory disease; postpartum symphosis separation or prostatitis. Additional exclusion criterion was having undergone therapy for the current adductor muscle strain. This was to control for confounding issues of determining the effect ART has on PPT as other treatments may contribute to this effect. Pain pressure threshold (PPT) is defined as the minimal amount of pressure that is applied to the tissue to change the pressure sensation to discomfort or pain at a specific site. PPT was assessed using a mechanical pressure algometer (Model GTA, Activator Methods Logo Pain Test Algometer e Wagner). The pressure algometer is a hand-held device consisting of a rubber disc (1 cm2) surface attached to a pole, which inserts onto a gauge that records pressure in kilograms (kg). Pressure thresholds are expressed in kg/ cm2. The measurements range from 0 to 10 kg/cm2 in increments of 0.01 kg/cm2. The intra-examiner reliability (ICC) for the use of a pressure algometer ranges from 0.6 to 0.97 and the inter-examiner reliability ranging from 0.4 to 0.98 (Levoska, 1993; Takala, 1990). The assessor (AR) applied continuous pressure with the algometer at a rate of approximately 1 kg/cm2/s until a recorded pressure correlating with a verbal response of pain was achieved. The subjects were instructed to state “now” when the pressure of the algometer located at the treatment site changed from pressure to pain. In the present study the site of the lesion was located on the basis of altered tissue texture, muscle tightness, restricted hip movement and pain by the second investigator (JP). Baseline PPT measurements of the injured adductor muscles were obtained during the initial visit prior to any treatment. All PPT measurements were obtained by the principal investigator (AR). Pre- and post-ART treatment PPT measurements were performed on each subject. Posttreatment PPT measurements were taken 2 min after the last application of ART at end of the treatment session in the same manner as the pre-treatment measurement. This short term follow-up is consistent with the time frame used by Fryer and Hodgson (2005) which will provide comparison of post-treatment PPT. The secondary investigator (JP) was responsible for administering the ART protocol to the adductor region. To localize the site to apply ART the following criterion are used in combination or in isolation according to ART protocol: altered tissue texture (increase tone, nodular, leather-like, taut) relative to the surrounding area and in comparison to the same location on the opposite leg, and provocation of pain with or without referral. The secondary investigator was blinded from the recorded PPT obtained from each subject. The concept for administering ART consists of a particular combination of forces (i.e. tension and compression) imparted specific to the tissue level through digital palpation. The investigator JP maintained the contact that reflects the density of the tissue, tolerance of the patient while the hip was moved from a flexed and adducted position (shorting of the adductor muscle length) to an extended and abducted position to permit lengthening of the adductor muscles. This contact is held
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for a short time (5e20 s). This was performed 3e5 times to the said injury site (Leahy, 2009). The mean and standard deviations of the values were calculated for each variable. To assess within group differences in PPT the student paired t-test was used to determine the statistical significance between pre- and post-treatment PPT measurements. The statistical analysis was conducted at a 95% confidence interval. A p-valueless than 0.05 was deemed statistically significant. Data was analyzed using SPSS package (version 10.0).
Results Nine subjects, all male, aged 21 1 years, participated in this study. The average time of injury presentation was 4 days in duration from onset. The average number of years of competitive ice-hockey was 6 years. Of the nine subjects, there were seven forwards and two defensemen. The intra-examiner repeatability of pre-test measurement reading was 0.85 (ICC) which suggests a high repeatability of PPT measurements. The pre- and post-treatment PPT values for the subjects are found in Table 1. The intra-group analysis revealed mean pre-treatment and post-treatment PPT values (mean SD) of 4.2 0.83 and 5.3 0.99, respectively. A difference between pre- and post-treatment PPT was 1.03 0.47 (95% CI: 1.39, 0.67). A negative result demonstrates an increase in PPT. The results present a significant improvement in PPT (t(8) Z 6.54, p Z 0.0002) from pre-treatment to post-treatment.
Discussion This current study was to evaluate the effectiveness of ART to modulate short term pain in the management of adductor muscle strains amongst ice-hockey players. This present study has demonstrated that adductor muscle pain sensitivity, identified as PPT, increased in response to a single treatment session with ART as measured using
Table 1 PPTs.
Baseline characteristics of hockey players and
Subject
Age
Injured groin
Pre-ART PPT (kg/cm2)
Post-ART PPT (kg/cm2)
1 2 3 4 5 6 7 8 9
21 19 21 20 20 19 24 21 22
R R R L L L L L L Mean PPT
4.8 3 5 4.2 3.1 5.3 4.9 3.9 3.9 4.2
5.3 4.7 6 5.1 3.3 6.8 6 5.3 4.9 5.3
PPT e pain pressure threshold; Tx1 e average baseline PPT at prior to treatment; Tx post e average PPT on the last treatment.
60 a pressure algometer. This is the first investigation to explore the short term effects of ART on pain thresholds. In this study attempts were made to recruit elite icehockey players with only adductor muscle strains. The adductor muscle group is commonly injured, 5e15% of all muscles injuries, among elite ice-hockey players with onethird of these injuries becoming chronic, and approximately 30% return to play at suboptimal levels healing (Bradshaw et al., 2008). The ability to reduce nociception is a critical factor in overall patient satisfaction, general mobility without aggravating the extent of the injury and being able to commence rehabilitation. The outcome of this study is similar with other soft tissue techniques that increased pain threshold to compromised muscle tissue. Understanding the mechanism of action for ART is to understand the effects of compression and tension as observed with other soft tissue techniques. Fryer and Hodgson (2005) concluded that latent triggers points in the upper trapezius muscle treated with muscle pressure release technique (MRT) elicited improved sensitivity to pressure. These authors concluded a significant increase in the mean PPT following the treatment protocols but not following the sham treatments (Fryer and Hodgson, 2005). Although the soft tissue pathology differs (trigger point vs. subacute strain) from this study the consistency of an increased threshold is found. Aguilera et al. (2009) investigated the immediate effects of ischemic compression (IC), also known as muscle pressure release, and ultrasound for the treatment of myofascial trigger points in the trapezius. Data were collected using active range of motion (AROM), surface electromyography (EMG), and pain threshold using an algometer as used in this current study. The results suggest that IC improved AROM, decreased muscle activity as measured using EMG, and increased pain threshold. These results and the results of our study suggest that pain sensitivity can be improved with manual soft tissue techniques utilizing compression. Fernandez-de-las-Penas et al. (2006) analyzed the immediate effects of a single treatment session of ischemic compression technique (IC) in comparison with transverse friction massage for cervical myofascial trigger point tenderness. Data were collected using a pressure algometer to obtain PPT and Visual Analogue Scale (VAS) for pain levels. The results concluded that each technique increased pain thresholds with no significant difference between treatment groups. These results also confirm the results of our study that manual soft tissue techniques utilizing compression and dynamic mobilization of the tissue occurs. The mechanism of therapeutic effect was not elicited from the study using compression. Hanten et al. (2000) investigated the effectiveness of IC followed by sustained stretching over active trigger points in the cervical spine over a 5-day period. The data were collected utilizing a pressure algometer to measure pain threshold and average daily pain using the VAS. The authors confirmed that the combined treatment significantly improved pain sensitivity as observed in our study. As observed in our study, unknown is the contributions of the two combined mechanical stimuli (compression and tension) on the effectiveness of reducing pain. The aforementioned studies utilize a single mode for application of soft tissue treatment (i.e. compression or
A. Robb, J. Pajaczkowski tension) and the efficacy of a combined approach is still unknown. The combined effects of tension and compression during ART protocol may be the mechanism by which the therapeutic effects are borne. A level of superiority is unknown at this time between techniques. In addition, these studies investigated the mechanism of the techniques using myofascial trigger points which is a stark contrast to a subacute strain from our study. There may be a physiological difference to elicit the therapeutic benefit. Clinical success is observed with PPT but the physiological mechanisms for local pain modulation may provide insight into the therapeutic effects. The ability to detect a clinical significant change in pain sensitivity when using pressure algometry is of importance to clinicians wanting to implement this as an objective outcome measure. Jaegar and Reeves (1986) investigated the correlation between pain sensitivity and pain subjectivity in active and latent trigger point among chronic neck pain patients. The authors concluded that clinically significant improvement in pain was observed with increases in pressure (pre 2.8 vs. post 3.8 kg/cm2) and reductions in visual analogue scores (pre 61.0 vs. post 35.2). Furthermore, this study concluded that although there were statistically significant changes in sensitivity and subjective reporting of pain no reliable relationship was observed between VAS and pressure algometry. The present study did not report VAS as an outcome measure for pain and consequently comparison cannot be determined. A similarity does exist with the absolute difference in sensitivity pre- and post-treatment (w1.0 kg/cm2) in both studies. Previous studies by Fryer and Hodgson (2005) and Hanten et al. (2000) reported lower magnitudes of increased in sensitivity to pain (0.2 kg/cm2 and 0.7 kg/cm2 respectively) compared to this study even though statistical significance was reached. The increase in sensitivity observed in this study is consistent with previous work but further investigation to determine whether an increase of 1 kg/cm2 is clinically significant. There is an argument that any change in pain reported in the clinical setting is evidence of therapeutic benefit.
Mechanism At the time of publication the authors have been unable to identify studies or reports that elucidate the pathophysiological and histological mechanisms responsible for these outcomes employing ART. The act of tensioning and compressing the affected tissue both with digital contact and through the active movement performed by the patient can be a plausible mechanism for tissue healing and reduced PPT in this study. A variety of theories can help explain the therapeutic effect of ART. The therapeutic mechanism for reducing pain has involved a neurophysiologic theory. Mechanical stimulation (digital compression) invokes a physiological response to both the cutaneous and muscular mechanoreceptors that may alter nociception and pain. Stimulation of cutaneous mechanoreceptors (therapist contact) may impart an inhibitory effect on the central nervous system resulting in a decrease in the Hoffman reflex (H-reflex). The H-reflex is a reflexive reaction evoked by muscle upon electrical stimulation of its afferent fibers (i.e. muscle spindle). The
Immediate effect on pain thresholds using active release technique reflex is used to objectively assess the monosynaptic stretch reflex as an indirect measure of alpha-motoneuron excitation or muscle activity (Schieppati, 1987). Mechanical stimulation of the muscular mechanoreceptors is thought to be mediated by the muscle afferents (i.e. muscle spindle) which also have been proposed to reduce the H-reflex (Goldberg et al., 1992). Ruffini endings and Type IV mechanoreceptors, also known as interstitial muscle receptors, have been shown to modulate pain responses with sustained deep pressure and stimulation of an autonomic response (Schleip, 2003). These effects in muscle tissue associated with compromised continuity (i.e. strain) may invoke a relaxed state by decreasing the alpha-motoneurons to decrease muscle tone that when mechanically stimulated (post-intervention algometer measurements) reduce pain thresholds (Hou et al., 2002). However, biochemical processes are also theorized to co-exist with the mechanical stimulation. Work by Hou et al. (2002) have suggested that analgesia may be the result of a reactive hyperaemia in the affected tissue which may in fact be modulated by type IV mechanoreceptors found in the tissue being mechanically stimulated (Schleip, 2003). With the mechanical stimulation of tissue to generate an analgesic effect the release of endocannibinoids is an emerging discussion. During mechanical stimulation of tissue it is thought that endocannibinoids are released to inhibit the descending pathway to provide an analgesic effect (de Fonseca et al., 2005). Endocannibinoids (EC) are transmitters that act on the presynaptic pathway to inhibit the transmission of nociception (de Fonseca et al., 2005). The release of EC is through noxious stimulation (Wilson and Nicoll, 2002). In the case of ART performing this therapy over the site of a subacute injury to produce a noxious stimulus causes the release of EC to reduce nociception (i.e. pressure algometer application). Caution is warranted as it is speculative and requires further investigation to suggest that ART and other manual soft tissue techniques produce the release of EC. It is plausible that any or all of the aforementioned mechanisms contribute to the short term symptom reduction noted in this study. To date, the use of ART as a successful treatment option in soft tissue injuries has been echoed by many authors (Agrios and Crawford, 1999; Baer, 1999; Howitt, 2006; Kazemi, 2000; Pajaczkowski, 2003). However the sample sizes of these studies are predominantly small and non-randomized. These studies did not elicit the mechanism for therapeutic effect. The current status of the literature necessitates further research in this area. There is an obvious deficiency that remains between anecdotal evidence for the use of ART as an effective treatment option for reducing pain and improving function in strained muscles and valid scientific evidence. The current study had several limitations that temper its external validity and utility. First, a small sample size is critical as this does not truly represent the overall population especially as ice-hockey players were selectively used. Secondly, the absence of a control group does not permit establishing a cause and effect relationship for the therapeutic intervention and does not rule out a placebo effect and a systematic bias from the investigators. Lastly, investigating the relationship between PPT and objective pain rating scales, such as the VAS, range of motion, or functional
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outcome measures was not conducted. This would have more clearly defined the relationship between pain and dysfunction experienced with the injured tissues. This implementation would permit study with sufficient power to elucidate the true therapeutic effects of ART: larger sample size to permit generalizability, a blinded randomized control trial with sham with follow-up elastography analysis to ascertain the true effect on tissue architecture. Considering the methodological quality of the study caution interpreting of the significant modulation in pain is necessary. This study does not support the sole application of ART for adductor strain or muscle injuries. The purported mechanism(s) have not been investigated directly with ART to ascertain the potential therapeutic mechanisms. A single outcome measure is not enough to support clinical decision making for clinical healing or return to activity because of the subjectivity associated with obtaining the increase PPT through patient feedback and the lack of functional outcome measures to reflect the change in tissue sensitivity. These considerations are recommended for future research. In conclusion, the pain sensitivity experienced by the ice-hockey players with adductor muscle strains in this study increased as measured using pressure algometry. Future research confirming the effect on pain on other muscle groups, across a spectrum of patients, and determining a clinical threshold of change for improvement is warranted. Investigating the mechanisms by which ART achieves therapeutic success requires consideration to better understand the therapeutic effects.
References Agrios, P., Crawford, J., 1999. Double crush syndrome of the upper extremity. Journal of Sports Chiropractic and Rehabilitation 13 (3), 111e114. Aguilera, J.F., Martin, D., Masnet, R., Botella, A., Soler, L., Morell, F., 2009. Immediate effects of ultrasound and ischemic compression techniques for the treatment of trapezius latent myofascial trigger points in health subjects: an randomized controlled study. Journal of Manipulative Physiological Therapy 515e520. Baer, J., 1999. Iliotibial band syndrome in cyclists: evaluation and treatment; a case report. Journal of Sports Chiropractic and Rehabilitation 13 (2), 66e69. Bradshaw, C., Bundy, M., Falvey, E., 2008. The diagnosis of longstanding groin pain: a prospective clinical cohort study. British Journal of Sports Medicine 42, 851e854. de Fonseca, F., Del Arco, I., Bermudez, F., Bilbao, A., Cippitelli, A., Navarro, M., 2005. The endocannibinoids system: physiology and pharmacology. Alcohol and Alcoholism 40 (1), 2e14. Emery, C., Meeuwisse, W., 2001. Risk factors for groin injuries in hockey. Medicine and Science in Sports and Exercise 33 (9), 1423e1433. Fernandez-de-las-Penas, C., Alonso-Blanco, C., FernandezCarnero, J., Miangolarra-Page, J., 2006. The immediate effect of ischemic compression technique and transverse friction massage on tenderness of active and latent myofascial trigger points: a pilot study. Journal of Bodyworks and Movement Therapies 10, 3e9. Fryer, G., Hodgson, L., 2005. The effect of manual pressure release on myofascial triggers in the upper trapezius muscle. Journal of Bodywork and Movement Therapies 9 (4), 248e255. Goldberg, J., Sullivan, S., Seaborne, D., 1992. The effect of two intensities of massage on H-reflex amplitude. Physical Therapy 72, 449e457. Hanten, W., Olson, S., Butts, N., Nowicki, A., 2000. Effectiveness of a home program of ischaemic pressure followed by sustained
62 stretch for treatment of myofascial trigger points. Physical Therapy 80 (10), 997e1003. Hou, C.R., Tsai, L.C., Cheng, K.F., Chung, K.C., Hong, C.Z., 2002. Immediate effects of various physical therapeutic modalities on cervical myofascial pain and trigger-point sensitivity. Archives of Physical Medicine and Rehabilitation 83 (10), 1406e1414. Howitt, S.D., 2006. Lateral epicondylosis: a case study of conservative care utilizing ART and rehabilitation. Journal of the Canadian Chiropractic Association 50 (3), 182e189. Jaegar, B., Reeves, J., 1986. Quantification of changes in myofascial trigger point sensitivity with pressure algometry following a passive stretch. Pain 27, 203e210. Jarvinen, T., Jarvinen, T.L., Kaariainen, M., Kalimo, H., Jarvinen, M., 2005. Muscle biology: biology and treatment. American Journal of Sports Medicine 33 (5), 745e765. Kazemi, M., 2000. Adhesive capsulitis: a case report. Journal of the Canadian Chiropractic Association 44 (3), 169e177. Leahy, Michael, 2009. Active Release Techniques: Lower Extremity Manual.
A. Robb, J. Pajaczkowski Levoska, S., 1993. Manual palpation and pain threshold in female office employees with and without neck-shoulder symptoms. Clinical Journal of Pain 9, 236e241. Nicholas, S., Tyler, T., 2002. Adductor muscle strains in sports. Sports Medicine 32 (5), 339e344. Pajaczkowski, J.A., 2003. Mimicking turf-toe: myofasciopathy of the first dorsal interosseous muscle treated with ART. Journal of the Canadian Chiropractic Association 47 (1), 28e32. Schieppati, M., 1987. The Hoffman reflex: a means of assessing spinal reflex excitability and its descending control in man. Progress in Neurobiology 28, 345e376. Schliep, Robert, 2003. Facial plasticity e a new neurobiological explanation part I. Journal of Bodywork and Movement Therapies 7 (1), 11e19. Takala, E.P., 1990. Pressure pain threshold on upper trapezius and levator scapulae muscles. Scandinavian Journal of Rehabilitation Medicine 22, 63e68. Wilson, R., Nicoll, R., 2002. Endocannibinoid signalling in the brain. Science 296 (5568), 678e682.
Journal of Bodywork & Movement Therapies (2011) 15, 63e67
available at www.sciencedirect.com
journal homepage: www.elsevier.com/jbmt
ORIGINAL RESEARCH
Comparison of an indirect tri-planar myofascial release (MFR) technique and a hot pack for increasing range of motion Jay Kain, PT, PhD, ATC, IMTC a, Laura Martorello, PT, DPE b,*, Edward Swanson, PT, PhD, MBA, MEd b, Sandra. Sego, PhD b a b
Jay Kain Physical Therapy, Great Barrington, MA 01230, USA American International College, 1000 State Street, Springfield, MA 01109, USA
Received 25 June 2009; received in revised form 7 December 2009; accepted 8 December 2009
KEYWORDS Myofascial release technique; MFR; Hot pack; Gleno-humeral joint
Summary Purpose: The purpose of the randomized clinical study was to scientifically assess which intervention increases passive range of motion most effectively: the indirect tri-planar myofascial release (MFR) technique or the application of hot packs for gleno-humeral joint flexion, extension, and abduction. Methods: A total of 31 participants from a sample of convenience were randomly assigned to examine whether or not MFR was as effective in increasing range of motion as hot packs. The sample consisted of students at American International College. Students were randomly assigned to two groups: hot pack application (N Z 13) or MFR technique (N Z 18). The independent variable was the intervention, either the tri-planar MFR technique or the hot pack application. Group one received the indirect tri-planar MFR technique once for 3 min. Group two received one hot pack application for 20 min. The dependent variables, passive glenohumeral shoulder range of motion in shoulder flexion, shoulder extension, and shoulder abduction, were taken pre- and post-intervention for both groups. Data was analyzed through the use of a two-way factorial design with mixed-factors ANOVA. Results: Prior to conducting the study, inter-rater reliability was established using three testers for goniometric measures. A 2 (type of intervention: hot packs or MFR) by 2 (pre-test or post-test) mixed-factors ANOVA was calculated. Significant increases in range of motion were found for flexion, extension and abduction when comparing pre-test scores to post-test scores. The results of the ANOVA showed that for passive range of motion no differences were found for flexion, extension and abduction between the effectiveness of hot packs and MFR. For each of the dependent variables measured, MFR was shown to be as effective as hot packs in increasing range of motion, supporting the hypothesis.
* Corresponding author. Tel.: þ1 413 205 3024; fax: þ1 413 654 1430. E-mail address:
[email protected] (L. Martorello). 1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.12.002
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J. Kain et al. Discussion and conclusion: Since there was no significant difference between the types of intervention, both the hot pack application and the MFR technique were found to be equally effective in increasing passive range of motion of the joint in flexion, extension, and abduction of the gleno-humeral joint. The indirect tri-planar intervention could be considered more effective as an intervention in terms of time spent with a patient and the number of patients seen in a 20-min period. No equipment is required to carry out the MFR intervention, whereby using a hot pack requires the hot pack, towels, and a hydraculator unit with the use of the indirect tri-planar intervention, a therapist could treat four to five patients in the time it would take for one standard hot pack treatment of 20 min, less the hands-on intervention of the therapist. ª 2009 Elsevier Ltd. All rights reserved.
Introduction Few studies have examined the effectiveness of myofascial release (MFR) techniques on the direct parameters of patient outcomes (Hanten, 1994; Barnes, 1997; Bucher, 1993, 1994; Weiselfish-Giammatteo and Kain, 2005). Additionally, experimental research does not exist that compares the effectiveness of MFR outcomes versus any modality intervention. Within the field of rehabilitation, especially physical therapy, a common outcome reference for evidence-based research lies in a pre- and post-assessment of range of motion (ROM). For the purposes of the most accurate reflection of change, passive ROM assessment appears to be the most objective to measure. Further, when ROM assessments utilize physiologic and accessory joint motion, outcomes are more reliable and objective (Weiselfish-Giammatteo and Kain, 2005; Kaltenborn, 1976; Prentice, 1990). The post-treatment effects of MFR intervention have been postulated to parallel those of massage and soft tissue mobilization techniques. These effects include circulatory changes, blood flow changes, capillary dilatation, cutaneous temperature changes, and changes in metabolism (Cantu and Grodin, 1992). These changes are reflected in increased ROM, improved biomechanics of the joint, increased extensibility of tissues, improved flexibility, muscle relaxation, reduction of spasm, decreased tone, reduction of edema and analgesia (Cantu and Grodin, 1992) Heat in its various forms has been a popular longstanding modality used to facilitate healing. Transmission of heat, either by conduction, convection, radiation, and/or conversion, comprises the most common methods of heat usage. Whether the modality is a whirlpool, hot pack, diathermy, moist air sauna, infrared, paraffin, whirlpool or ultrasound the outcome potential is nearly the same (Taylor, 1990). For the purpose of this study, hot packs were chosen as our comparative modality for a number of reasons: (1) (2) (3) (4) (5)
the simplicity of access to the modality the ease of application the accepted usage within the field of rehabilitation minimal contraindications standardization of application.
Predicted outcomes for the use of heat parallel those of MFR. However, Taylor (1990) points out that many of the
assumed outcomes of heating are not backed up by scientific evidence. One such example Taylor (1990) offered was that the reduction of stiffness of arthritic joints is more the result of decreased viscosity of synovial fluid rather than the heating effect on connective tissues. Taylor (1990) further noted that there was no objective evidence that superficial heating had a suppressive effect on the mechanisms responsible for maintaining muscle spasms. The outcome predictors for the application of superficial heat were the result of ‘‘. secondary physiological and/or psychological factors from the heat application’’ (Taylor, pp. 835e848). The purpose of this study was to compare end results, passive ROM, after MFR techniques and hot pack application. The MFR technique is specifically described as an indirect three-planar soft tissue MFR technique as outlined by Weiselfish-Giammatteo and Kain (2005). The technique was applied for 3 min while the hot pack was applied for a standard 20 min. As MFR and the superficial heat application of hot packs have similar outcome predictors, it was felt that passive ROM assessment would yield similar results with both treatments. Should ROM assessments demonstrate comparable outcomes, MFR would exhibit a significant improvement in treatment efficacy (3 min versus 20 min). This study would be one of the first to show objective, measurable changes from the use of an MFR technique.
Methods Participants This study was reviewed by the Human Participants Review Board at American International College and was approved for data collection. Each participant signed an informed consent prior to testing. All testing was administered at American International College in Springfield, Massachusetts. All participants (N Z 31) were selected from a sample of convenience from the junior and senior physical therapy classes and were randomly assigned into two treatment groups The independent variable used was the type of intervention, either the tri-planar MFR technique or the hot pack application. Group one (N Z 18) received the indirect tri-planar MFR technique once for 3 min. Group two (N Z 13) received one hot pack application for 20 min. The dependent variables, passive gleno-humeral shoulder range of motion in shoulder flexion, shoulder extension, and
Indirect tri-planar MFR or a hot pack for increasing range of motion shoulder abduction were taken pre- and post-intervention for groups one and two. Both groups received treatment to their dominant upper extremity. All participants were goniometrically tested in supine position for range of motion at the gleno-humeral joint. Prior to conducting the study, inter-rater reliability (r Z 0.96) was established using three different testers for goniometric measures. Inclusion criteria included participants who were painfree in their dominant upper extremity with no history of acute or sub-acute injury. Participants’ dominant arm was utilized for testing procedures. This was determined by establishing which hand the participant used when writing. No attempt was made to further delimit the study based on gender, time of day, chronic injuries (beyond 6 months), race, or age.
Experimental procedures Participants were tested on the same day using two different examination rooms. Participants were positioned on standard plinths in the supine position to standardize testing. The head and neck were placed in the neutral position (i.e. zero degrees of side bending/rotation and flexion of the head and neck while supine). The dominant arm was placed at the side at zero degrees abduction, flexion, and rotation as a starting point for the measurement of passive range of motion (PROM) during pre- and post-testing. This position was maintained during application of the hot packs as well as the MFR techniques. Participants were allowed to talk during either intervention, yet allowing no movement of the head or neck in any plane. The practitioner’s hands were placed lightly on the body during application of the tri-planar MFR technique. The practitioner’s hands remained in light contact with the participant’s shoulder throughout the treatment intervention. Every effort was made not to change or alter hand pressure during the treatment.
Instrumentation and measurements Inter-rater reliability was established prior to testing to demonstrate accuracy in range of motion measurements between examiners. Shoulder PROM was goniometrically measured by independent examiners who were unaware of the interventions used for each participant. One examiner measured PROM using a standard goniometer, while another examiner passively moved the participant dominant extremity through a designated ROM. ROM assessments utilized Kaltenborn’s convex/concave constructs in determining the end ROM (Kaltenborn, 1976). End ROM was established when the examiner was able to palpate the humeral head move in an anterior/superior pattern. All motion was measured in the three cardinal planes of movement (i.e. sagittal, coronal, and transverse planes). Flexion and extension were measured in the sagittal plane; abduction was measured in the coronal plane. In situations where the accessory movement was not palpable, movement at the tendon insertion or muscle belly was used to determine the end point of motion. Standard goniometric measurements were taken using landmark assessment as outlined by Kendall and McCreary (2005) and Worthingham
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and Daniels (1972). All motion was limited to pure, planar alignment, and alteration from the criteria excluded the participants from testing. Passive range of motion was performed on all participants’ pre- and post-treatment by the same individuals. Participants who were randomly assigned to the hot pack (superficial heat) application received a standard hydrocollator pack. It contained silicate gel in a cotton canvas bag. The hot pack was placed in a heating unit filled with water maintained at a steady 79.4 C (175 F). The packs were layered equally and enclosed in terrycloth covers. A standard six layers of towels were used with all participants. More layering was added only during treatment time if requested by the participant due to excessive heat build up. All hot packs were applied for 20 min with the patient in the supine position with hot packs positioned over the anterior shoulder of the extremity examined. Participants assigned to the MFR group received treatment in the supine position. The same physical therapist performed all treatment interventions. The specific MFR technique was the clavi-pectoral indirect soft tissue threeplanar fulcrum release. The technique required the practitioner to sit on the side of the participant’s dominant extremity, slightly superior to the gleno-humeral joint to be treated. The practitioner’s hands were then spread maximally on the anterior and posterior aspects of the participant’s gleno-humeral joint. The palms of the practitioner were facing the participant. A light touch that allowed for full contact with no added pressure was utilized. The fingers were spread so as to engage as much tissue around and over the joint as possible. Once contact was established, the practitioner gently moved both hands in opposite directions in one plane at a time. The typical sequence for planar assessment was the sagittal, coronal, and then transverse planes. Once the practitioner moved the hands in opposite directions, they were then returned to the starting point and moved in the same plane in opposite directions. The practitioner then determined which two-handed combination moved with greater ease. The hands would be moved into that easier direction and held steady until the later two planes were assessed and stacked on the first plane. Once the direction of the sagittal plane movement was determined, the practitioner held both hands in that position of ease. This constituted the first part of the threeplanar fulcrum. The next step was to move both hands in opposite directions in the coronal plane while maintaining the hands in the direction of ease in the sagittal plane. Again, the practitioner determined the direction of combined movements which were easiest. Once determined, the practitioner stacked the coronal plane ease of movement on the sagittal plane hand position. This completed the second part of the three-planar fulcrum. The practitioner then held both hands in two different directions of tissue ease. The process was then repeated a third time in the transverse plane with the last plane of the indirect fulcrum motion stacked on the first two planes of movement. The practitioner moved his hands in three planes, establishing a fascial fulcrum over the gleno-humeral joint and clavi-pectoral region. All participants were treated in the supine position for a period of 3 min. The timing started
66 once the three-planar fulcrum was established by the practitioner. Post-test passive range of motion was then repeated for that joint for each participant.
Results A total of 31 participants were tested in this study. Participants were randomly assigned to one of two groups and were measured with a goniometer for passive range of motion of the gleno-humeral joint pre-intervention and post-intervention. Prior to conducting the study, inter-rater reliability was established using three testers for goniometric measures (r Z 0.96). Groups consisted of participants receiving one of the two interventions, hot pack or myofascial release. Thirteen participants received the hot pack intervention while 18 received the myofascial release intervention. A 2 (type of intervention: hot packs or MFR) by 2 (pre-test or post-test) mixed-factors ANOVA was calculated. Significant increases in range of motion were found for flexion, F(1,29) Z 12.42, p Z 0.001 when comparing pre-test scores to post-test scores. Significant increases in range of motion were found for extension, F(1,29) Z 20.34, p Z 0.001 when comparing pre-test scores to post-test scores. Significant increases in range of motion were found for abduction, F(1,29) Z 14.51, p Z 0.001 when comparing pre-test scores to post-test scores. The purpose of the study was to examine whether or not MFR was as effective in increasing range of motion as hot packs. The results of the ANOVA showed that for passive range of motion no differences were found for flexion between the effectiveness of hot packs (M Z 56.85, SD Z 6.35) and MFR (M Z 58.33, SD Z 7.58), F(1,29) Z 1.822, p Z 0.187. This suggests that for flexion, the MFR treatment is as effective as hot packs. For the extension of the gleno-humeral joint, the ANOVA showed no significant differences in the use of hot packs (M Z 39.27, SD Z 6.00) and MFR (M Z 41.22, SD Z 4.47), F(1,29) Z 0.241, p Z 0.628. Finally, for abduction the hot packs (M Z 60.08, SD Z 5.02) did not differ in effectiveness from the MFR (M Z 60.86, SD Z 4.35), F(1,29) Z 0.44, p Z 0.512. For each of the dependent variables measured, MFR was shown to be as effective as hot packs in increasing range of motion, supporting the hypothesis.
Discussion Since there was no significant difference between the types of intervention, both the hot pack application and the myofascial release technique were found to be equally effective in increasing passive range of motion of the joint in flexion, extension, and abduction of the gleno-humeral joint. The group receiving the hot pack intervention had an increase in joint passive range of motion from pre to post application as did the myofascial group. The MFR intervention was as effective as the standard intervention of hot packs. In determining which intervention to administer, the clinician needs to consider some basic elements; how much time does the clinician have to provide treatment?, is equipment an issue?, and does the clinician have the necessary skills to effectively administer the intervention?
J. Kain et al. Providing myofascial techniques requires decreased time to administer the intervention, no equipment to purchase in order to administer the intervention, no preparation time; however, this technique does require additional training on the part of the physical therapist in order to provide a safe, effective intervention. On the other hand, the clinician is aware that hot pack use requires more time to administer the intervention but is easy to administer, requires the purchase of a hot pack, the hot pack cover, and towels, requires preparation time but does not require additional training. Hot pack use requires up to 20 min to administer the intervention, while the myofascial release technique requires 3 min to administer. In the time needed to apply and administer a hot pack on one patient, approximately 5e6 patients could have been treated using the myofascial release technique with similar outcomes in range of motion. The hot pack intervention requires the purchase expenses as listed above, while the myofascial technique requires the hands of the skilled clinician to administer. The speed of the myofascial release technique and the lack of equipment would suggest that it is a more time efficient type of intervention, provided the therapist is trained in this technique. Both interventions have been found to be equally effective in increasing passive range of motion. This study did not take measurements for either intervention long-term, resulting in a limitation of the study to truly assess the effectiveness of joint range of motion over a long period of time. However, it is the responsibility of the physical therapist to establish strategies for maintaining range of motion gained during the therapy visit. Based upon the premise that each clinician has the right to be an autonomous practitioner, both of the identified modalities should be considered in physical therapy intervention strategies. Editor’s note: The description of the MFR method, described in this paper as ‘tri-planar indirect MFR’, might be confusing for some readers. In osteopathic circles, in particular, this approach would more commonly be described as a Functional Positional Release approach. (Johnstone 2003).
References Barnes, M.F., 1997. Efficacy study of the effect of a myofascial release treatment technique on obtaining pelvic symmetry. Journal of Bodywork and Movement Therapies 1 (5), 289e296. Bucher, B.M., 1993. Myofascial manipulative release of carpal tunnel syndrome: documentation with magnetic resonance imaging. Journal of the American Osteopathic Association 93 (12), 1273e1278. Bucher, B.M., 1994. Myofascial release of carpal tunnel syndrome. Journal of the American Osteopathic Association 93 (1), 92e94. 100e101. Cantu, R., Grodin, A., 1992. Myofascial Manipulation: Theory and Clinical Application. Aspen Publishers, Gaithersburg, MD. Hanten, W.P., 1994. The effects of myofascial release leg pull and sagittal plane isometric contract relax techniques on passive straight leg raise angle. Journal of Orthopedic and Sports Physical Therapy 20 (3), 138e144. Johnston, W.L., 2003. Functional technique: an indirect method. In: Ward, R.C. (Ed.), Foundations for osteopathic medicine, 2/e. Lippincott, Williams & Wilkins, Philadelphia, pp. 969e 984.
Indirect tri-planar MFR or a hot pack for increasing range of motion Kaltenborn, F., 1976. Manual Therapy for the Extremity Joints. Olaf Norlis Bokhandel, Oslo, Norway. Kendall, F., McCreary, E., 2005. Muscles, Testing and Function. Williams and Wilkins, Baltimore, MD. Prentice, W., 1990. Rehabilitation Techniques in Sports Medicine. Times Mirror/Mosby College Publishers, Saint Louis, MO.
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Taylor, L.P., 1990. In: Taylor’s Manual of Physical Evaluation and Treatment, vol. II. Slack Inc., Thorofare, NJ. Weiselfish-Giammatteo, S., Kain, J., 2005. Integrative Manual Therapy for the Connective Tissue System: Myofascial Release. North Atlantic Books, Berkeley, CA. Worthingham, C., Daniels, L., 1972. Muscle Testing: Techniques of Manual Examination, third ed. WB Saunders, Philadelphia, PA.
Journal of Bodywork & Movement Therapies (2011) 15, 68e74
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OMT EFFECT IN ESSENTIAL HYPERTENSION
Osteopathic manipulation as a complementary treatment for the prevention of cardiac complications: 12-Months follow-up of intima media and blood pressure on a cohort affected by hypertension Francesco Cerritelli, MS, DO a,b,*, Fabrizio Carinci, MS a, Gianfranco Pizzolorusso, DO a,b, Patrizia Turi, DO a,b, Cinzia Renzetti, MD, DO b, Felice Pizzolorusso, DO b, Francesco Orlando, DO b, Vincenzo Cozzolino, MD, DO b, Gina Barlafante, MD, DO b a b
European Institute for Evidence Based Osteopathic Medicine (EBOM), Viale Unita` d’Italia 1, 66100 Chieti, Italy AIOT Research Institute, Pescara, Italy
Received 18 September 2009; received in revised form 5 March 2010; accepted 20 March 2010
KEYWORDS Cardiovascular disorders; Intima-media thickness; Systolic/diastolic blood pressure; Osteopathic manipulative treatment
Summary Background: Aim of the present study was to investigate the association between osteopathic treatment and hypertension. Methods: The design was a non-randomized trial including consecutive subjects affected by hypertension and vascular alterations, using preepost differences in intima-media thickness, systolic and diastolic blood pressure as primary endpoints. Statistical analysis was based on univariate t tests and multivariate linear regression. Results: A total of N Z 31 out of N Z 63 eligible subjects followed by a single cardiologist received osteopathic treatment in addition to routine care. Clinical measurements were recorded at baseline and after 12 months. Univariate analysis found that osteopathic treatment was significantly associated to an improvement in all primary endpoints. Multivariate linear regression showed that, after adjusting for all potential confounders, osteopathic treatment was performing significantly better for
* Corresponding author. Via Prati 29, 65124 Pescara, Italy. Tel.: þ39 339 4332801; fax: þ39 0873 380520. E-mail address:
[email protected] (F. Cerritelli). 1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2010.03.005
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intima-media thickness (delta between preepost differences in treated and control groups: 0.517; 95% c.i.: 0.680, 0.353) and systolic blood pressure (4.523; 6.291, 2.755), but not for diastolic blood pressure. Conclusion: Our study shows that, among patients affected by cardiovascular disorders, osteopathic treatment is significantly associated to an improvement in intima-media and systolic blood pressure after one year. Multicentric randomized trials of adequate sample size are needed to evaluate the efficacy of OMT in the treatment of hypertension. ª 2010 Elsevier Ltd. All rights reserved.
Background The relation between endothelial wall modifications (Cheng et al., 2002), vessels wall alterations (Schmidt-Trucksass et al., 1999), and change of the endothelial carotid wall (Simon et al., 2002; Labropoulos et al., 2000; Safar et al., 2003) on hypertension is well documented by the scientific literature. The degeneration of the endothelial layer is associated to a variation of metabolic processes in vessels, determining plaques growing (Cheitlin, 2003) and variations in the hemodynamic of blood fluid (Schmidt-Trucksass et al., 1999) that may trigger the atherosclerosis process (Howard et al., 1993) through an increase in intima-media thickness (IMT) (Belcaro et al., 1996, 2001). The condition of the vascular wall can be altered by endogenous factors, e.g. genetic alterations, or exogenous determinants, which can include many potential aspects of the complex interaction between the subject and the outer environment. Behavioural factors e.g. a high level of physical activity are significantly associated to a decreased incidence of atherosclerosis (Rosenwinkel et al., 2001; Goldsmith et al., 2000; Carter et al., 2003; Tanaka et al., 2002). Psycho-physical conditions e.g. stress, through their influence on the autonomic nervous functions, may lead to alterations of both the arterial pressure (Charkoudian et al., 2005) and the endothelium (Dinenno et al., 2000). Manipulative techniques may be included in the range of exogenous factors of potential interest in the prevention of hypertension and cardiovascular events (Kalinina and Efimova, 2006). In this field, evidence-based guidelines applied by clinical cardiologists for high risk subjects include continuous monitoring through the regular measurement of blood pressure (BP) and the evaluation of IMT and the arterial wall (Belcaro et al., 1996, 2001). A thorough research of the scientific literature, including relevant papers from integrative and complementary medicine journals, shows that the potential role of osteopathic manipulative treatment (OMT) has been already considered in the treatment of hypertension, mainly as a possible modifier of the relationship between somatic dysfunctions and hypertension (Williams, 1994; Johnston and Golden, 2001; Johnston et al., 1995; Johnston and Kelso, 1995). The aim of the present study was to investigate the direct association between OMT and hypertension through the observation of relevant clinical parameters that are routinely used in clinical practice to prevent long-term cardiovascular disorders.
Methods Objectives and endpoints of the study The main objective of the study was to evaluate the efficacy of OMT on a subgroup of consecutive subjects presenting hypertension and vascular alterations following cardiologic examination. Primary endpoints of the study were differences between treated and control groups in changes from baseline for IMT and BP (systolic, diastolic) after 12 months.
Study population The study was coordinated by the Osteopathic Clinical Centre “AIOT” in the city of Pescara, located in Central Italy with a population of 120,000. A private cardiologist was asked to refer to the Centre all consecutive subjects visited in year 2007 that were meeting the following inclusion criteria: presence of hypertension, classified as grade 1þ according to the specifications of WHO
What is OMT? Osteopathic manipulative treatment (OMT) is the process through which osteopaths treat somatic dysfunctions. Somatic dysfunctions are catalogued as disease of musculoskeletal system (ICD-9, code 739) and are identified by TART parameters (see text). OMT is characterized by different techniques, i.e. myofascial release, craniosacral, High Velocity Low Amplitude (HVLA) manipulation, Balanced Ligamentous Tension (BLT), Muscle Energy Technique, biodynamic, strainecounterstrain, etc. This wide range of techniques permits the operator to choose the more appropriate to apply on a patient in a given moment. During scientific studies, OMT can be used as an approach, as was done in this study, or as an isolated technique. The former uses individualized techniques in relation to the need of the patient while the latter one employs standardized technique. These reflect two different ways of utilising OMT. One is based on effectiveness e meaning how the use of a global approach can change outcomes. The second is based on the efficacy of just one technique, on outcomes.
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(Brookes, 2004), and B-ultrasound morphology classified as II, III, IV (Table 1). A total of N Z 72 eligible subjects entered the study. A subgroup of N Z 9 patients was considered more severe and thus excluded from the cohort, due to the presence of multiple risk factors and/or relevant complications in the previous 10 years. The assessment was conducted by the same cardiologist on the basis of the history of renal/retinal disease, hypercholesterolemia (>250 mmol/l), diabetes, metabolic problems (as obesity or X syndrome) and smoking. Among the 63 patients finally enrolled in the cohort, N Z 31 were non-randomly assigned to OMT, and N Z 32 continued to be observed as a control group. All patients enrolled were invited to conduct in the same visit a series of baseline instrumental examinations (BP, IMT, BMI, height, weight, rest heart rate). Patients assigned to OMT were separately treated by a registered trained osteopath every fortnight, for a period of one year. A final follow up cardiologic visit was scheduled after 12 months to test preepost variation of measurements recorded at baseline. All subjects expressed their consent to the study and were followed up by the same cardiologist.
(Kuchera and Kuchera, 1994), and then treated the patient focusing on selected targets. Evaluation represents a key preliminary component of osteopathic practice. It allows to collect basic information on tissue characteristics and to highlight the presence of functional alterations (also known as TART– for Tenderness, Asymmetry, Range of motion change, Tissue texture change) in specific areas of the body. Palpation provides essential knowledge of the structures positioned in regions of the body that are more subject to changes in the tone of the autonomic nervous system (Longmire, 2006), identified by particular patterns of stiffness/tenderness of the tissues (muscles, fascias, etc). In the present study, the following tests (Greenman, 2003) were performed at each visit: the “spring test”, for dorsal and lumbar spine; the “F.AB.ER. test” for hips; the “internal and external rotation test” for arms; and the “six movements test” for the neck. In each case, a state of initial resistance denoted the potential presence of somatic dysfunction. Osteopathic treatment was performed on the part of the body presenting greater TART modifications applying fascial, cranial and balanced ligamentous tension techniques (Greenman, 2003).
Pharmacological treatment Antihypertensive treatment was routinely administered to all patients over 12 months, according to updated evidencebased guidelines routinely applied by the clinical cardiologist. Calcium channel blockers (CA2þ), ACE-inhibitors (ACE), beta-blockers (BB) and diuretics were prescribed either alone or in combination.
Treatment procedures and specific target parameters Osteopathic treatment consisted of a visit during which a single operator initially performed a series of specific tests to evaluate the mobility of different parts of the body
Table 1
Ultrasound morphology and classes.
Class
Ultrasound Morphology
I
Normal: Three ultrasonic layers (intimae-media, adventitia, and periadventitia) clearly separated. No disruption of lumen-intimae interface for at least 3.0 cm, and/or initial alterations (lumen-intimae interface disruption at intervals of <0.5 mm). Intimae-media granulation: Granular echogenicity of deep, normally unechoic intimal-medial layer and/or increased intimae-media thickness (1 mm). Plaque without haemodynamic disturbance: Localized wall thickening and increased density involving all ultrasonic layers. Intimae-media thickness >2 mm. Stenotic plaque: As in III, but with haemodynamic stenosis on duplex scanning (sample volume in the centre of the lumen), indicating stenosis >50%.
II
III
IV
Clinical measurements All subjects underwent 24-hour ambulatory monitoring system (Holter) as part of the cardiologic test for hypertension performed at study entry. In the same visit, clinical measurements were also performed, including BMI, height, weight, rest heart rate and a series of instrumental tests for BP and IMT. All measurements were repeated after 12 months. Resting BP was measured using a standard sphygmomanometer, with the subject lying in supine rest position for 30 min at the time of ultrasound examination. The retained value was the average of three consecutive measurements, rounded to the nearest integer mm/Hg. Both carotid and femoral arterial bifurcations were studied to measure IMT in millimetres (mm). All measurements were performed using an ATL Ultramark 4 duplex scanner with a high-resolution, 7.5-MHz linear transducer. After localizing the carotid and femoral bifurcations through a transverse scan, the probe was rotated 90 to record a longitudinal image of both the anterior and posterior walls. The carotid artery was evaluated for a length of about 3 cm (1.5 cm proximal and 1.5 cm distal to the flow divider). The femoral artery was examined at the femoral bifurcation and scanned for a length of 3 cm (1.5 cm proximally and distally to the flow divider). Through this technique, the three ultrasonic vessel wall layers (intima media, adventitia, and periadventitia) were made clearly visible. Technical ultrasound parameters (dynamic range, depth range, power, reject, edge, gray scale, and smooth) were kept constant. The aforementioned ultrasound-based morphological classification (Schmidt-Trucksass et al., 1999; Howard et al., 1993; Belcaro et al., 1996) included five classes, with scores ranging 0e8 (Howard et al., 1993) for each artery. In the present study, classes I and II were merged into a single category, as they could not be univoquely identified using histological results only.
Osteopathic Manipulative Therapy A single ultrasound score for each subject was obtained as the sum of the scores recorded for the four arteries (Howard et al., 1993), measured through the aid of VHS. All characteristics recorded for each individual were computerized using an Excel spreadsheet by the osteopath, including results of automated cardiologic measurements (instrumental print out).
Statistical analysis Descriptive analysis was performed using frequencies, arithmetic means and standard deviations. Univariate statistical tests included formal tests of differences between study and control groups using c2 for categorical variables and unpaired t tests for continuous measurements. Primary outcomes included differences in preepost changes of IMT, systolic blood pressure (SBP) and diastolic blood pressure (DBP). Potential confounders included the following categorical variables: gender, total dose of CA2þ, ACE, BB and diuretic alone and in combination, OMT. Continuous variables were categorized to favour clinical interpretation, based upon upper quartiles: baseline values of age (55, >55), BMI (25, >25), heart rate (72, >72), IMT (4, >4), SBP (154, >154), DBP (96, >96) and total daily dose of the above medications (75 mg, >75). Multivariate linear regression was used to estimate the independent effect of OMT on primary outcomes, simultaneously adjusting for all other potential confounders, and preepost changes in the endpoints (where relevant). Statistical significance was based on a probability level (alpha) equal to 0.05. Results were expressed in terms of point estimates and 95% confidence intervals (c.i.). All analyses were performed using the statistical programming language R (The R Development Core Team, 2008).
Results Association between clinical patterns and primary outcomes Descriptive statistical analysis showed no significant imbalances among treated and control groups in terms of main characteristics measured at baseline, including pharmacological treatment (Table 2). Patients were evenly distributed across classes of B-ultrasound morphology. At the end of follow-up, all subgroups identified by different levels of potential confounders, except for patients not submitted to OMT, showed a general improvement in all primary endpoints (Figure 1). Reductions observed across all categories ranged between 0.12 and 0.53 mm for IMT, 21.69 and 26.48 mmHg for SBP, and 9.16 and 13.71 mmHg for DBP. At univariate analysis, baseline characteristics were found to be significantly associated to the main endpoints as follows: baseline BMI to change in SBP (p Z 0.03); heart rate to change in DBP (p Z 0.03); SBP to change in IMT (p Z 0.04); baseline SBP/DBP to change in DBP (p < 0.01; <0.001); baseline IMT to change in DBP (p < 0.001); OMT to change in IMT (p < 0.0001), SBP (p < 0.0001) and DBP (p < 0.01).
71 Table 2 General characteristics of the study population at baseline (t0). N* Males* Age Height Weight CA2+* ACE* BB* Diuretics* Tot dose IMT BMI SBP DBP Heart rate
Study group
Control group
p value
31 (49.2) 16 (51.6) 50.0 5.7 1.7 0.1 68.3 8.1 13 (59.1) 5 (38.4) 15 (46.9) 3 (42.9) 50.1 64.9 2.8 1.5 24.2 1.7 148.9 5.7 93.4 4.3 69.1 4.0
32 (50.8) 15 (46.9) 49.6 6.1 1.7 0.1 67.9 8.6 9 (40.9) 8 (61.5) 17 (53.1) 4 (57.1) 51.6 65.1 3.0 1.6 24.2 1.3 149.2 6.1 93.1 4.0 69.0 4.4
0.70 0.79 0.75 0.86 0.75 0.96 0.47 0.23 0.92 0.61 0.95 0.85 0.73 0.97
Numbers in table are means.d.; p value from t test. * n(%); p value from c2 test.
The independent role of OMT Multivariate linear regression (Figure 2) showed that increased BMI was significantly associated to a deterioration of IMT (mean difference per unit between change in treated and control groups: 0.046; 95% c.i.: 0.004, 0.088), as well as change in total medications (0.007; 0.001, 0.006), baseline SBP to lowered SBP (0.894; 1.239, 0.550) and increased DBP (0.591; 0.249, 0.933), change in SBP to increased DBP (0.394; 0.168, 0.621), baseline DBP to increased SBP (0.654; 0.173, 1.135) and decreased DBP (1.080; 1.422, 0.740), change in DBP to increased SBP (0.499; 0.212, 0.785). After adjusting for all the above characteristics, OMT was found to be significantly and independently associated to a significant improvement in IMT (0.517; 0.680, 0.353) and SBP (4.317; 6.421, 2.214), but not to a difference between changes in DBP.
Discussion The aim of the present study was to evaluate the efficacy of OMT on a population of patients affected by essential hypertension, in terms of improvements in IMT and BP. To the best of our knowledge, the application of OMT in the prevention of cardiovascular diseases has never been investigated in detail, except for observational studies focusing on BP (Johnston and Golden, 2001; Johnston and Kelso, 1995; Kuchera and Kuchera, 1994; Spiegel et al., 2003). Our study shows that, after one-year follow-up, OMT is associated to improved IMT and SBP. A possible explanatory mechanism is shown in the hypothetical diagram reproduced in Figure 3, explained as follows. In the presence of trauma or somatic dysfunction changing the structure of the tissue, OMT, consistently with in-vitro models (Meltzer and Standley, 2007), may decrease the production of inflammatory factors (cytokines), generating a cascade effect on mechanisms that generally
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Figure 1 Figure summarizes results from univariate statistical analysis that showed an association between clinical patterns and primary outcomes at the end of follow-up. Bmi Z body mass index, sbp Z systolic blood pressure, dbp Z diastolic blood pressure, imt Z intima media thickness, omt Z osteopathic manipulative treatment.
improve the metabolism of the arterial wall. On the other hand, OMT may also improve the functionality of the sympathetic nerve system (ANS) affected by a cardiovascular event, re-establishing the physiological function of the spinal cord (Johnston and Kelso, 1995; Kuchera and Kuchera, 1994). Through the important role played by the sympathetic tone in modifying the metabolism and hemodynamic factors (Narkiewicz et al., 2005), OMT may then affect the metabolism of the arterial wall, especially in situations in which the state of intima media is not substantially compromised (classes II and III).
In our case, all patients showed a general improvement after 12 months of cardiologic care. The result is consistent with the effective application of clinical guidelines for the strict monitoring and control of high risk patients. In this framework, the results that we obtained through the application of OMT may represent an important indication of the possible added value that can be obtained by introducing a noninvasive complementary treatment in routine cardiologic practice. Further investigations, including experimental tests and randomized clinical trials, are needed to shed light on the
Figure 2 Figure describes results from multivariate linear regression that showed an independent role of OMT on primary outcomes. BMI Z body mass index, IMT Z intima media thickness, SBP Z systolic blood pressure, DBP Z diastolic blood pressure, OMT Z osteopathic manipulative treatment.
Osteopathic Manipulative Therapy
Figure 3 Hypothetical diagram shows a possible explanatory mechanisms of OMT based on cardiovascular and neurological patterns. ANS Z autonomic nervous system, HR Z heart rate.
actual mechanisms involved in the application of OMT on cardiovascular parameters. To overcome the scarcity of information available in this field, new studies should also incorporate methodological procedures that were not applied in our case purely for practical reasons. In particular treatment was not randomly assigned, the sample size was not based on a formal power computation, and the sample treated by a single cardiologist/osteopath may not represent adequately the average target population. Nevertheless, the present study shows that after a oneyear follow-up, osteopathic treatment is associated to improved conditions of the arterial wall and reduced blood pressure. These results highlight a potential beneficial effect of osteopathic manipulation in the management of subjects at high risk of cardiovascular events, using measures that can be easily obtained in similar conditions in everyday cardiologic practice at the international level. Our approach, mainly exploratory and hypothesis generating, may be used as a basis for further investigation in different populations and practices. The strength and causal explanations of the efficacy of osteopathic treatment on key clinical parameters need to be validated under more general conditions.
Disclosure None.
Appendix A Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.jbmt.2010. 03.005.
References Belcaro, G., Nicolaides, A.N., Laurora, G., Cesarone, M.R., De Sanctis, M., Incandela, L., et al., 1996. Ultrasound morphology
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74 Narkiewicz, K., Phillips, B.G., Kato, M., Hering, D., Bieniaszewski, L., Somers, V.K., 2005. Gender-selective interaction between aging, blood pressure, and sympathetic nerve activity. Hypertension 45, 522e525. Rosenwinkel, E.T., Bloomfield, D.M., Arwady, M.A., Goldsmith, R.L., 2001. Exercise and autonomic function in health and cardiovascular disease. Cardiology Clinics 19, 369e387. Safar, M.E., Levy, B.I., Struijker-Boudier, H., 2003. Current perspectives on arterial stiffness and pulse pressure in hypertension and cardiovascular diseases. Circulation 107, 2864e2869. Schmidt-Trucksass, A., Grathwohl, D., Schmid, A., Boragk, R., Upmeier, C., Keul, J., et al., 1999. Structural, functional, and hemodynamic changes of the common carotid artery with age in male subjects. Arteriosclerosis Thrombosis and Vascular Biology 19, 1091e1097. Simon, A., Gariepy, J., Chironi, G., Megnien, J.L., Levenson, J., 2002. Intima-media thickness: a new tool for diagnosis and treatment of cardiovascular risk. Journal of Hypertension 20, 159e169.
F. Cerritelli et al. Spiegel, A.J., Capobianco, J.D., Kruger, A., Spinner, W.D., 2003. Osteopathic manipulative medicine in the treatment of hypertension: an alternative, conventional approach. Heart Disease 5, 272e278. Tanaka, H., Seals, R.D., Monahan, K.D., Clevenger, C.M., DeSouza, C.A., Dinenno, F.A., 2002. Regular aerobic exercise and the age-related increase in carotid artery intima-media thickness in healthy men. Journal of Applied Physiology 92, 1458e1464. The R Development Core Team, 25 August 2008. R: a language and environment for statistical computing. Available at: http://cran. r-project.org/doc/manuals/fullrefman.pdf Reference index, version 2.7.2. Williams, A.M., 1994. An osteopathic cardiologist’s review of hypertension: beyond the Fifth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. Journal of American Osteopathic Association 94, 833e847.
Journal of Bodywork & Movement Therapies (2011) 15, 75e81
available at www.sciencedirect.com
journal homepage: www.elsevier.com/jbmt
CLINICAL APPROACHES
The effect of pelvic floor muscle exercise on women with chronic non-specific low back pain Mohammad A. Mohseni-Bandpei, PhD, PT a,b,*, Nahid Rahmani, MSc, PT a,*, Hamid Behtash, MD c, Masoud Karimloo, PhD d a Physiotherapy Department, University of Social Welfare and Rehabilitation Sciences, PO Box 1985713834, Evin, Tehran, Iran b Rehabilitation Dept., School of Medicine, Khazar Blvd., PO Box 48168, Sari, Mazandaran, Iran c Department of Spine Surgery, Hazrat Rasoul-e-Akram Teaching Hospital, Iran University of Medical Sciences, Tehran, Iran d Department of Medical Statistics, University of Social Welfare and Rehabilitation Sciences, PO Box 1985713834, Evin, Tehran, Iran
Received 5 August 2009; received in revised form 17 October 2009; accepted 8 December 2009
KEYWORDS Pelvic floor muscle; Chronic low back pain; Exercise; Perineometer
Summary Dysfunction of spinal stability seems to be one of the causes of low back pain (LBP). It is thought that a large number of muscles have a role in spinal stability including the pelvic floor muscle (PFM). The purpose of this study was to investigate the effect of PFM exercise in the treatment of chronic LBP. After ethical approval, a randomized controlled clinical trial was carried out on 20 women with chronic LBP. Patients were randomly allocated into two groups: an experimental and a control group. The control group was given routine treatment including electrotherapy and general exercises; and the experimental group received routine treatment and additional PFM exercise. Pain intensity, functional disability and PFM strength and endurance were measured before, immediately after intervention and at 3 months follow-up. In both groups pain and functional disability were significantly reduced following treatment (p < 0.01), but no significant difference was found between the two groups (p > 0.05). All measurements were improved in both groups (p < 0.01) although patients in the experimental group showed greater improvement in PFM strength and endurance (p < 0.01). It seems that the PFM exercise combined with routine treatment was not superior to routine treatment alone in patients with chronic LBP. ª 2009 Elsevier Ltd. All rights reserved.
* Corresponding authors. Physiotherapy Department, University of Social Welfare and Rehabilitation Sciences, PO Box 1985713834, Evin, Tehran, Iran. E-mail addresses:
[email protected] (M.A. Mohseni-Bandpei),
[email protected] (N. Rahmani). 1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.12.001
76
Introduction Low back pain (LBP) is one of the most common conditions affecting all population, worldwide (Jin et al., 2004; Mohseni-Bandpei et al., 2006, 2007). It is ranked first as a cause of disability and inability to work and approximately one quarter of adults in the United Sates (US) reported having LBP lasting at least one day in the past 3 months (Luo et al., 2004; Deyo et al., 2006). A high prevalence rate and high associated economic and social costs were reported in France due to LBP (Gourmelen et al., 2007). In Iran, a lifetime prevalence of LBP in nursing population and pregnant women was reported to be 62% and 84%, respectively (Mohseni-Bandpei et al., 2006, 2009) and it was responsible for 33.7% of work absenteeism during past month in nurses (Mohseni-Bandpei et al., 2006). The costs was estimated to be 0.7% of Gross Domestic Product (GDP) in Sweden and 1.7% of GDP in the Netherlands (Ekman et al., 2005). A German cost-of-illness study estimated total costs of LBP at around V17 billion, equating to 0.9% of the GDP (Wenig et al., 2009). It has been suggested that the overall mechanical stability of the spinal column, especially in dynamic conditions and under heavy loads, is provided by the spinal column and the precisely coordinated surrounding muscles (Richardson et al., 1999; Hodges et al., 2007). The spinal stabilizing system of the spine was primarily suggested by Panjabi (1992), consisting of three subsystems: the spinal column providing intrinsic stability; spinal muscles, surrounding the spinal column, providing dynamic stability; and the neural control unit evaluating and determining the requirements for stability and coordinating the muscle response (Panjabi, 1992; Sahrmann, 2002). Under normal conditions, the three subsystems work in harmony and provide the needed mechanical stability (Bergmark, 1989; Barr et al., 2005). Among various documented risk factors for LBP such as smoking (Mikkonen et al., 2008), obesity (Mirtz and Greene, 2005), pregnancy (Mohseni-Bandpei et al., 2009), physical activity (Hartvigsen and Christensen, 2007), mental health (Strine and Hootman, 2007), recent research has focused on the relationship between LBP and respiratory disorders, incontinence and gastrointestinal problems (Hodges et al., 2007; Smith et al., 2009). Smith et al. (2009), in a study on 2943 younger, 2298 mid-age and 2258 old women from the Australian longitudinal study on women’s health reported that women with pre-existing incontinence, gastrointestinal problems and breathing disorders were more likely to develop LBP than women without such problems. This was considered to be a result of changes in control of the trunk muscles following involvement with incontinence, respiratory and gastrointestinal problems. Changes in morphology and altered postural activity of the trunk muscles including muscles of respiration and continence which provide mechanical support to the spine and pelvis has been shown to be related to the development and occurrence of LBP (Hides et al., 2001; Cholewicki et al., 2005). In addition to the well documented role of pelvic floor muscle (PFM) in patients with urinary and faecal incontinence (Bo et al., 1999, 2009a; Morkved et al., 2003), the PFM have also an important role in proper muscular activation for lumbar stabilization (Sapsford and Hodges, 2001; Sapsford et al., 2001). The pelvic floor forms the base of the
M.A. Mohseni-Bandpei et al. abdominal cavity and during different tasks that elevate intra-abdominal pressure, muscles must contract to maintain continence and contribute to pressure increases (Gilpin et al., 1989). In a small experimental trial of healthy subjects, strong voluntary abdominal muscle contraction caused PFM activity at the same intensity as maximal PFM’s effort (Sapsford and Hodges, 2001). Bø et al. (2009b) have recently compared the effect of instruction of PFM and TrA contraction on constriction of the levator hiatus of 13 women with pelvic organ prolapse using 4D perineal ultrasonography. They reported that all hiatus dimensions were significantly greater during PFM than TrA contraction. Although the sample of their study was very small, they concluded that instruction of PFM contraction is more effective in reducing the levator hiatus than instruction of TrA contraction in women with pelvic organ prolapse. Morkved et al. (2007) have investigated the effect of group training during pregnancy in prevention of lumbopelvic pain. Self-reported symptoms of lumbopelvic pain, sick leave, and functional status were measured on 301 healthy nulliparous women who were randomly allocated into a training group (148) or a control group (153). The control group received daily PFM training at home, and the training group was given weekly group training over 12 weeks including aerobic exercises, PFM and additional exercises, and information related to pregnancy. Although their study were suffered from some methodological flaws such as lack of an objective measures, lack of a defined inclusion and exclusion criteria, unavoided intervention, etc. they reported that at 36 weeks of gestation women in the training group were significantly less likely to report lumbopelvic pain and had significantly higher scores on functional status but there was no difference in sick leave during pregnancy. However, they concluded that a 12-week specially designed training program during pregnancy was effective in preventing lumbopelvic pain in pregnancy. Sapsford et al. (2001) investigated the co-activation pattern of the pelvic floor and the abdominal muscles via needle electromyography (EMG) for the abdominals and surface EMG for the pelvic floor. They found that the abdominals contract in response to a pelvic floor contraction command and that the pelvic floor contracts in response to both a ‘‘hollowing’’ and ‘‘bracing’’ abdominal command. The results from this research suggest that the pelvic floor can be facilitated by co-activating the abdominals and vice versa. However, no published evidence was yet found to assess the function of PFM in patients with LBP or to evaluate the effect of PFM exercises in the treatment of such patients. Those studies investigating the function of PFM in healthy subjects or in incontinent women suffered from some methodological flaws such as small sample size, heterogeneous sample, lack of a standardized reliable and valid procedure, lack of a defined inclusion and exclusion criteria, testing different muscles at different positions, etc. The purpose of the present study which appears to be the first of its kind was to investigate the effect of PFM exercise in the treatment of patients with chronic LBP. As PFM has an important role in lumbar spine stability, and lumbar instability was suggested to be one of the causes for LBP, it was hypothesized that PFM exercise could be of benefit for patients with chronic LBP.
The effect of pelvic floor muscle exercise
Materials and methods Study design and sampling Following ethical approval from the Medical Ethics Board of the University of Social Welfare and Rehabilitation Sciences, 20 women with non-specific LBP were recruited according to the inclusion and exclusion criteria of the study. Patients were included if they were married (as unmarried women are usually expected to be virgin in Iran) and aged between 20 and 50 years old with a good general health. The exclusion criteria were: any history of diabetes, any history of neurological conditions or autoimmune connective tissue disorders, a sacroiliac joint dysfunction, vaginal cavity size inadequate to comfortably insert the perineometer, pregnancy, respiratory disease, metabolic disease, and a degree of pelvic organ prolapse sufficient to prevent maintenance of the perineometer inserted intravaginally at rest. All patients were given written information about the aims and plans of the study and then they were asked to sign a consent form if they agreed to participate. The participants who met the inclusion and exclusion criteria were randomly assigned to one of the two groups through a block-style randomization scheme (Piantadosi, 1997).
Procedure The assessment was performed in crook lying position (supine position with both knees bent up) for all patients using a vaginal pressure measurement device. The Peritron perineometer (Cardio Design Pty Ltd, Oakleigh, Victoria, Australia), which is a conical vaginal insert, 28 mm in diameter and 108 mm in length with an active surface measurement length of 55 mm, was used. The vaginal insert is connected to a handheld microprocessor with latex tubing, allowing for transmission of pressure readings in centimeters of water when the insert is compressed by external pressure. The insert was covered with a sterile latex sleeve for each patient. The perineometer was inserted into the vaginal canal until the full extent of the compressible portion of the device was above the level of the hymeneal ring. The baseline pressure reading was recorded and then the device was zeroed. Patients were instructed to contract their PFM and to squeeze with maximum perceived effort for two to three seconds. They were asked to pull the PFM in and up as much as possible. Three squeezes were recorded in succession with a 10-s rest interval between efforts (Hodges et al., 2007). The peak of the three successive contractions was recorded as maximum perceived strength of PFM. In order to measure the endurance, 60% of maximum perceived strength was calculated. Patients were then instructed to maintain this squeeze pressure until fatigue occurred or the squeeze pressure returned to 50% of the primary effort. For each effort, a maximum perceived pressure and duration of squeeze were considered as strength and endurance of PFM. In order to minimize any increase in perineometer recording caused by excessive raises in intra-abdominal pressure, each PFM contraction was checked through observation of a perineal lift and the use of a pressure biofeedback device placed in the lumbar spine.
77 Patients were required to perform 4 contractions lasting for 5-s with 4-s rest between each contraction. They were asked to increase the number of contractions up to 10 lasting for 10-s. Patients were encouraged to repeat the exercise for 6 times per day (Laycock and Jerwood, 2001).
Data collection Twenty women with non-specific chronic LBP were recruited and randomly assigned into two groups; an experimental group (n Z 10) and a control (n Z 10). Before intervention, pain intensity was measured on visual analogue scale (VAS) and functional disability was assessed using Oswestry Disability Questionnaire. PFM strength and endurance in both groups were also assessed using perineometer (Bø and Finckenhagen, 2001). The control group received traditional physiotherapy treatment for LBP including electrotherapy (transcutaneous electrical nerve stimulation, infra red and therapeutic ultrasound) and general exercises (back flexor and extensor strengthening exercises). The experimental group was given traditional physiotherapy treatment and PFM exercise in addition. All measurements were taken just before randomization, immediately after 8 weeks treatment and at 3 months follow-up. The intra-rater reliability of perineometer (within-day and between-days) in the assessment of PFM strength and endurance has already been achieved. PFM strength and endurance measurements using perineometer were shown to be very reliable with high intraclass correlation coefficient values (0.95 for strength and 0.94 for endurance) for within-day measurements and high intraclass correlation coefficient values (0.88 for strength and 0.83 for endurance) for between-days measurements (Rahmani and Mohseni-Bandpei, 2009).
Data analysis Table 1 shows the baseline characteristics of patients in each treatment group. Paired t-tests were used to evaluate within-group changes. Differences between the two groups were assessed using an independent samples t-test. Data analysis was preformed using SPSS software version 16.
Results Short-term effects Within-group changes As is shown in Table 1, there was no statistically significant difference between the two groups at baseline. A significant improvement in pain intensity, functional disability, PFM endurance and strength were found in each group (p < 0.01 in all instances) following treatment. Table 2 provides detailed information for within-group changes following treatment. Between-groups differences Between-groups analysis showed that patients in the experimental group demonstrated greater improvement in PFM endurance and strength and this was statistically significant compared with the control group (p < 0.01 in both instances). No significant difference was found
78
M.A. Mohseni-Bandpei et al.
Table 1
Characteristics of the patients.
Variable
Age(year) Height(cm) Weight(kg) BMIc Parity VASd ODIe Endurance Strength a b c d e
Experimental group a
Control group
p-value
Mean
SD
Range
Mean
SD
Range
34.71 1.72 70.65 23.89 2.91 5.96 40.60 41.07 37.94
5.03 0.05 4.79 2.48 1.66 1.48 19.02 21.30 14.38
27e42 1.64e1.80 62.5e76 18.98e26.89 1e5 3.9e8.3 18e74 25.5e104.8 18.9e57.3
34.91 1.70 71.23 24.05 2.31 5.79 40.40 42.95 33.36
6.29 0.06 4.93 2.27 1.15 0.74 12.89 8.46 7.63
27e46 1.65e1.81 61.5e77.0 20.83e27.55 1e4 4.9e7.2 26e62 27.3e51.3 20.1e43.3
NSb NS NS NS NS NS NS NS NS
Standard deviation. Non-significant. Body mass index. Visual analogue scale. Oswestry disability index.
between the two groups in terms of pain intensity and functional disability (p < 0.05 in both instances). Table 2 provides detailed information for between-groups changes following treatment.
Effect of treatment at 3 months follow-up Three months follow-up was performed to all patients to assess any changes in pain intensity, functional disability, PFM endurance and strength. Fifteen patients (8 patients from the experimental group and 7 patients from the
control group) were referred for follow-up assessment. None of these 15 patients had sought further treatment for their back pain during follow-up. Loss of contact was the main reason for attrition at three months follow-up. A paired t-test showed that both groups still demonstrated significant improvement compared with the measurements taken before treatment (Table 3). A significant difference was found for both pain intensity and functional disability in each group. In the between-groups analysis, patients in the experimental group demonstrated greater benefit than those in the control group in terms of PFM endurance and strength (Table 3).
Table 2 Within-group and between-groups changes in pain intensity (cm, on visual analogue scale), Oswestry disability index (%), pelvic floor muscle endurance (second) and strength (water centimetre) following treatment period. Group
Variable
Within-group changes Experimental Pain Intensity group Oswestry Disability Index Endurance Strength Control group
Pain Intensity Oswestry Disability Index Endurance Strength
Variable
Between-groups changes Pain intensity Oswestry disability index Endurance Strength a b
Confidence intervals. Degrees of freedom.
95% CIa
dfb
3.55 27.00
2.57e4.52 14.52e39.47
9 9
90.32 68.99
49.25 31.05
61.80 to 44.01 to
5.79 40.40
2.35 12.80
3.44 27.60
2.85e4.02 18.58e36.61
42.95 33.36
45.72 35.37
2.77 2.01
Pretest
Posttest
5.96 40.60
2.41 13.60
41.07 37.94
Changes in experimental group 3.55 27.00 49.25 31.05
Mean difference
Changes in control group
3.44 27.60 2.77 2.01
36.69 18.08
3.42 to 2.11 3.20 to 0.81 Mean difference
0.11 0.60 46.48 29.04
T value
Correlation
p-value
8.21 4.89
0.395 0.425
0.000 0.001
9 9
8.87 5.41
0.910 0.441
0.000 0.000
9 9
13.40 6.92
0.244 0.257
0.000 0.000
9 9
9.58 3.79
0.994 0.979
0.000 0.004
95% CI
1.16 to 0.94 13.69 to 14.89 58.15 to 34.80 41.13 to 16.94
df
T value
18 18 18 18
0.21 0.08 8.36 5.04
p-value
0.829 0.931 0.000 0.000
The effect of pelvic floor muscle exercise
79
Table 3 Inter-groups changes in pain intensity (cm, on visual analogue scale), Oswestry disability score (%), pelvic floor muscle endurance and strength at three months follow-up. Variable
Between-groups analysis Pain intensity Oswestry disability index Endurance Strength a b
Changes in experimental group 3.16 25.50 49.25 31.05
Changes in control group 3.09 225.94 2.77 2.01
Mean difference
0.07 0.44 31.05 16.19
95% CIa
1.03 to 0.82 11.21 to 10.53 44.12 to 18.37 24.01 to 8.29
dfb
T value
14 14 14 14
0.29 0.47 6.01 4.11
p-value
0.41 0.72 0.000 0.000
Confidence intervals. Degrees of freedom.
Discussion The results of the present study demonstrate that the PFM exercise were only beneficial in improving PFM strength and endurance in both at the end of treatment and at 3 months follow-up. It appeared that PFM exercise combined with routine physiotherapy treatment had a similar effect and was not superior to the routine physiotherapy program in the treatment of patients with chronic LBP. However, the PFM’s role in continence, spine stability and the correlation with LBP will be discussed in relation to the findings of the present study. Eliasson et al. (2008) investigated the occurrence of urinary incontinence in women with LBP compared with a control group. They found that 78% of women with LBP reported urinary incontinence. The prevalence of urinary incontinence and signs of PFM dysfunction were greatly increased in the LBP group compared with the reference group. It appears that LBP is a risk factor for urinary incontinence and assessment of PFM function may be of value when treating patients with LBP. Research revealed that exercise of the abdominal muscles may be beneficial in maintaining PFM coordination, support, endurance, and strength. Similar exercise has the potential to be useful in the rehabilitation of persons with symptoms of PFM dysfunction. For instance, contraction of the abdominal muscles may provide an efficient mechanism with which to initiate and train contraction of the PFM (Sapsford and Hodges, 2001; Bø et al., 2009b). Adequate evidence support the idea that incontinent women have smaller and weaker PFM compared with continent women although different study designs, sample sizes, instruments used, etc, make the conclusion difficult (Bo et al., 1994; Dumoulin et al., 2003; Devreese et al., 2004). In the present study, assessment after 8 weeks intervention and also at 3 months follow-up demonstrated that all patients in both groups (the experimental and the control group) showed improvement in PFM function (strength and endurance). However, the results of the present study are consistent with those reported that employing PFM exercise is an effective treatment to improve PFM function as patients in the experimental group demonstrated greater improvement compared with those in the control group both at the end of treatment and at 3 months follow-up. A few small studies have explored the synergy between abdominal muscles and PFM in healthy volunteers. EMG activity of PFM and abdominal muscles demonstrated that during voluntary activity of PFM all abdominal muscles
including rectus abdominis (RA), transverse abdominis (TrA), internal oblique (IO) and external oblique (EO) were activated at different levels (Sapsford et al., 2001; Neumann and Gill, 2002). Meanwhile, Sapsford and Hodges (2001) suggested that when different abdominal isometric manoeuvres were performed (abdominal hollowing, abdominal bracing and abdominal bracing with breath hold), increasing abdominal muscle EMG activity resulted in increasing EMG activity in PFM (Sapsford and Hodges, 2001). Neumann and Gill (2002) reported that it was not possible for continent women to fully contract their PFM without contracting the TrA and the IO muscles, which was consistent with the findings of Bo et al. (1990). These findings indicate that the high relative activation levels of PFM and abdominal muscles particularly with TrA and IO muscles which contract synergistically in continent women (Madill and McLean, 2008). In fact, the PFM seems to be an integral part of trunk and lumbopelvic stability in addition to contributing continence (Richardson et al., 1999). Although strong evidence supports the co-contraction of PFM and abdominal muscles, the results of the current study showed that these co-contractions either were not large enough to have an effect or had no real effect on patients with LBP participating in the present study. It was also suggested that recruitment of abdominal muscles function in association with voluntary contraction of PFM may be affected by spine position (Sapsford et al., 2001). Placing the lumbar spine in flexion or extension would change the length-tension properties of the abdominal muscles and may have an influence on their response to PFM contraction. As Sapsford et al. (2001) highlighted the increase in EO activity with contraction of the PFM was smaller in lumbar extension compared with other positions. On the other hand, the increase in TrA activity with PFM activity was significantly greater compared with EO and RA in lumbar extension. It was suggested that a neutral or extended lumbar spine position is preferable for PFM exercise. In addition, these findings indicate that contraction of the PFM may be used to initiate contraction of the abdominal muscles. Evidence from randomized controlled clinical trials indicates that specific training of the TrA can assist with the management of LBP (O’Sullivan et al., 1997; Richardson et al., 1999). The results of their investigation revealed that this could be best achieved by contraction of the PFM with the spine positioned in either a neutral or extended position. In the present study patients were
80 instructed to perform PFM exercise in crook lying position. This might result in lower level of co-activation of TrA that is believed to be significantly activated in lumbar extension. In a randomized controlled clinical trail, Koumantakis et al. (2005) compared the effect of general exercise approach with a general trunk muscle endurance exercise approach enhanced with specific stabilization exercise (8 weeks), on 55 patients with LBP. Although their study suffered from some methodological flaws such as small sample size, heterogeneous sample (subacute and chronic LBP), unavoided co-intervention, etc. which might have an influence on the results, they concluded that stabilization exercise had no additional effect to patients with subacute and chronic LBP. They have also reported that all outcome measures were improved in both groups and patients in the general exercise only group demonstrated more improvement on self-reported disability immediately after intervention. They suggested that from a clinical point of view general exercise only may be sufficient to activate the stabilization system in parallel with the mobilizing muscles. It was also hypothesized that specific stabilization retraining is only relevant to patients with instability symptoms. May and Johnson (2008) examined the literature to identify whether stabilization exercise are effective for the treatment of pain and dysfunction in patients with LBP. They reported that there was little evidence to support the use of stabilization exercise in acute LBP and some evidence to support the use of stabilization exercise in chronic LBP. Although the evidence was contradictory, they concluded that there may be a role for stabilization exercise in some patients with chronic LBP but these were not more effective than other active interventions. In addition to routine electrotherapy, patients in both groups in the present study performed general exercises (back flexor and extensor muscles strengthening exercise) and did not receive any kind of stabilization exercises which seems to mainly focuses on back stabilizer muscles such as TrA and IO muscles. The results demonstrated that despite the existence of evidence of synergic activation of PFM and abdominal muscles, employing PFM exercise alone had no statistically significant effect in the treatment of patients with LBP in the present study. It seems that a combination of PFM and stabilization exercises, performing PFM exercise in neutral or extended position as well as recruiting patients with lumbar instability may offer different results, which remain as future research projects for the authors of the present study. However, further research with larger sample size and considering the results of this study is needed to determine whether PFM exercise have an effect on patients with chronic LBP.
Limitations Although the employed design of the present study (a randomized controlled clinical trial) is of importance the recruited small sample size could be a potential limitation of the current study. Based on sample size estimation with the power of the study 1 b Z 80%, and in order to detect the effect size of d Z 0.5 with a significance level of
M.A. Mohseni-Bandpei et al. a < 0.05, 50 participants were needed for each group. Although there were no difference on pain and functional disability reduction between the two groups in the current study, it seems that further research with adequate sample size (at least 50 in each group) might offer different results and provide significant difference if there is any. This shortcoming made the study of relationship between some variables including age and parity (number of deliveries) with LBP impossible. Lack of an objective outcome measure such as measuring muscle activity and muscle thickness using EMG or ultrasound along with measuring pain intensity and functional disability is another limitation of the present study. Meanwhile, all studies investigating the co-activation link between PFM and TrA were carried out in small groups of healthy subjects. However, more work is required before concluding that PFM training is beneficial for patients with LBP.
Acknowledgments The authors acknowledge the University of Social Welfare and Rehabilitation Sciences and Mazandaran University of Medical Sciences for financial support of this study.
References Barr, K.P., Griggs, M., Cadby, T., 2005. Lumbar stabilization: core concepts and current literature, Part 1. American Journal of Physical Medicine and Rehabilitation 84, 473e480. Bergmark, A., 1989. Stability of the lumbar spine. A study in mechanical engineering. Acta Orthopaedica Scandinavia Supplement 230, 1e54. Bo, K., Kvarstein, B., Hagen, R., Larsen, S., 1990. Pelvic floor muscle exercise for the treatment of female stress urinary incontinence: II. Validity of vaginal pressure measurements of pelvic floor muscle strength and the necessity of supplementary methods for control of correct contraction. Neurourology and Urodynamics 9, 479e487. Bo, K., Stien, R., Kulseng-Hanssen, S., Kristofferson, M., 1994. Clinical and urodynamic assessment of nulliparous young women with and without stress incontinence symptoms: a caseecontrol study. Obstetrics and Gynecology 84, 1028e 1032. Bo, K., Talseth, T., Holme, I., 1999. Single blind, randomized trial of pelvic floor exercises, electrical stimulation, vaginal cones and no treatment in management of genuine stress incontinence in women. British Medical Journal 318, 487e493. Bø, K., Finckenhagen, H.B., 2001. Vaginal palpation of pelvic floor muscle strength: inter-test reproducibility and comparison between palpation and vaginal squeeze pressure. Acta Obstetricia et Gynecologica Scandinavica 80, 883e887. Bø, K., Morkved, S., Frawley, H., Sherburn, M., 2009a. Evidence for benefit of transversus abdominis training alone or in combination with pelvic floor muscle training to treat female urinary incontinence: a systematic review. Neurourology and Urodynamics 28, 368e373. Bø, K., Braekken, I.H., Majida, M., Engh, M.E., 2009b. Constriction of the levator hiatus during instruction of pelvic floor or transversus abdominis contraction: a 4D ultrasound study. International Urogynecology Journal and Pelvic Floor Dysfunction 20, 27e32. Cholewicki, J., Silfies, S.P., Shah, R.A., Greene, H.S., Reeves, N.P., Alvi, K., Goldberg, B., 2005. Delayed trunk muscle reflex responses increase the risk of low back injuries. Spine 30, 2614e2620.
The effect of pelvic floor muscle exercise Devreese, A., Staes, F., De Weerdt, W., Feys, H., Van Assche, A., Penninckx, F., et al., 2004. Clinical evaluation of pelvic floor muscle function in continent and incontinent women. Neurourology and Urodynamics 23, 190e197. Deyo, R.A., Mirza, S.K., Martin, B.I., 2006. Back pain prevalence and visit rates: estimates from US National Surveys, 2002. Spine 31, 2724e2727. Dumoulin, C., Bourbonnais, D., Lemieux, M.C., 2003. Development of a dynamometer for measuring the isometric force of the pelvic floor musculature. Neurourology and Urodynamics 22, 648e653. Ekman, M., Jonhagen, S., Hunsche, E., Jonsson, L., 2005. Burden of illness of chronic low back pain in Sweden: a cross-sectional, retrospective study in primary care setting. Spine 30, 1777e1785. Eliasson, K., Elfving, B., Nordgren, B., Mattsson, E., 2008. Urinary incontinence in women with low back pain. Manual Therapy 13, 206e212. Gilpin, S.A., Gosling, J.A., Smith, A.R.B., et al., 1989. The pathogenesis of genitourinary prolapse and stress incontinence of urine: a histological and histochemical study, 1989. British Journal of Obstetrics and Gynaecology 96, 31e38. Gourmelen, J., Chastang, J.F., Ozguler, A., Lanoe, J.L., Ravaud, J.F., Leclerc, A., 2007. Frequency of low back pain among men and women aged 30 to 64 years in France. Results of two national surveys. Annales de Readaptation et de Medicine Physique 50, 640e644. Hartvigsen, J., Christensen, K., 2007. Active lifestyle protects against incident low back pain in seniors: a population based 2-year prospective study of 1387 Danish twins aged 70e100 years. Spine 32, 76e81. Hides, J.A., Jull, G.A., Richardson, C.A., 2001. Long-term effects of specific stabilizing exercises for first-episode low back pain. Spine 26, E243eE248. Hodges, P.W., Sapsford, R., Pengel, L.H., 2007. Postural and respiratory functions of the pelvic floor muscles. Neurourology and Urodynamics 26, 362e371. Jin, K., Sorock, G.S., Courtney, T.K., 2004. Prevalence of low back pain in three occupational groups in Shanghai, People’s Republic of China. Journal of Safety Research 35, 23e28. Koumantakis, G.A., Watson, P.J., Oldham, J.A., 2005. Trunk muscle stabilization training plus general exercise versus general exercise only: Randomized Controlled Trial of patient with recurrent low back pain. Physical Therapy 85, 209e225. Laycock, J., Jerwood, D., 2001. Pelvic floor muscle assessment: the PERFECT scheme. Physiotherapy 87, 631e642. Luo, X., Pietrobon, R., Sun, S.X., Liu, G.G., Hey, L., 2004. Estimates and patterns of direct health care expenditures among individuals with back pain in the United States. Spine 29, 79e86. Madill, S.J., McLean, L., 2008. Quantification of abdominal and pelvic floor muscle synergies in response to voluntary pelvic floor muscle contractions. Journal of Electromyography and Kinesiology 18, 955e964. May, S., Johnson, R., 2008. Stabilisation exercises for low back pain: a systematic review. Physiotherapy 94, 179e189. Mikkonen, P., Leino-Arjas, P., Remes, J., Zitting, P., Taimela, S., Karppinen, J., 2008. Is smoking a risk factor for low back pain in adolescents? A prospective cohort study. Spine 33, 527e532. Mirtz, T.A., Greene, L., 2005. Is obesity a risk factor for low back pain? An example of using the evidence to answer a clinical
81 question. Chiropractic and Osteopathy 13, 2. doi:10.1186/17461340-13-2. Mohseni-Bandpei, M.A., Fakhri, M., Bagheri-Nesami, M., AhmadShirvani, M., Khalillan, A.R., Shayesteh-Azar, M., 2006. Occupational back pain in Iranian nurses: an epidemiological study. British Journal of Nursing 15, 914e917. Mohseni-Bandpei, M.A., Bagheri-Nesami, M., Shayesteh-Azar, M., 2007. Nonspecific low back pain in 5000 Iranian school-age children. Journal of Pediatric Orthopedics 27, 126e129. Mohseni-Bandpei, M., Fakhri, M., Ahmad-Shirvani, M., Bagheri Nessami, M., Khalilian, A., Shayesteh-Azar, M., et al., 2009. Low back pain in 1100 Iranian pregnant women: prevalence and risk factors. Spine Journal 9, 795e801. Morkved, S., Bo, K., Schei, B., Salvesen, K.A., 2003. Pelvic floor muscle training during pregnancy to prevent incontinence: a single-blind randomised controlled trial. Obstetrics and Gynecology 101, 313e319. Morkved, S., Salvesen, K.A., Schei, B., Lydersen, S., Bo, K., 2007. Does group training during pregnancy prevent lumbopelvic pain? A randomised clinical trial. Acta Obstetricia et Gynecologica Scandinavica 86, 276e282. Neumann, P., Gill, V., 2002. Pelvic floor and abdominal muscle interaction: EMG activity and intra-abdominal pressure. International Urogynecology Journal 13, 125e132. O’Sullivan, P.B., Twomey, L.T., Allison, G.T., 1997. Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine 22, 2959e2967. Panjabi, M.M.T., 1992. The stabilizing system of the spine. Function, dysfunction, adaptation, and enhancement. Journal of Spinal Disorders 5, 389e390. Piantadosi, S., 1997. Clinical Trial: a Methodologic Perspective. John Wiley & Sons, New York. Rahmani, N., Mohseni-Bandpei, M.A., 2009. Application of perineometer in the assessment of pelvic floor muscles strength and endurance: a reliability study. Journal of Bodywork and Movement Therapies. doi:10.1016/j.jbmt.2009.07.007. Richardson, C., Jull, G., Hodges, P., Hides, J., 1999. Therapeutic Exercise for Spinal Segmental Stabilization in Low Back Pain. Churchill Livingstone, Edinburgh. Sahrmann, S.A., 2002. Diagnosis and Treatment of Movement Impairment Syndromes. Mosby, St. Louis. Sapsford, R.R., Hodges, P.W., 2001. Contraction of the pelvic floor muscles during abdominal maneuvers. Archives of Physical Medicine and Rehabilitation 82, 1081e1088. Sapsford, R.R., Hodges, P.W., Richardson, A.C., Cooper, D., Markwell, S.J., Jull, G.A., 2001. Co-activation of the abdominal and pelvic floor muscles during voluntary exercises. Neurourology and Urodynamics 20, 31e42. Smith, M.D., Russell, A., Hodges, P.W., 2009. Do incontinence, breathing difficulties, and gastrointestinal symptoms increase the risk of future back pain? The Journal of Pain 10, 876e886. Strine, T.W., Hootman, J.M., 2007. US national prevalence and correlates of low back and neck pain among adults. Arthritis and Rheumatism 57, 656e665. Wenig, C.M., Schmidt, C.O., Kohlmann, T., Schweikert, B., 2009. Costs of back pain in Germany. European Journal of Pain 3, 280e286.
Journal of Bodywork & Movement Therapies (2011) 15, 82e91
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CLINICAL TECHNOLOGY
Measurement of balance in computer posturography: Comparison of methodsdA brief review Hans Chaudhry, Ph.D. a,d, Bruce Bukiet, Ph.D. b,*, Zhiming Ji, Ph.D. c, Thomas Findley, MD., Ph.D. a,d a
Department of Biomedical Engineering, New Jersey Institute of Technology, Newark, NJ 07102, USA Department of Mathematical Sciences, Center for Applied Mathematics and Statistics, New Jersey Institute of Technology, Newark, NJ 07102, USA c Department of Mechanical Engineering, New Jersey Institute of Technology, Newark, NJ 07102, USA d Center for Healthcare Knowledge Management, VA Medical Center, East Orange, NJ 07018, USA b
Received 15 January 2008; received in revised form 7 March 2008; accepted 16 March 2008
KEYWORDS Balance; Computer posturography; Methods; Comparison
Summary Some symptoms related to disequilibrium may not be detected by a clinical exam. Therefore, objective study is important in assessing balance. In this paper, methods to measure balance in computer posturography are compared. Center of pressure (COP) displacement, equilibrium score (ES) and postural stability index (PSI), the main measures of assessing balance are described and their merits and disadvantages are discussed. Clinicians should apply that measure which suits the specific strategies in a specific situation. Measuring devices such as Force plate, Balance Master and Equitest are also discussed. Although the Balance Master and Equitest devices are more costly compared to the force plate only, they are more useful for assessing balance relevant to daily life activities that might result in falls. ª 2008 Elsevier Ltd. All rights reserved.
Introduction Posture is the orientation of any body segment relative to the gravitational vector (Winter, 1995). Postural stability/
* Corresponding author. Tel.: þ1 973 596 8392; fax: þ1 973 596 5591. E-mail address:
[email protected] (B. Bukiet).
Balance is an essential component in assessing the efficacy of interventions for improving balance (Berg et al., 1992; Horak, 1997). Balance is a generic term that means both postural steadiness (static) and postural stability (dynamic). ‘‘Postural steadiness is the characterization of postural sway during quiet standing. The terms posturometry, posturography, stabilometry, and stabilography are usually associated with postural steadiness’’ (Prieto et al.,
1360-8592/$ - see front matter ª 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2008.03.003
Measurement of balance in computer posturography: Comparison of methodsdA brief review 1993). ‘‘Postural stability, also referred to as dynamic posturography, is the postural response to an external or volitional perturbation of the postural control system’’ (Johansson and Magnuson, 1991). Earlier methods for evaluating balance are summarized in (Terekhov, 1976). Postural steadiness can be determined directly by evaluating head, limb or trunk movements with ultrasonic distance sensors embedded on the head (Yoshizawa et al., 1991). Balance is also measured by assessing motor control function during sitting, standing and/or walking (Tyson and Desouza, 2002). Clinicians have available only a limited number of clinical tests to quantify balance, such as seconds standing on one leg or performance on multiple observable tasks. Equipment which has previously been used primarily in a laboratory with biomedical engineering staff, is now more widely available for use in clinical settings. More clinicians will have access to this equipment, or to results done in more specialized balance clinic settings. However, there is a plethora of laboratory measures which can be confusing to the clinician. In this paper, the authors focus on methods of computerized dynamic posturography (CDP), since this has become an important tool for assessing balance in clinical settings (Fabio et al., 1998; Johansson et al., 2001; Piirtola and Era, 2006). As will be explained in the Methods section, common instrumentation includes force plates, Balance Master and Equitest. These three instruments measure ground reaction forces. From these ground reaction forces, one can compute center of pressure (COP) displacements, sway of the center of mass (COM), equilibrium score (ES), postural stability index (PSI) and other quantities. A detailed description of how ES and PSI are computed will be provided in the Methods section. A key test in the Equitest (2001) device and Balance Master (2001) CDP systems, the Sensory Organization Test (SOT) provides information about the integration of the visual, proprioceptive and vestibular components of balance which leads to an outcome measure called the ES, reflecting the overall coordination of these systems to maintain standing posture (Chaudhry et al., 2004). The Equitest System consists of a support surface (platform) and a visual surround. The Equitest device performs a SOT with six conditions: conditions 1, 2 and 3 with the platform fixed and conditions 4, 5 and 6 with the platform moving. When the platform moves, it is referenced to the subject’s sway such that as the individual leans forward, the platform tilts forward to minimize the degree of changed proprioceptive input from the self-generated sway. This platform adjustment is called ‘‘sway-referenced motion’’. Similarly, in conditions where the visual surround moves, the surround is referenced to the person’s sway so as to minimize the ability to obtain visually relevant information about how far the individual is from the vertical. In other conditions, visual input is removed instead by asking the subject to close his or her eyes. Participants are asked to stand quietly and steadily for 3 trials in each of the following 6 conditions: (1) eyes open, surround and platform stable, (2) eyes closed, surround and platform stable, (3) eyes open, swayreferenced surround, (4) eyes open, sway-referenced platform, (5) eyes closed, sway-referenced platform and (6) eyes open, sway-referenced surround and platform.
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Equipment used to measure balance Force plate only As the name implies, force plate is a device that measures ground reaction forces as the person stands quietly in conditions (1, 2) only, as described above and is used to determine the COP displacement. It is then used to obtain sway of the COM which can be used to determine the ES. Its estimated cost is $6500.
Balance Master This device consists of a movable support surface (force plate) and a visual surround with a harness to prevent fall during testing. Its estimated cost is $50,000. It can determine the COP displacement as well as the sway of COM in conditions 1, 2, 4 and 5. It cannot be used for conditions 3 and 6 since the surround cannot move in a sway-referenced manner. It can be used to determine the ES and PSI.
Equitest (see Figure 1) This device also consists of a movable support surface (force plate) and a visual surround, which can move in a sway-referenced manner, along with a harness to prevent fall during testing. Its estimated cost is $100,000. It can determine the COP displacement as well as the sway of COM. in conditions 1e6. It can be used to determine the ES and PSI.
Methods to measure balance Center of pressure (COP) The COP is the location of the vertical ground reaction vector on the force platform (Winter, 1995). This is different from the vertical projection of the center of gravity (COG). Under static conditions, COP coincides with the COG projection. COP is usually measured by the force plate in conditions 1 and 2 only. However, it can also be measured in all six conditions of the SOT from the Equitest device and in conditions 1, 2, 4 and 5 from the BalanceMaster. Since the COP reflects the movement of the body to keep the COG over the base of support, its displacement from its equilibrium position is generally greater in magnitude than the displacement of the COG (Prieto et al., 1993). The controlled variable, i.e., COG/COM, is seen to be virtually in phase with the controlling variable, COP (Winter et al., 2003). In both anterioreposterior (AP) and medialelateral (ML) directions, a simple inverted pendulum model (Winter et al., 1998) for quiet standing showed that: COP COMZK ðhorizontal acceleration of COMÞ I where KZ : Wh Here I is the total body moment of inertia about the ankles, W is the body weight and h is height of the COM above the ankles.
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Figure 1 NeuroCom EquiTest System. The NeuroCom EquiTest System consists of a support surface with sensors at the corners below the surface and a visual surround. The EquiTest device performs a sensory organization test (SOT) with six conditions: conditions 1, 2 and 3 with the platform fixed and conditions 4, 5 and 6 with the platform moving. Participants are asked to stand quietly and steadily for 3 trials for each of the following 6 conditions: (1) eyes open, surround and platform stable, (2) eyes closed, surround and platform stable, (3) eyes open, sway-referenced surround, (4) eyes open, sway-referenced platform, (5) eyes closed, sway-referenced platform and (6) eyes open, sway-referenced surround and platform.
A dual force plate is used to locate the position of the COP for the left foot and the right foot separately. The combined COP can be determined from the COP of each foot and the weight supported by each foot. When one force plate is used, only the combined COP is available. It has been demonstrated (Clair and Riach, 1996) that the test duration on the force plate is important for the reliability and validity of stability measures based on COP, with longer duration tests providing more valid results. Doyle et al. (2007) reported that COP measures reached acceptable levels of reliability (for displacement, average velocity and 95% confidence ellipse area) with five 60 s trials. Postural sway has been found to increase as a result of narrowing the base of the support (Amiridis et al., 2003). Six different conditions were used by Melzer and Kaplanski (2004) to assess COP measurements. Subjects were asked to stand still on a single force plate in the following conditions: (1) wide stance, (1a) eyes open, (1b) eyes closed, (1c) eyes open standing on foam and (2) same as in (1ae1c) in narrow stance (heals and toes touching). Six different force-platform-based balance instruments have been used by different researchers to measure postural balance (Piirtola and Era, 2006). The references to the papers by these researchers are given in Piirtola and Era (2006). All these instruments measure COP displacement. Movement of the COP in quiet standing may be influenced by internal dynamics associated with the respiratory (Jeong, 1991) and cardiovascular systems (Goldie et al., 1989). ‘‘COP measures of postural steadiness can be classified as time domain measures of distance, area or velocity; and frequency-domain measures of spectral magnitude or distribution’’ (Prieto et al., 1993). ‘‘Time domain measures include characterization of the COP path, average distance from its geometric mean, mean velocity of the COP, total distance traveled by the COP, the range of the COP, the enclosed area as a percentage of the base of support area and the confidence ellipse area. Frequency-
domain measures are usually calculated from the power spectral density’’ (Prieto et al., 1993). A stability criterion was proposed to assess the standing condition of a subject from the COP measurements (Popovic et al., 2000). In this criterion, four stability zones, i.e., high preference, low preference, undesirable and unstable zones are identified. The boundaries of stability zones are modeled using ellipses to capture the twodimensional form and orientation of the stability zone. However, in practice it is difficult for physicians to identify these stability zones to assess postural stability of a patient and assign a quantitative measure of the balance. In addition, this technique does not assign a single value to assess the stability of a subject. It is preferable that a single number (as will be seen for ES and PSI) representing postural stability/instability be assigned to a subject before and after a specific intervention. From the before and after values, the clinician can quickly determine the efficacy of the intervention. It is also not clear from the COP studies as to which parameter(s), i.e., area, velocity, total distance, or frequency should be used to quantitatively assess balance. However, COP displacements can be used to compare balance between two different groups, such as the young and the elderly, fallers and non-fallers. Those having higher magnitudes of any of the above parameters are considered less stable. In the study done by Piirtola and Era (2006), mediolateral (ML) movements of the COP during normal standing, the mean amplitude of the ML movements of the COP and the root-mean square value of the ML displacement of the COP, all with eyes open and closed were the indicators that showed significant association with future falls. But the strength of association/correlation is not evaluated in this study. Similarly, the findings by Benjuya and Kaplanski (2004) show an increase in ML sway in fallers in older people for narrow base stance studies.
Measurement of balance in computer posturography: Comparison of methodsdA brief review The authors of the current article note that although poor postural balance is one of the major risk factors for falling and can be measured by ES and PSI, the method usually used for prediction of falls is based upon the COP displacement in conditions 1 and 2 only. Comments on COP measurements of area and distance (excursion) In a recent study by the authors of this article regarding COP trajectories (Figure 2) of a subject during quiet standing in different conditions and trials, it was found that there is large variation in the area and excursion length in three trials for the same test condition. This does not allow one to arrive at a specific conclusion about assessing the balance using COP measurements. Examples of the plots of COP trajectory are shown below. In these plots, the calculated values of their corresponding 95% confidence ellipse area (Prieto et al., 1996)
85
and total excursion are also displayed, where ‘‘A’’ is for the corresponding 95% confidence ellipse area in cm2 and ‘‘L’’ is for the total excursion of the COP in cm. Trajectory 11 means trajectory for condition 1 and trial 1. Similarly, trajectories 12 and 13 mean trajectory for condition 1 and trials 2 and 3, respectively. AP means Anterioreposterior, and ML means medialelateral. The values of area and excursion for conditions 1, 2 and 3 of the same subject are summarized in Table 1.
Equilibrium score (ES) The force plate, the Balance Master and the Equitest are used to calculate the ES in conditions 1 and 2; 1, 2, 4 and 5; and conditions 1e6, respectively. ES for each trial in each condition is calculated according to a simple formula: 12:5 ½qmax ðantÞ qmax ðpostÞ ESZ 12:5
ð1Þ
Figure 2 (aec) COP trajectories of a subject during quiet standing in condition 1 for three 20-s duration trials. Trajectory 11 means trajectory for condition 1 and trial 1. Similarly, trajectory 12 and trajectory 13 mean trajectory for condition 1 and trials 2 and 3, respectively. AP means anterioreposterior and ML means medialelateral.
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Table 1 Excursion length and area for a subject over 3 trials in each of 3 conditions. Trial 1 Excursion (cm) Condition 1 28.356 Condition 2 27.351 Condition 3 24.716 Area (cm2) Condition 1 1.559 Condition 2 0.481 Condition 3 0.197
Trial 2
Trial 3
Mean
SD
43.514 27.164 25.046
28.020 25.340 24.555
33.30 26.62 24.77
8.85 1.11 0.25
5.787 0.230 0.171
2.022 0.299 0.274
3.12 0.34 0.21
2.32 0.13 0.05
4. where q (ant) is the maximum anterior sway angle in degrees during a trial; q (pos) is the maximum posterior sway angle in degrees during the same trial; 12.5 is the limit of sway in degrees in the sagittal plane for normal stance; and 12.5 is assumed to be the limit of stability for a normal individual (Balance Master, 2001, PO-5, Appendix, 6). No movement of the subject results in a perfect score of ‘‘100’’. If the subject falls or the value of the ES is negative, the subject receives a score of ‘‘0’’. Thus, the ES ranges between 0 and 100.The Composite ES is evaluated as a weighted average of the scores from the six conditions of the SOT of a subject, where each condition consists of three identical, 20-s trials with force data sampled at 100 Hz. The composite ES in three trials is evaluated according to the formula: CESZ
ESð1Þ þ ESð2Þ þ 3½ESð3Þ þ ESð4Þ þ ESð5Þ þ ESð6Þ 14
where CES is the composite equilibrium score, ES(1) is the average of ES in all three trials in condition 1. Similarly, ES(2) is the average of ES in all the three trials, in condition 2 and so on. Note that the ES in the most challenging conditions (3e6) is given 3 times the weight of conditions 1 and 2. Ambiguities/disadvantages of ES Ambiguities/disadvantages of ES include the following (Chaudhry et al., 2004): 1. For some subjects, the limits of stability may vary significantly from the age- and height-matched norms, i.e., the limit of sway may be more or less than 12.5 , say 11 or 14 . Thus, the assumptions about the overall magnitude of the limits of stability can introduce errors into the ES calculation for individuals. 2. It is also known from experimental results (Balance Master, 2001, PO-3, Appendix, 7) that functional stability limits for the average adult subject are approximately 7 of anterior sway and 5 of posterior sway. Thus, there is an asymmetry in the usual limit of stability that is disregarded in the ES calculation. 3. Many combinations of anterior and posterior sway across the same overall range can give the same ES. For example, the overall limit of stability of 6 can be made up of the many combinations (e.g., 6 of anterior sway and 0 of posterior sway; or 3 of anterior sway and 3 of posterior sway, etc.). These
5.
6.
7.
8.
combinations would result in the same composite ES. Yet, a subject with a þ6/0 of sway combination, has a greater risk of falling than a subject with a þ3/3. combination, since the former is close to the functional stability limit on the anterior side, and is therefore indicative of greater risk of fall on the anterior side, whereas the second combination is not close to the functional stability limit on either side, and therefore indicates a smaller risk of fall either on the anterior or the posterior side. Therefore, the ES which would be identical in these two situations, can be insensitive to functionally relevant differences in postural stability. To assess postural stability, the formula for a stability measure should include important biomechanical information, such as mass and height of the subject and ankle torque produced to maintain stability. These are absent in the formula for ES. The ES considers only the two extreme values of the sway angle in a given trial, not the complete sway history (2000 data points) in a trial of 20 s. It was reported by Chaudhry et al. (2005) that the composite ES score increases as composite ankle stiffness increases (Figure 3). This is counter-intuitive. It was also demonstrated by Chaudhry et al. (2004), by performing experiments on 30 subjects, that as the average sway angle, which is an important facet of balance (Lee et al., 2001; Stalenhoef et al., 2002; Stel et al., 2003), increases, the composite ES also increases (Figure 4). This is also counter-intuitive. The effect of the shear force as well as the mass and rotation of the force plate are ignored in the formula for machine-reported ES.
In order to overcome the above ambiguities, Chaudhry et al. (2004) devised a new formula for assessing stability/ balance, known as PSI that reflects balance or postural stability. PSI incorporates a broader range of biomechanical aspects of upright stance. PSI is described in the following section.
Postural stability index (PSI) PSI overcomes the ambiguities in ES as described above. The BalanceMaster and the Equitest devices are used to evaluate PSI in conditions 1, 2, 4 and 5 and 1e6, of the SOT, respectively. To assess postural stability, the effort (stabilizing torque) needed to maintain stability should be considered (Chaudhry et al., 2004). The total value of the stabilizing torque is considered to counteract the destabilizing torque due to gravity in quiet standing. PSI is defined as the percentage ratio of the total stabilizing ankle torque, t, and the total destabilizing torque due to gravity (obtained from the product of the weight, height and the sine of the sway angle) during quiet standing in any of the six conditions (see Figure 3). Since the sway angle is typically small, the approximation sin qzq is traditionally applied to simplify the calculations. A value of 100 indicates perfect stability. The amount of instability is reflected in how much the PSI is less than 100, and the range of PSI is 0e100. In mathematical terms, PSI is expressed as
Measurement of balance in computer posturography: Comparison of methodsdA brief review
87
90
Composite Score
80
Composite ES y = 0.0329x + 26.274 R = 0.189737
70 60 50
Composite PSI
40
Composite ES
30
Composite PSI y = -0.0312x + 68.844 R = -0.466798
20 10 0
0
100
200
300
400
500
600
700
Composite Ankle Stiffness
Figure 3
Composite ES and PSI vs. composite ankle stiffness. The units of ankle stiffness.
P jMghqðtÞj PSIZ P jtðtÞj
ð2Þ
In Eq. (2), M is the mass of the subject, g is acceleration due to gravity, h is 0.55 times the height of the subject (the average distance of COM from the platform, based on anthropometric data), t(t) is the stabilizing torque at the ankle at Pany time t, the vertical bars indicate the absolute value, is the summation of the values inside the bars and q(t) is the sway angle of COM in radians at any time t during the test (Ji et al., 2004). In Eq. (2), when the numerator and the denominator are equal, the PSI is 100%, and the subject is perfectly stable. When the numerator is greater than the denominator, the PSI is calculated as the ratio of the denominator to the numerator. Eq. (2) can be used to independently calculate a PSI value for each condition. The composite PSI is evaluated in the same way as the composite ES described above. In this model, the sway angle q and the torque t at 2000 data points (20 s at 100 Hz) are given by Mh½ðFF FR Þd þ FH e mga þ IFH qðtÞZ 2 2 M gh I½ðM þ mÞg ððFF þ FR Þ=ðk þ 1ÞÞ
ð3Þ
and tðtÞZðFF FR Þd þ FH e mga cos
kqðtÞ kþ1
ð4Þ
The detailed derivation of these equations is given in Ji et al. (2004). The calculated sway angle q of COM has been validated by comparing the theoretical curve for sway with the experimental one (Ji et al., 2004). Thus, the torque t given by (4) is also valid. It is noted that the above formula for evaluating PSI is based upon using an ankle strategy, i.e., hip muscles are ignored. It is noted that ‘‘normal individuals move primarily about the ankle joints when stable, and shift to hip movements as they become less stable.’’ [SmartEquitest System, p. 1] Hip movements generate horizontal (shear) forces against the support surface that are proportional to the second derivative of the hip joint angle, i.e. the angular acceleration. During hip movements, the vertical force
position changes only when the hip movement also causes change in the COG (center of gravity) sway angle [SmartEquitest System, 2001, PO-7]. Mok et al. (2004) showed that ‘‘in normal adults, postural adjustments in bilateral stance on a flat surface are generally achieved using an ankle strategy in which ankle torque maintains the COM over the base of the support. In this strategy, muscle activity occurs in a distal to proximal sequence. If the support surface is short in relation to foot length, this strategy is replaced by a hip strategy that involves operation of horizontal shear forces from torques at the hip, rather than shifting the center of vertical foot pressure by the torques at the ankle. This strategy involves motion at the trunk and hip, using a proximaledistal sequence of muscle activation’’. They also showed by studying 24 participants with chronic low back pain (LBP) and 24 matched controls that ‘‘the hip strategy was reduced with increased visual dependence in study participants with LBP. The failure rate was more than 4 times that of the control in the bilateral standing task on short base with eyes closed. Analysis of COP motion also showed that they have inability to initiate and control a hip strategy’’. Postural strategies associated with somatosensory and vestibular loss have been studied by measuring flexion at ankle and hip joints (Horak et al., 1990). Postural responses at the ankle and hip have been described in terms of feedback control gains (Park et al., 2004). The torques at ankle and hip can be studied by using a multi-joint inverted pendulum model (Colobert et al., 2006; Horak and Nashner, 1986; Guihard and Gorce, 2002; Rungea et al., 1999). The parameters involved in Eq. (2) can be seen in Figures 3 and 4. Note that a (in Eq. (4)) is not shown in Figure 4 since it is very small. It is the perpendicular distance from the line through the ankle and pin joints to the COM of the foot (see also Figures 5 and 6).
Total angular momentum of all body segments In studying the postural control of young and elderly adults when stance is perturbed, Gu et al. (1996) used the
88
H. Chaudhry et al. 100 90
Composite ES y = 91.834x + 60.869 2 R = 0.0708
Composite Score
80 70 60
Composite ES
50
Composite PSI
40
Composite PSI y = -184.99x + 79.974 R2 = 0.5035
30 20 10 0
0
0.02
0.04
0.06
0.08
0.1
0.12
0.14
0.16
0.18
Average Sway Angle
Figure 4
Composite ES and PSI vs. Average Sway Angle (radians).
criterion that ‘‘peak values of total body angular momentum of all body segments about the ankles are measures of instability. The rate at which consecutive peak values diminish when a standing person is subjected to various types of perturbations indicates the extent to which control of balance is achieved. For these reasons, the time history of the total angular momentum was computed for each response from the measured kinematic data and the scaled anthropometric data’’. Shepard et al. (1993) also used this criterion in comparing the instability of young and elderly adults. The Equitest and BalanceMaster devices can be used to assess the total angular momentum of all the body segments. However, according to Gu et al. (1996) ‘‘total angular momentum does not fully quantify the task difficulty. That quantification requires knowledge not only of how much angular momentum must be arrested, but also what moment can be developed to do that arresting’’. In view of the above comments, this method may not be appropriate for assessing balance since the quantitative values of the arresting angular momentum have not yet been established. Comparison of ES and PSI (i) Two individuals with different magnitudes of anterior and posterior sway, but with the same overall sway range will have the same ES (see Eq. (1)), but typically, they will have different PSI values (see Eq. (2)) (Chaudhry et al., 2004). That is because ES depends only on the overall sway range, whereas PSI depends on the entire sway history, and on the individual’s mass, height and the torque at the ankle. Thus, the PSI relies on biomechanical data recorded from each individual, whereas the ES relies heavily on a normative assumption. (ii) Again, it was demonstrated by Chaudhry et al. (2004) that the ES of two subjects can be the same while one might spend more of the test duration near the stability limit than the other does. For one particular case, they found two subjects with ES of 74, where one
subject spent 9.44 s at the boundary and the other subject spent 11.25 s at the boundary in condition 5 in a trial lasting 20 s. The PSI calculated for the former subject is 61.37, whereas the PSI for the latter subject is 45.41. Here, the subject who spent less time near the stability boundary had higher PSI, indicating better stability. With respect to the ambiguities 6 and 7 in ES, mentioned above, it is demonstrated in Chaudhry et al. (2004, 2005) that: (iii) Composite PSI decreases as composite ankle stiffness increases, as expected (Figure 3), contrary to the results obtained in ES. (iv) As the average sway angle, which is an important facet of balance (Lee et al., 2001; Stalenhoef et al., 2002, Stel4) increases, the composite PSI decreases as expected (Figure 4), contrary to the results obtained in ES. In view of the above findings, it was concluded that PSI is a more valid measure of stability than ES. However, the above formula for PSI is based upon ankle strategy only (Chaudhry et al., 2005). The software for ES is installed in the BalanceMaster as well as in Equitest machines to give the ES results directly from the machines. The software for PSI based upon the formula for PSI needs to be installed to obtain the results directly from the machines. However, the PSI calculation can be obtained easily by feeding the input data into a computer.
Discussion The authors of this article have described the methods and equipment commonly used in measuring balance, and discussed the advantages and disadvantages of each. However, the most appropriate method and the equipment may depend on the specific situation. For example, if
Measurement of balance in computer posturography: Comparison of methodsdA brief review
Figure 5 Free-body diagram of body (above ankle). The ankle is at the small open circle. Here, M is the mass of the body above the ankle, q is the absolute sway angle with respect to a fixed vertical reference, FV is the vertical force acting at the ankle joint, FH,A is the horizontal force acting at the ankle joint, t is the torque acting at the ankle joint and g is acceleration due to gravity.
future falls are to be predicted, the ML movements of the COP during normal standing, or the mean amplitude of the ML movements of the COP or the root-mean square value of the ML displacement of the COP, all with eyes open and closed may be used as they show significant association with future falls (Piirtola and Era, 2006). For assessing
Figure 6 Free-body diagram of feet with force plate. Here, FF, FR are reaction forces measured with front and rear force transducers respectively, d is the distance from the force transducer to the pin axis on the force plate, FH is the horizontal reaction force (shear force) measured with force transducer at the pin joint of the force plate, e is the distance from the horizontal force transducer to the ankle joint, FV is the vertical force at the ankle joint, m is the total mass of the feet and the force plate, M is the mass of the body above the ankle joint, 4 is the rotation angle of the force plate during sway-referenced motion, g is the acceleration due to gravity, qm is the measured relative sway angle with respect to the line perpendicular to the force plate and FH,A is the horizontal force acting at the ankle joint.
89
balance before and after interventions, PSI or ES may be employed. However, PSI may be used in preference to ES due to many ambiguities in ES as discussed above. Objective measurements of stability are important since subjects and clinicians often cannot detect symptoms related to disequilibrium (Kaufman et al., 2006; Sataloff et al., 2005). Kaufman et al. (2006) compared subjective and objective measurements of balance disorders following traumatic brain injury. They report that ‘‘objective measurement (such as SOT and COM motion) can quantify the patient’s functional deficits. Therefore, objective measurement techniques should be used to assess the clinical complaints of imbalance for patients with TBI (Traumatic Brain Injury)’’. Sataloff et al. (2005) reported that although ENG caloric testing (for diagnosing inner eye disease based on eye movements) was normal in 33 dizzy patients, CDP showed abnormal disequilibrium in these patients. A force plate, although cheaper compared to the BalanceMaster and the Equitest devices, measures the balance in the ideal conditions 1 and 2 only in quiet standing by measuring COP displacements. But in daily life activities, inside and outside the home, one encounters sudden up and down slopes, stairs, conflicting visual stimuli such as busy shopping malls, large moving objects, abrupt changes in smooth and rough ground surfaces, loud noises, etc. The SOT takes into account many of these situations so that balance is more realistically assessed by evaluating ES and PSI, using the BalanceMaster and Equitest devices. Although these are more costly compared to the force plate, they have greater applicability. It has been noted earlier in this paper that it is so far unclear from COP studies using force plates, as to which parameter(s), i.e., area, velocity, total distance or frequency should be used to assess balance. Also in the authors recent study of COP trajectories of a subject during quiet standing in different conditions and trials, it was found that there is large variation of area and excursion in three trials for the same subject and for the same condition. However, Doyle et al. (2007) reported that COP measures reached acceptable levels of reliability with five trials of 60 s duration for each trial. More research on the uses of COP needs to be performed to allow researchers and clinicians to come to definite conclusions about the preferable COP parameters for assessing balance. It is observed that most of the models ignore the nonlinear behaviors of viscoelastic loading at the joints in the free-body diagrams. However, recently Kuczynski and Ostrowska (2006) used a viscoelastic model to investigate the effect of viscoelasticity on 37 postmenopausal women (aged 42e79 years) diagnosed with osteopenia or osteoporosis. They found that irrespective of age, increased ML viscosity was the sole predictor of falls. As people lean forward at the ankle, the calf muscle fibers paradoxically shorten (Loram et al., 2004); this implies that the fascial and ligamentous structures must be lengthening even more than required by the amount of forward lean. While Loram concludes from his studies that neural control of length of the musculature is important for balance, he ignores the influence of fascial and other connective tissues to the total length of the muscular complexes. Furthermore, Huijing et al. (2007) has shown substantial extramuscular
90 myofascial force transmission of up to 40% of the total muscle force generated, between both synergistic and antagonistic muscles, which is particularly important at lower firing frequencies (Meijer et al., 2006). These recent research findings suggest that the fascial system may also have an important bearing on balance and that this system also needs investigation. Indeed, bodywork directed at the fascial system (Structural Integration or Rolfing) does improve balance measured by computerized posturography (Findley et al., 2004). Current research does not suggest specific palpatory and other observational findings of the fascial system related to balance, but that these are fruitful subjects for further fascial research. Such areas include the fascial connection between the hamstring and the calf muscles which transmits hamstring forces directly to the foot (Wicke and Zajac, 1981) but has been little studied since its report more than 25 years ago.
References Amiridis, G.A., Hatzitaki, V., Arabatzi, F., 2003. Age-induced modifications of static posture control in humans. Neuroscience Letters 2003 (350), 137e140. Balance Master Operator’s Manual, 2001. Clackamas (OR). Neuro.Com. International. Benjuya, M.N., Kaplanski, J., 2004. Postural stability in the elderly: a comparison between fallers and no-fallers. Age and Ageing 33 (6), 602e607. Berg, K., Wood-Dauphinee, S., Williams, J.I., Maki, B., 1992. Measuring balance in the elderly: Validation of an instrument. Canadian Journal of Public Health. Chaudhry, H., Findley, T., Quigley, K., Bukiet, B., Ji, Z., Sims, T., Maney, M., 2004. Measures of postural stability. Journal of Rehabilitation Research and Development 41 (5), 713e720. Chaudhry, H., Findley, T., Quigley, K., Ji, Z., Maney, M., Sims, T., Bukiet, B., Foulds, R., 2005. Postural stability is a more valid measure of stability than equilibrium score. Journal of Rehabilitation Research and Development 4, 547e556. Clair, K.L., Riach, C., 1996. Postural stability measures: what to measure and for how long. Clinical Biomechanics 11 (3), 176e178. Colobert, B., Cre ´tual, A., Allard, P., Delamarche, P., 2006. Forceplate based computation of ankle and hip strategies from double-inverted pendulum model. Clinical Biomechanics 21 (4), 427e434. Doyle, R.J., Wecksler, E.T.H., Ragan, B.G., Rosengren, K.S., 2007. Generealizability of center of pressure measures of quiet standing. Gait & Posture 25, 166e171. Fabio, R.B., Emasthi, A., Paul, S., 1998. Validity of visual stabilization used with computerized dynamic platform posturography. Acta Otolaryngolica (Stockholm) 118, 449e454. Findley, T., Quigley, K., Maney, M., Chaudhry, H., Agbaje, I., 2004. Improvement in Balance with Structural Integration (Rolfing): A Controlled Case Series in persons with myofascial pain. Archives of Physical Medicine and Rehabilitation 85 (9), E34. Goldie, P.A., Bach, M., Evans, O.M., 1989. Force platform measures for evaluating postural control, reliability and validity. Archives of Physical Medicine and Rehabilitation 70, 510e517. Gu, M.J., Schultz, A.B., Shepard, N.T., Alexander, N.B., 1996. Postural control in young and elderly adults when stance is perturbed: dynamics. Journal of Biomechanics 29 (3), 319e329. Guihard, M., Gorce, P., 2002. Hip strategy applied to biped dynamic control. IEEE International Conference on Systems, Man and Cybernetics 1, 159e164. Horak, F.B., 1997. Clinical assessment of balance disorders. Gait & Posture 6, 74e86.
H. Chaudhry et al. Horak, F.B., Nashner, L.M., 1986. Central programming of postural movements: adaptation to altered support surface configurations. Journal of Neurophysiology 55 (6), 1369e1381. Horak, F.B., Nashner, L.M., Diener, H.C., 1990. Postural strategies associated with somatosensory and vestibular loss. Experimental Brain Research 82, 167e177. Huijing, P.A., van de Langenberg, R.W., Meesters, J.J., Baan, G.C., 2007. Extramuscular myofascial force transmission also occurs between synergistic muscles and antagonistic muscles. Journal of Electromyography & Kinesiology 17 (6), 680e689. Jeong, B.Y., 1991. Respiration effect on standing balance. Archives of Physical Medicine and Rehabilitation 72 (99), 642e645. Ji, Z., Findley, T., Chaudhry, H., Bukiet, B., 2004. Computational method to evaluate ankle muscle stiffness with ground reaction forces. Journal of Rehabilitation Research and Development 41 (2), 207e214. Johansson, R., Magnuson, M., 1991. Human postural dynamics. CRC Critical Reviews in Biomedical Engineering 18, 413e427. Johansson, R., Magnusson, P.A., Karlberg, M., 2001. Multi-stimulus multi-response posturography. Mathematical Biosciences 174, 41e59. Kaufman, K.R., Brey, R.H., Chou, L.S., Rabatin, A., Brown, A.W., Basford, J.R., 2006. Comparison of objective measurements of balance disorders following traumatic brain injury. Medical Engineering & Physics 28, 234e239. Kuczynski, M., Ostrowska, B., 2006. Understanding falls in osteoporosis: the viscoelastic modeling perspective. Gait & Posture 23 (1), 51e58. Lee, J., Fujimoto, N., Batiner, A., Cervo, F., Meyer, J., Rubin, C., McLeod, K., 2001. Prediction of fall risk in the elderly: time dependent measures of postural sway dynamics. San Francisco, CA, Meeting of the Orthopaedic Research Society. Loram, I.D., Maganaris, C.N., Lakie, M., 2004. Paradoxical muscle movement in human standing. Journal of Physiology 556 (3), 683e689. Meijer, H.J., Baan, G.C., Huijing, P.A., 2006. Myofascial force transmission is increasingly important at lower forces: firing frequency-related length-force characteristics of rat extensor digitorum longus. Acta Physiologica 186 (3), 185e195. Melzer, N.B., Kaplanski, J., 2004. Postural stability in the elderly: a comparison between fallers and non-fallers. Age and Aging 33 (6), 602e607. Mok, N.W., Brauer, M.S., Sandra, G., Hodges, P.W., 2004. Hip strategy for balance control in quiet standing is reduced in people with low back pain. Spine 29 (6), E107eE112. Park, S., Horak, F.B., Kuo, A.D., 2004. Postural feedback responses scale with biomechanical constraints in human standing. Experimental Brain Research 154, 417e427. Piirtola, M., Era, P., 2006. Force platform measurements as predictor of falls among older peopleda review. Gerontology 52, 1e16. Popovic, M.R., Pappas, I.P.I., Nakazawa, K., Keller, T., Morari, M., Dietz, V., 2000. Stability criterion for controlling standing in able-bodied subjects. Journal of Biomechanics 33, 1359e1368. Prieto, T.E., Myklebust, J.B., Myklebust, B.M., 1993. Characterization and modeling of postural steadiness in the elderly: a review. IEEE Transactions on Rehabilitation Engineering 1, 26e34. Prieto, T.E., Myklebust, J.B., Hoffmann, R.G., Lovett, E.G., Myklebust, B.M., 1996. Measures of postural steadiness: differences between healthy young and elderly adults. IEEE Transactions on Biomedical Engineering 43 (9), 956e966. Rungea, C.F., Shupert, C.L., Horak, F.B., Zajac, F.E., 1999. Ankle and hip postural strategies defined by joint torques. Gait & Posture 10 (2), 161e170. Sataloff, R.T., Hawkshaw, M.J., Mandel, H., Zwislewski, A.B., Armour, J., Mandel, S., 2005. Abnormal computerized dynamic posturography findings in dizzy patients with normal ENG results. ENTdEar, Nose & Throat Journal 84 (4), 212e214.
Measurement of balance in computer posturography: Comparison of methodsdA brief review Shepard, N., Schultz, A., Alexander, N.B., Gu, M.J., Boismier, T., 1993. Postural control in young and elderly adults when stance is challenged: clinical versus laboratory measurements. Annals of Otology, Rhinology & Laryngology 102, 508e517. Smart Equitest System Operator’s Manual, 2001. NeuroCom International. Stalenhoef, P.A., Diederiks, J.P., Knottnerus, J.A., Kester, A.D., Crebolder, H.F., 2002. A risk model for the prediction of recurrent falls in community-dwelling elderly: a prospective cohort study. Journal of Clinical Epidemiology 55, 1088e1094. Stel, V.S., Smit, J.H., Pluijm, S.M., Lips, P., 2003. Balance and mobility performance as treatable risk factors for recurrent falling in older persons. Journal of Clinical Epidemiology 56, 659e668. Terekhov, Y., 1976. Stabilometry and some aspects of its applicationsda review. Biomedical Engineering 11, 12e15. Tyson, S., Desouza, 2002. A systematic review of methods to measure balance and walking post-stroke. Part-1. Ordinal scales. Physical Therapy Review 7, 173e186.
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Wicke, R.W., Zajac, F.E., 1981. Isometric torque produced by the hamstrings muscle about the ankle as a function of hindlimb position. Society for Neuroscience, Abstracts 7, 648. Winter, D.A., 1995. Biomechanics of motor control and human movements, second ed. In: Winter, D.A. (Eds.), Human Balance and Posture Control During Standing and Walking (Review article). Gait & Posture 3(4), 193e214. Winter, D.A., Palta, A.E., Prince, F., Ishac, K., Perczak, G., 1998. Stiffness control of balance in quiet standing. Journal of Neurophysiology 80, 1211e2121. Winter, D.A., Palta, A.E., Ishac, M., Gage, W., 2003. Motor mechanism of balance during quiet standing. Journal of Electromyography and Kinesology 13, 49e56. Yoshizawa, M., Takeda, H., Ozawa, M., Sasaki, Y., 1991. A hypothesis that explains the human postural control characteristics. In: 13th Annual International Conference on IEEE 13, 2005e2006.
Journal of Bodywork & Movement Therapies (2011) 15, 92e102
available at www.sciencedirect.com
journal homepage: www.elsevier.com/jbmt
COMPARATIVE REVIEW
Osteopathy and (hatha) yoga Torsten Liem* Osteopathie Schule Deutschland (OSD), Institute of Integrative Morphology, Frahmredder 16, 22393 Hamburg, Germany Received 6 February 2009; received in revised form 23 October 2009; accepted 11 November 2009
KEYWORDS Physicality; Healing; Consciousness; Asana; Pranayama; Stillness
Summary Differences and points of contact between osteopathy and yoga as regards their history and practical application are outlined. Both seek to promote healing. Yoga seeks the attainment of consciousness; osteopathy aims for providing support to health. One fundamental difference is the personal involvement of the individual in yoga. Teacher and student alike are challenged to re-examine the attitudes of mind they have adopted toward their lives. Osteopathy generally involves a relatively passive patient while the osteopath is active in providing treatment. Practical examples are used to highlight points of contact between yoga and osteopathy. The text includes a discussion of the importance of physicality and a description of ways of using it in healing processes. Furthermore, processes of attaining consciousness are outlined. Possible reductionist misconceptions in yoga and osteopathy are also pointed out. Fundamental attitudes and focus that complement each other are presented, taking the concept of stillness as a particular example. ª 2009 Elsevier Ltd. All rights reserved.
Introduction From the historical point of view there are major differences between yoga and osteopathy. Whereas yoga has existed in India for some thousands of years, osteopathy came into being around the middle of the nineteenth century. It was founded mainly in reaction to an early model of medicine in the United States. Osteopathic medicine is a profession as well as a social movement. As a social movement it espouses a philosophy and a set of principles (Gevitz, 2004).
* Tel.: þ49 170 32 60 957; fax: þ49 40 46 88 23 99. E-mail address:
[email protected].
Osteopathy, as a kind of revelatory teaching, can be traced chiefly to Andrew Taylor Still (1828e1917). The revelatory teaching of yoga cannot be traced to any one historical individual. From the beginning, osteopathy has postulated a unity of body, mind and spirit, as do the physically oriented forms of yoga. This unity is approached, both in osteopathy and in hatha yoga, primarily through the body. There are, however, clear differences in practical focus and in aims. Osteopathy is a system of manipulative treatment (Gevitz, 2004) whose emphasis is on the promotion of health in the body and being of the individual. It comprises special methods of diagnosis and treatment. The main focus lies on the structural relationships and interactions of
1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.11.001
Osteopathy and (hatha) yoga the various tissues and their functions and the body as a unit. In the West, the main value of the physically oriented forms of yoga is seen in its health aspects. Traditional hatha yoga, though, and yoga as taught by Patanjali are in essence an experience-based method of focusing the movements of the mind. This is also true for all other forms of yoga. The aim is to free contractive conditioning and to direct the attention to an immediacy of consciousness. The result should be an undistorted and unconditioned perception and awareness of a higher, transpersonal and post-rational self. There is a clear difference in terms of focus: yoga is concerned with the practice, the responsibility and the insight of the individual performing it. The demand made of both teachers and students is an equal one. In osteopathy e since it is a type of system of treatment e the patient often remains relatively passive, in contrast to the osteopath, who is active in providing the treatment.
Points of contact: practical examples Despite these differences, there are many points of contact between the practice of yoga and osteopathic treatment. The following examples from the authors personal practice can be given. A vertebra may be ‘restricted’, i.e. held or ‘blocked’ in its movement. (Note that systematic reviews has shown poor interrater reliability for soft tissue paraspinal palpatory diagnostic tests (Seffinger et al., 2004, Najm et al., 2003, Christensen et al., 2006, Haneline et al., 2008). Regional range of motion is more reliable than segmental range of motion (Seffinger et al., 2004)). Initially, it may have occasioned no symptoms. In the author’s experience, if the patient begins to practise a form of hatha yoga, positive changes soon emerge. Another possible course, however, is that restricted vertebrae may not necessarily be resolved, even with advanced techniques of yoga. Instead, hypermobility may develop in vertebral segments above or below the affected segment. The yogi generally feels no pain in the affected segment, but instead develops symptoms in the neighbouring segments above and/or below the affected vertebra. In the author’s experience, osteopathic treatment can be helpful in this instance. Another personal clinical example involves a difference in leg length, whether an actual or a compensatory difference (brought about by pelvic torsion) in excess of 1 cm. In the long term, when left untreated, this could lead to pain and disturbances when performing, for example, a forward bend in the standing position (a yoga pose named padangusthasana). The asymmetry causes unequal tension on performing the pose. If these disturbances cannot be released by osteopathic treatment, slightly bending the knee of the longer leg when performing a forward bend in the standing position (padangusthasana) might solve the problem. On the other hand, in the author’s clinical experience most patients with a ‘chronic’ condition are found to experience improvement when they begin to assume responsibility for their own state of health. Yoga, along with many other methods, can be very helpful in this respect.
93
Physicality as a means to enhance the processes of healing and attainment of consciousness Our physicality is, in its first sense, our physical form or being (it also includes the consciousness of the body). It takes shape according to genetic information and environment. This process involves the stimulation, activation and expression of genetic information. Not only that; from the very start of our development we are exposed to numerous formative influences Among these might be named: electrical, magnetic (Becker, 1994; Adey and Lawrence, 1984) electrodynamic fields, morphogenetic fields, (Gurwitsch, 1910, 1912, 1922; Spemann, 1921; Weiss, 1939; Thompson D’Arcy, 1973; Thom, 1975; Goodwin, 1985; Beloussov, 2001) bio photons (Popp, 1976, 1984a,1984b; Popp et al., 1981; Hameroff et al., 1984; Van Wijk et al., 1993; Galle et al., 1991; Gu and Popp, 1992) chemotactic mechanisms and mechanical stresses (Brouzes and Farge, 2004; Beloussov and Grabovsky, 2003; Cowin, 2000; Beloussov et al., 2000, 1988, 1975; Chiquet, 1999; Beloussov, 1998; Beloussov et al., 1990) Prenatal and perinatal experience can have an enduring formative influence on life after birth (Janus, 2000, 2002). A first degree of autonomy and interrelationship with the mother are developed by the fetus in the womb. Through the medium of maternal moods and experiences the fetus even develops an indirect relationship to the outside world (Nathanielsz, 1999; www.birthworks.org). Studies have shown that our health is partly determined by that of our parents, including their life before conception. This can be brought about, for example, by their exposure to fat-soluble chemical substances (InfanteRivard and Sinnett, 1999; Dimich-Ward et al., 1998; Nelson et al., 1996; Alaluusua et al., 1993, 1999; Garcia-Rodriguez et al., 1996; Paulozzi et al., 1997; Forman and Moller, 1994; Auger et al., 1995; Mizuno, 2000; Davis et al., 1998). Other factors that can influence our physicality are: Physical and neurobiological mechanisms (Fischer, 2006; Csatho et al., 2003) The family, historical, cultural and social environment in which we are brought up and live our lives (Uexku ¨ll and Arnim, 1994; Winterfeld et al., 1998) The experiences of birth and the first years of life in particular (Zhang et al., 2002; Janus, 2002, 2000; Emerson, 1997; Peters, 1986) Our nutrition Diseases, accidents, psychological trauma (Huether, 1998; Emerson, 1997) Conditions during learning and at work Many rhythm-determining patterns of regulation and organization (Nelson et al., 1996) Other influences, stresses and habits (Chang and Merzenich, 2003) Acquired patterns of life and decisions made
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T. Liem
Table 1 Philosophical hermeneutics Neostructuralism
Theory dealing with the interpretation of texts and with understanding. It reflects on the conditions that control understanding A further development of structuralism: e On the one hand, the range of subject areas is extended (in addition to linguistics (Saussure), it incorporates such fields as ethnology (Levi-Strauss), psychoanalysis (Lacan), science of history (Foucault), literature (Barthes), philosophy (Lyotard, Derrida) etc.) e On the other, it subjects the fundamental insights of structuralism to critique
All these factors have a formative influence on us. They condition us and determine how we perceive ourselves and the world around us and identify ourselves with our ‘self’. Our bodies and their physiological processes and the way we feel, think and perceive, are influenced and determined by all these factors. Our own inner growth is intimately connected with how we understand, deal with, accept, integrate and master the above factors contained within our consciousness, our experiences and influences. We may be useful to bear in mind that patterns of feeling, thought and belief tend to find physical expression in our body and being (Keleman, 1992; Kurtz and Prestera, 1979; Latey, 1996). Consequently, every individual exhibits quite specific physical characteristics, attitudes and tensions depending on their experiences. As a general rule we might say that the stronger the unprocessed experiences and events (e.g. a psychophysical traumatic event), the stronger the stiffness, tensions, tissue hardness and restrictions are generally found to be. This could also be accompanied by a weakening of the individual’s overall stability. We might describe this as a correlation of tissue-energy-consciousness (Liem, 2006, pp. 203ff). Physically oriented forms of yoga and osteopathy both use the body. The body reflects deconditioning from abnormal chronic bodily tensions and faulty postures. Ideally the practical application of osteopathy and hatha yoga should take into account the integration of restrictive patterns of consciousness, feeling and belief (especially the neglected or unconscious parts or dissociated subpersonalities) in order to be effective. At present, however, the author sees this aspect as often neglected in practice. It is important, in his view, for people practising yoga and osteopathy patients to make the connection between the circumstances of their lives, subconscious issues and behaviour, and their general state of health, bodily tensions and posture. Yet his impression is that they generally receive little support in doing so. Certainly light is being cast on the connections and influences that exist between body and mind/spirit. Some scientific disciplines (such as empiricism, positivism, the neurosciences and cognitive sciences), offer far-reaching explanations as to these, both within their own particular fields and in interdisciplinary debate. (The work of Piaget, Goleman, Kegan, Beck and Cowan (see below) may be mentioned here, for example.) In contrast, the great strength of the hatha yoga tradition is that it offers an immense wealth of information about the system encompassing the human body, mind and soul (Feuerstein, 2008) from the subjective standpoint of
the practitioner. Here, hatha yoga uses methods with a long and well-tried tradition. On the other hand, such approaches as philosophical hermeneutics (Gadamer, 1990; Vattimo, 1994) and neostructuralism (Frank, 1984; Mu ¨nker and Roesler, 2000) cast light on intersubjective factors that are not considered by yoga or the objective sciences (Table 1). Hermeneutics, neostructuralism and findings of the objective sciences could help to relativize some of the bliss-imbued explanatory models and inappropriate metaphysical views of early yoga (such as levitation, atomization, travelling through the air or walking on water, claimed as the result of certain yogic practices and featuring for example in the sutras of Patanjali (Woods, 2007, 267e278, Taimni, 2005); or methodically categorizing subtle, causal states of consciousness as existing beyond the material realm) (Thieme, 2008). Thus, the essence could be rendered more accessible to experience. The asanas (postures) of yoga can confront us with unprocessed experiences and emotions. At the same time they are able to link us with our inner resources and strength. Conscious breathing and inner focus in combination with the asanas enable us e in the author’s personal experience e to pass through and integrate the patterns of sensation stored in the tissue. This is achieved in a gentle and conscious manner. As our bodies become successively more flexible, there is the chance that we may achieve greater flexibility in our inner selves. The author’s experience is that, as this happens, bound energies become increasingly integrated, become free, and begin to flow again. This may bring a change in the way we experience the moment: greater presence, joy and vitality (Figure 1). The relationship between yoga and health is not only mentioned in yoga related publications (e.g. McCall, 2007; Shah, 2006; Shankardevananda, 2002; Telang, 1999). Increased research interest has been shown in the topic over the past 3 decades, with a growing use of randomized controlled trials. The types of medical condition studied have included psychopathological (e.g. depression; anxiety), cardiovascular (e.g. hypertension; heart disease), respiratory (e.g. asthma), diabetes, and a variety of others. The therapeutic effects of yoga for children have also been studied. (Khalsa, 2004; Raub, 2002; Ebert, 1988; Birdee et al., 2009; Galantino et al., 2008) Thus hatha yoga has been described as a process to achieve physical, mental, emotional and psychological balance (Muktiodhananda, 1998, p. 26). According to
Osteopathy and (hatha) yoga
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Figure 1 Pashimottanasana e intensive stretching of the back (the western aspect of the body, ‘pashima’); strengthens the abdominal organs, strengthens the kidneys, improves the digestion and exerts a positive effect on the spinal column, etc. Photograph: ª Karsten Franke, Hamburg.
Muktiodhananda the individual’s entire being is systematically refined, strengthened, transformed and purified. This process begins with the physical body, so as to enable it to experience higher levels of consciousness. In osteopathy one way that this might be achieved is by locating and releasing dysfunctional tensions in the body. Here too the potential exists to differentiate and achieve an integration of emotional and psychological energies.
Possible reductionist misconceptions relating to physically oriented forms of yoga and osteopathy In physically oriented yoga the primary aim is not to perform acrobatics or achieve certain bodily contortions. To see it as such is to completely misunderstand and miss the deeper goal of yoga (Muktiodhananda, 1998, p. 20). In this respect, there is a certain danger in paying exclusive attention to physical yoga. The increasing flexibility and strengthening of the body can in some circumstances lead yoga practitioners to an excessive identification with their body. The danger of a one-sided concentration on the physical aspects of yoga is that it avoids conflicts and opportunities for learning on the level of the emotions, relationships, needs and values. This could reduce the individual’s capacity to remain focused on the present. It could also hinder the process of loosening identification with the limited, small self and ego, and expansion into a transpersonal consciousness. For this reason the main text on the subject of hatha yoga has long emphasized that this discipline only develops its full potential when practised in the greater context of raja yoga (the yoga of spiritual control) (Yogi Hari, 2007; Svatmarama, 2007). Hatha yoga should also be
seen in the context of other consciousness exercises. These guidelines regulate and harmonize the individuals’ relationship and attitude to others or to the outside world (Yama) and to themselves or inwardly (Niyama) (Yogi Hari, 2007, pp. 47e62). The initial step according to Patanjali is for the aspirant to adhere to a certain code of morality, so as to curb unwholesome impulses of the mind (Tandon, 1995) (Table 2). In the sutras of Patanjali, the first methodological text on yoga, very little space is devoted to the asanas. Asana according to Patanjali had to provide a means of sitting steadily and comfortably for lengthy periods; this can be achieved when it is effortless and the mind tends towards infinity (Tandon, 1995). There are many other ways of focusing consciousness, such as pranayama (consciousness/ control of the breath), retraction of the senses, concentration, meditation, etc (Desikachar, 2003, pp. 78e98). Patanjali did realize that there was a close connection between the breath and the mind, which explained why, for example, excitement, anger, or agitation led to short and irregular breathing. In order to soothe the ruffled mind, Patanjali prescribed the practice of pranayama (Tandon, 1995). Tandon describes Patanjali Pranayama as ‘a stretch of the prana and observation in its natural course, which makes the practitioner aware of its three stages (external, internal, static). Gradually from its gross stage it becomes subtler and subtler, reaching an extreme, when one may experience absolutely no respiratory movement’ (Tandon, 1995). This is different from the pranayama in hatha yoga which sometimes involves retention of breath with effort (Tandon, 1995). Hatha yoga originally began with pranayama (the control of the breath) and nadi purification. Nadi refers to the channels of the hypothetical astral body; impurities can be
96 Table 2
T. Liem Yama and Niyama: Yogic ethical precepts.
Yama Ahimsa Satya Brahmachary Asteya Aparigraha Niyama Saucha Santosha Tapas Swadyana Ishwarapranidhana
Dealing in a gentle and caring way with our own self and other living beings, often understood as meaning non-violence. Truthfulness Often refers to sexual abstinence; also refers to moderation and carefulness in the way we deal with the energy that has contact with the outside world through the agency of our senses Not stealing Confining ourselves to the essential, to what belongs or is due to us. This requires self-understanding Inner and outer purity (this also includes the cleansing and detoxifying of the body); this helps create inner peace and lessens inordinate concern about the transient aspects of the body Contentment; non-attachment to external circumstances, desires and patterns of rejection Usually understood as asceticism and spiritual discipline; it also refers to the resolution of blockages and contractions in body and spirit by which we maintain a certain discipline in our lives. The study of wise writings and the seeking of wisdom Reverence for a higher power or the acceptance of our own limitation before the infinite or before God
removed, for example, through practices such as abdominal massage (Nauli) and meditation. Cleansings are a late invention - see Gheranda-Samhita (Feuerstein, 20091). Although important relationships undoubtedly exist between the body, the world of the emotions and that of consciousness, this may lead to reductionist misconceptions. Especially in the cult of the body encountered the West (Tiedke, 2007), and indeed in the author’s own personal experience in many different hatha yoga classes, the degree of bodily flexibility often seems to be equated with the degree of development that has been achieved in the personality. It is clearly false, and too one-dimensional a judgement, to draw conclusions about individuals’ consciousness merely on the basis of the degree of flexibility achieved by their bodies. The situation in fact appears to be the opposite: it seems that many distinct strands of development take shape relatively independently of each other in the individual, step by step and at varying speeds (Wilber, 2001, pp. 45ff). Examples are cognitive development (Piaget et al., 2003; Kegan, 1986; Ginsburg et al., 2004), the development of values (Beck and Cowan, 2007) and emotional development (Goleman, 1997). Other examples are the development of needs (Maslow, 2002), spiritual development and physical performance. There is a certain risk here, that excessive focus on increased bodily flexibility and control in hatha yoga might compensate suppressed elements or deeper levels of other strands of development (e.g. in the field of interpersonal relationships). This would replace a process involving greater acceptance, differentiation, relativization (distancing from oneself) and integration. The effect might sometimes even be to create dissociation. This applies above all to those forms of yoga that place excessive stress on the physical. This kind of development can occur in many varieties of every type of discipline, especially where there is a monopolistic approach. In osteopathy the danger of reductionist misconception presents itself differently. Phenomena that are human and interpersonal might be attributed to exclusively 1 Feuerstein G., 1/2009. Personal communication with the author.
anatomical, physiological processes. This approach is typical of osteopathic procedures as currently practised. The danger is one of reducing the person to an anatomical object to be worked upon, or some kind of very complicated machine or complex energetic phenomenon. This happens when inner experiences are reduced to the energetic or physical aspects. It is therefore important to note that human phenomena have both an outside and an inside. Structural and physical dynamics describe only the former. Therefore, whilst it is right to view these as a human determinant, they are not the only factor. For example, although the emergence of physical life forms is based on physical laws, life forms also go beyond such laws. Just as physical laws are inadequate to explain the properties of biological entities, so biological explanations are inadequate to account for aspects that belong to the psyche. If we are to treat the wholeness of the individual, it is not enough to treat only the tissue correlate. Osteopathic treatment can sometimes make it more difficult for patients to assume responsibility for their state of physical and psychological health. This is another weak point of the system. Frequently, patients tend to hand over their bodies to the osteopath in the same way as they might take their car to the garage to be repaired. If osteopaths uncritically accept this role, they miss the chance of helping their patients to decide to participate actively in the healing process. Further, it makes it easier for the patient to suppress his psychic associations (Nathan, 1999). Another problem is the language in which much of the theory of the manipulative therapy professions is expressed: too often the terminology is bioreductionistic. These two issues may make it more difficult for patients to explore their own experience and behaviour on the one hand and the associated disturbances in their state of health and wellbeing on the other. Therapists are invited to develop the skills necessary to help the patient to recognize and integrate possible psychic associations in relation to somatic dysfunction and disease. One approach might be to develop methods that encourage the active involvement of the patient in healing processes. The therapist could adopt a method of palpation that
Osteopathy and (hatha) yoga supports the patient in the healing process; for example, patients could be encouraged to be aware of bodily and emotional sensations during the treatment. Or patients could be encouraged to be aware of changes in their breathing pattern during the treatment. Or patients could be trained in their awareness of how differently the experiences of daily life will feel in a dysfunctional area, for example, or in the solar plexus, or in the neck, shoulder, tongue, chest or heart region, etc. Or the patient could be trained to recognize and to allow a feeling of inner flow in areas of somatic dysfunction or other body regions, etc. Basically the patient is encouraged in the process of experiencing and understanding the connections between health disturbances, dysfunction and associated inner and external circumstances of life. Promoting the development of subjective experience of therapist or patient has been little cultivated as a methodological principle in osteopathy, in the author’s view. Such development is distinct from techniques of experiencing the tissue by means of palpation. This does not imply that osteopaths did not receive training (depending on their different countries and schools) in psychiatric disorders or recognition of yellow flags. They might well have been taught some techniques (e.g. based on cognitive behavioural therapy) to encourage patients to take control of their situation. In yoga, in contrast, the aim is an undistorted and unconditioned perception of all aspects of one’s own life. According to Feuerstein (2008, p. 26, 41e45), Desikachar, Krusche (2007, pp. 44e48), Eliade (1985, p. 8) this is true for all kinds of yoga practised. The achievement of the transformation in oneself alone makes the individual competent to assist others. (Feuerstein, 2008, pp. 50e55, 503; Advaya Taraka Upanishad (tr. Ramachander, 2009), Hariharananda, 2006; Desikachar, 20082) To understand the effect of manual medicine on the ‘psyche-in-the-body’ or ‘lived body’, a phenomenological description is needed (Nathan, 1999). Phenomenology was developed at the beginning of 20th century by Edmund Husserl. The name is derived from the Greek words phaino ´menon (that which appears) and logos (study). It is concerned with the systematic reflection of the structures of the consciousness and the phenomena which arise in acts of consciousness. The technique uses a highly modified ‘‘first person’’ viewpoint. In phenomenology, ‘bodyness’ is neither limited to the physical body nor confined to consciousness alone; it consists of both. Human existence is composed of both, since we are constantly present in bodily form in the world (Husserl and Biemel, 1952). To be a human being, in phenomenology, is to be a body and to have a physical body. The subjective experience of the phenomenon (its appearance for me) and its objective presence (the appearance of something) constitute a unity. According to phenomenology, consciousness does not operate in a ‘transcendental’ nowhere (Flatscher, 2008). Historical reality and the space-time character of existence (Boss, 1999, pp.237e314) together determine its directedness. Within osteopathy a number of endeavours are currently being made to demonstrate the effectiveness of treatment, 2 Desikachar T.K.V., 1/2008. Personal communication with the author, Madras.
97 e.g. in Germany the Akademie fu ¨r Osteopathie (AFO), in the United States the Osteopathic Research Center. It is mainly the work of devoted individuals using objective science. In contrast to this, quite unthinking and regressive tendencies are emerging in certain other fields (particularly in those related to the ‘cranial’) under the guise of ‘wholeness’. The author feels that there are such tendencies, for example, in prerational osteopathic neospiritual views, evangelistic proponents of embryology, quantum mechanical manipulators of the cranial bones, or fundamentalist divine healers. There is a problem in applying quasiobjective positivism and ‘evidence-based medicine’ in any absolutist way in osteopathy. Absolutist ideas of the subjective, idealistic kind, sometimes clothed in anatomical and physiological concepts, are just as surely reductionist misconceptions as the more obvious ones, and so to be avoided, for the following reason. ‘Materialistic’ approaches describe a given situation from the outside; ‘idealistic’ ones describe the same situation from the inside. Each of them represents only half of the case and the cure, therefore both are important. For religious or idealistic models to act as if they were quasi-objective science, even maybe to hide behind anatomical or embryological approaches, or make use of them to promote (simplistic) religious ideas, seems inappropriate. One indication that this is happening might be, for example, if therapists constantly use words such as ‘embryology’, yet at the same time show little knowledge of any of the processes involved. The terms may simply be a way of expressing commonplace spiritual ideas. The next issue to consider is whether facts relating to intersubjective matters are integrated and applied in yoga and osteopathy. C.G. Jung warned against uncritically importing eastern teachings, for example, on the grounds that the psychological constitution of the peoples from the east and west being different (Jung and Clarke, 2005). There is sometimes a tendency in yoga to adopt traditional forms of the art without taking cultural differences sufficiently into account. For example, in the Ashtanga yoga system, the third sitting position of the very first series is a half lotus forward stretch (Ardha baddha padma pashimottanasana) (Jois, KP 1999). This seems relatively easy for people who have been used to sitting cross-legged since childhood, as many Indians would be, but difficult for westerners, who are used to sitting on chairs. Incorrectly applied hatha yoga practice can even produce injuries (Patel and Parker, 2008; Khalil et al., 2008; Caso et al., 2005; Paul, 2007). As we come to consider the importance of intersubjectivity, it is first of all important to remember that subjective inner experiences show up within a mostly unconscious background of intersubjective structures. Poststructuralist approaches criticize monopolistic and absolutistic inner experiences (Derrida, 2000). In yoga, it is almost universal to take one’s individual inner experience as absolute (e.g. Woods, 2007, 267e278). Structuralism, as one of the sciences concerned with intersubjectivity, has only been around for 100 years. This is one of the great postmodern discoveries. Therefore there is almost no reference to intersubjective matters in the classic yoga texts, and it is also very rare in contemporary literature. This work has still to be done. However, the elements of an individual’s perception are one thing. The psychological and collective
98 structures forming the background of elements of the person’s consciousness are another. These structures are largely beyond the reach of exclusively phenomenological practice (Habecker, 20082). Nor can they be seen by purely subjective introspection. This remains true even when it is carried out in a manner that modestly acknowledges ignorance and avoids aggressive exclusion, and even if it is done with the greatest of honesty and devotion. Undertaking introspection as a monologue can help us better study the phenomena of our individual consciousness. It does not, however, enable us to discover psychodynamic aspects (a ` la Freud and Jung) or structures of development (e.g. emotional or cognitive development, or that of values, needs or ethics) (a ` la Gebser, Graves, Kegan, Cook-Greuter) (Habecker, 20082). To find these, we have to understand the particular individual and historical cultural contexts (intersubjective structures). The approach needed for this involves dialogue and hermaneutics. The author has found that there is often great resistance to this among certain yogis. Maybe we are too easily led by insidiously monopolistic models because they offer tempting promises. Our responsibility as mature human beings is relinquished the moment we enter that realm. We rest in the blissful confidence that we have at last found the new place where we belong, a place beyond confusing words and opinions. The consequence of this is the abstruse, sometimes dangerous adoption of Indian techniques and systems into western yoga studios (example see above). Certain hatha yoga systems cannot be adapted directly for use by westerners. Fundamentalist tendencies (refusing to depart from the original system) are blind to such insights. Although explanatory models of yoga do exist, its metaphysically based theory and traditions are rooted in its original time. However, all of these bases are no longer in tune with the present time, and attempts at explanation fail to stand up to modern discourse. But this is not the only problem. People at the time when yoga began were not in a position to take account of intersubjective influences. So, as explained above, there is a tendency to give absolute validity to subjective experiences. (See comments relating to structuralism and also, above, the claimed results of certain yogic practices.) Cognitive disciplines such as psychoanalysis and developmental structuralism are very important as regards human consciousness. These theories are only 100 years old. The practice of introspection, in contrast, has a tradition going back thousands of years. This explains why little is found of the former in those traditions (Habecker, 20083). Practitioners who follow the old models uncritically transmit archaic, magical and mythical elements to modern practitioners of introspection, as ‘timelessly valid truths’. It is one of the reasons why modern science assigns the contemplative traditions in general, along with their exceptionally valuable phenomenological heritage, to the scrapheap of human knowledge (Habecker, 20083). Many modern practitioners of yoga cannot recognize this infection of consciousness by the old intersubjective elements of the teaching, however much introspection and yogic practices they apply. This, in fact, is one of the 3 Habecker M., 10/2008. Personal communication with the author.
T. Liem greatest weaknesses of the old teachings: the general inability of people at that time to realize that subjective experiences were not truths in their own right (e.g. inner perceptions of atomization, travelling through the air, etc. (Woods, 2007, 267e278) or certain visions of Indian gods) but instead determined mainly by collective, intersubjective and individual psychodynamic elements. This means that yogis can find e sometimes profound e inner experiences arising within terms of reference that no longer accord. The resulting inner conflict in these yogis inevitably leads to reductionist, narrow attitudes. This can even have the effect of hindering them in many other strands of their development, instead of aiding them. The change needed here is usually small. The yogi has to supplement the old teachings, to view the old frame of reference in a relative light. He has to integrate it into the more differentiated, comprehensive (i.e. more fully developed) frame of reference of the postmodern world. The author believes that this would also bring the valuable gems of this tradition more clearly to the fore and would in fact enable the yogi to achieve healthy and sufficient integration. A similar, though less extreme situation occurs in osteopathy, when osteopathy is understood entirely as a teaching arising from a kind of revelation. Then, no account is taken of the effects of cultural and social elements or the influences in the history of scientific knowledge that helped to shape it. This approach not only excludes evolutionary potentials but also reduces any deeper healing impulses that might be present in the treatment. The value of reflection on one’s own cultural history is often underestimated because it cannot directly be ‘seen’; however, hermeneutic and structuralist processes provide a way of recognizing the conscious and unconscious elements that make up its background. Hermeneutics as a method in the humanities investigates the historicity of human beings in the world in which they live. For example, hermeneutical comparison could be used to investigate associations arising in different osteopaths while performing particular subjective palpatory examinations of tissue qualities. A structuralist investigation could look at such matters as recognition of recurring patterns in osteopathic palpation. Another point to be borne in mind is that sometimes the concepts used by Still (such as ‘material body’, ‘spiritual body’, and ‘body of mind’) may be understood quite differently today than they were in his times (Still, 1986, pp. 16ff; Stark, 2003; Townbridge, 1991, p.161; Dippon, 2005).
The fundamental attitude and focus in yoga and osteopathy It is only natural to seek the ultimate simple technique, the ‘magic trick’ that will solve all our problems. Yet this is not how healing and growth actually work. The simplicity in fact lies in our fundamental attitude. We have to detach ourselves from expectations and ideas as to how inner growth and health ought to manifest themselves. Instead, we should begin each yoga session in a state of un-knowing, leaving open the question as to where in our body and being change will occur and what its nature might be. In osteopathy it is the same: osteopaths
Osteopathy and (hatha) yoga are not miraculous healers. They can accompany and support the patient, according to the extent to which their patients are able to integrate the therapeutic impulses delivered during treatment. It seems typical in almost all systems of medicine, including osteopathy, that short-term relief from pain (e.g. through osteopathic manipulation, for example) is often achieved at the cost of a gain in understanding of the connection between disease symptoms and the coherence of the person’s own life. The patient has the freedom to decide. No reproach need necessarily be made of osteopathy here as long as the patient is made aware of that freedom to choose. However, when there is a failure to recognize possible emotional wounds in a somatic dysfunction and no account is taken of them in the process of resolving the dysfunction, treatment will only produce translative compensation. This can become necessary to avoid physical breakdown, for example. But at the same time it can also hinder transformative processes. This will persist at least until the next phase of instability or appearance of symptoms. On the other hand the patient may make use of the energy gained in the pain-free period to support transformative processes. The performance of an asana is characterized by stability (sthira) and lightness (sukha) (Woods, 2007, p.141; Veda Bharati, 2004, p.568) (Figure 3). These qualities equally assist an osteopath when carrying out treatment in a patient. In yoga as in osteopathy the attention can be fixed on the release of restrictions or the strengthening of weaknesses. This total absorption of attention brings the risk of noticing only negative findings and being concerned only with those. In yoga and osteopathy, therefore, the attention is focused on a vision or a goal. It might be something greater than ourselves that makes sense to us and provides motivation. In yoga, for example, this might be the focusing of our attention on the flow that is happening within and around us. It might also be the awareness of the union of the small self with eternity or of an unconditioned form of sympathy or joy. Osteopaths, when performing treatment, establish a resonance with the homoeostatic forces, the health or flow in the patient. There are also some treatment approaches in which the osteopath’s attention roams in the distance or rests in infinity.
The concept of stillness in osteopathy and in yoga Stillness is an important element in osteopathy (Becker and Brooks, 2000, pp. 66e71; Sutherland, 1990) as it is in yoga (Woods, 2007, pp.8ff). It is in a state of stillness that palpation can develop without preconception. Osteopaths behave as ‘empty vessels’ and in that way are touched by impressions received from the patient. To touch, for an osteopath, means to listen. The osteopath is simply present and awaits with gentle attention the moment when the tissue offers information. It is then that the therapist begins to understand its own special, individual history. The capacity to enter a state of stillness or to be receptive to stillness is essential in order to do this. The more highly developed the therapists’ level of consciousness, the greater or deeper their ability to synchronize with stillness. In Patanjali’s collection of sutras, the definition of yoga that he gives in the second sutra is: yogasˇ citta vrthi
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1.
2.
3. Figure 2 Steps in the progression from dharana (concentration) through dhyana (meditation) to samadhi. 1. Dharana: focus of the mind on an object, the breath, a part of the body, a sound, the concept of sympathy, etc. 2. Dhyana: our mind unites with the object, in the sense of establishing a continuous connection. 3. Samadhi: our mind merges with the object, becomes one. Yamas, niyamas, asanas, pranayama and pratyahara (the ability to retract and focus the senses) provide preparation for this process.
nirodhah (Woods, 2007, pp. 8ff; Desikachar and Krusche, 2007, pp. 44ff; Veda Bharati, 1986, pp. 93e113; Feuerstein, 1989, pp. 26ff). Literally translated this means ‘yoga is the cessation of the activity of the mind’. With these words he defines it as the attainment of the ability to achieve total focus and to maintain it undistracted. Thus the mind can make the transition from a state of restlessness and drivenness to a state of calm, stillness and clarity. From this definition we gain an impression of the depth of this stillness that opens up to the deconditioned mind. The extent of a person’s ability to experience stillness is directly related to the conscious differentiation, relativization and integration of that person’s own sensory and mental and psychoemotional conditioning. The limiting patterns of perception have a constricting effect on this stillness that opens up to the deconditioned mind. Therefore the ability to experience stillness is the expression of the development of the person’s own consciousness, of a deconditioned mind. In Yoga Vasishta it is described as ‘‘the silent that knows the truth, is always in the self-same state of tranquillity, whether he be walking or sitting any where, or remain in the states of waking and sleeping’’ (Prakash Arya, 1998) The maturing of the person; our own inner equilibrium and ability to remain centred in the present, in stillness and in ‘being’; the ability to open ourselves up to life (instead of trying to control and manipulate it); the ability to surrender ourselves, as well as access to our own vulnerability and self-consciousness, all exert a direct influence on the therapeutic interaction and on our ability to palpate in a judgment-free way. The therapist’s conditioned attitudes and ways of seeing are not something that can be consciously changed in an instant. They do however have a decisive effect on the extent and quality of stillness that the therapist is able to contact. Osteopathy does not teach any method of achieving this kind of inner deconditioning. In this respect, approaches that exist in yoga can be useful in developing the capacities of the osteopath. All systems of yoga aim specifically to release the person engaged in
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T. Liem
Figure 3 Ashtavakrasana e named in honour of the wise Ashtavakra. This strengthens the arms, hands and abdominal muscles. Photo: ª Kirsten Petersen, Hamburg.
perception from conditioned ways of seeing which cloud the view. In jnana yoga, for example, this is the achievement of true knowledge. In raja yoga, it is the capacity for control of the mind. In bhakti yoga it is self-surrender and in karma yoga selfless service and action (Glasenapp von, 1986; Bru ¨ck, 2007). One possible system of promoting ‘inner deconditioning’ and attainment of consciousness is presented in Patanjali’s sutras on yoga (see Figure 2). All this, of course, goes far beyond the day-to-day professional practice of osteopaths. True synchronization with deeper levels of being in the other demands, as a prerequisite, our own authentic awareness of these levels; one that encompasses all aspects of life (our relationship with and views of our body, life partner, children, friends, ‘enemies’, sex, food, holiday, money, power, etc.). This may not always be comfortable. Sometimes it might even provoke anxiety, since seen like this there is no strict distinction between the professional and the private. Last but not least it is precisely in the private sphere that our darker sides are mostly found. On the other hand e once we have begun to open ourselves up in this sphere e a much greater depth and coherence become accessible to us. We can use this resource in the therapeutic interaction and potentiate the manual means at our disposal. A more mature, non-judgmental awareness or ‘witness consciousness’ opens up to us step by step. It works not only in our wakefulness but during sleep, especially in deep sleep and in that openness to stillness that is free of all expectation.
Concluding thoughts In osteopathy, too, the primary aim is not to achieve a symptom-free state but rather healing or becoming whole. This is aimed at as a form of a higher order or complexity (even if this is not always applied in practice). This is underlined by
the words ‘health’, ‘healing’ and ‘wholeness’, which can all be traced to the old word ‘haelan’ (Morris, 2000). These connections indicate points of contact where osteopathy and yoga can enrich each other. Osteopathy as a healing art in the field of medicine, and yoga as a primary system of experiencing the self, coincide. However, as mentioned above, both osteopathy and yoga e though sometimes for different reasons e require new frames of reference and additional development. This is the only way they will be adequate for the postmodern world and develop their potentials.
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Journal of Bodywork & Movement Therapies (2011) 15, 103e107
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PREVENTION & REHABILITATION: EDITORIAL
Warrick McNeill, Dip. Phyty. (NZ) MCSP, Associate Editor* Physioworks 4 Mandeville Place, London W1U 2BG, UK
A young Profession In a February edition of Sports Illustrated, the journalist Wernick (1962) described his regular sessions in New York with the ‘gruff, Teutonic,’ Joseph Pilates. ‘Contrology’ was the exercise system developed by Joseph Pilates that is now commonly known by his last name. Wernick says in his article, ‘Don’t ask me what contrology is. Don’t ask Joe either, for orderly exposition is not his specialty. Contrology has something to do with rational tension and relaxation of the muscles, and it comes from a profound knowledge of bodily kinetics learned in no classroom. Joe figured out the principles.in Germany by watching children at play and animals in the forest.’ Wernick concluded that the highest accolade Joe could ‘bellow’ after the eventual, successful demonstration of an exercise, worked on for some time was, ‘Now you are an animal!’ The Pilates discipline is still a relatively young profession with a burgeoning scientific proof, largely ‘borrowed’ from motor control research, as there is limited high quality research defending the technique (Bernardo, 2007). It is perhaps similar to complementary therapies that have valuable input in treating and preventing a myriad of conditions, syndromes or injuries but have yet to fully convince the world of science of their rightful places in ‘evidence based practice.’ After Joseph Pilates death his technique was initially taught to others by his prote ´ge ´es: Mary Bowen, Ron Fletcher, Eve Gentry, Kathy Grant, Romana Kryzanowska, Lolita san Miguel, Carola Trier. Some sources, such as the Pilates Method Alliance, refer to some or all of the Prote ´ge ´es as ‘Elders.’ I interviewed Fritzke and Voogt (2007), Pilates Teachers (developers of the Triadball), in 2007 at a Body Control Pilates Conference in London. Fritzke and Voogt had come to
the conclusion, after discussions with several of the ‘Elders,’ that Joe Pilates had taught in reaction to ‘the body in front of him.’ In other words he altered his approach to each individual clients needs. This means that the differences between the ‘Elders’ approaches, and their eventual Pilates certification programs, were, in part, due to the differences in emphasis Joseph Pilates was required to take in adapting his technique for their individual bodies. Fritzke and Voogt report that each ‘Elder’ could only interpret ‘their piece of the puzzle.in essence the variety of approaches to the Pilates concept is only due to the interpretive differences of the same philosophy.’ I took from that interview the inclusive and positive idea that each different Pilates approach has merit, and is worth investigation.
Bias Later generations of teacher trainees now work to certification syllabi, under a variety of organisations with long or short courses. I have noted that most Pilates Teachers come to the profession for a second, or ancillary career. I have tried to analyse those who begin to train as Pilates Teachers and have sub-grouped them. There are the:
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‘Ex-dancers’ - very movement aware people who are knowledgeable about how to learn movement. ‘Pilates Converts’ - usually at one point having had a ‘Road to Damascus’ moment when they realised that Pilates exercise had ‘saved’ them. They can be very enthusiastic teachers having rehabilitated themselves from injury or poor physical conditions. ‘Change-of-Lifers’ - use the teaching of Pilates as an antidote for previous, unfulfilling, often office based, careers. These teachers may also struggle with their own lack of movement awareness. ‘Fitness Professionals’ - they bolt-on a Pilates training to improve their curriculum vitae and may develop a very rounded understanding to the entire fitness sphere.
PREVENTION & REHABILITATION e EDITOR: WARRICK MCNEILL
Decision making in Pilates
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PREVENTION & REHABILITATION e EDITOR: WARRICK MCNEILL
‘Therapists’ - a sub-group who want to use Pilates as an extra weapon in their therapy tool kit. What is clear is that they all bring different skills to the Pilates table. This means that the diverse pool of potential clients have a group of equally diverse teachers they can choose from, which can only be beneficial for all. What a newly graduated Pilates Teacher soon learns is that, what worked for them personally while learning the movement does not necessarily translate well to all their clients. What they must recognise is that they have developed biases e an ex-dancer who is hyper-mobile will not necessarily have experienced what it is to be very tight, a Fitness Professional may want to work a client hard to strengthen them when the client actually needs to learn to find the least effort required to successfully achieve a movement, or sustain a posture. As a member of the ‘Therapist’ sub-group I always asked, on my Pilates training course, over and over, ‘Why do we do this exercise?’ It took me a long time through the course to answer my own question. ‘Sometimes it is just about the movement.’ A famous Pilates quote (Pilates and Miller 1945) says that a man is as young as his spine. ‘If your spine is inflexibly stiff at 30, you are old; if it is completely flexible at 60, you are young..’ I believe that, as we mature from childhood to adulthood, we change the way we move. In the first part of life we learn to move. Later, due to the pressures of work, family, or the mode of life we choose, we start reducing the types and amount of movements we make. The eventual net effect is that, over time, we lose available joint and muscle range, and the flexibility of the brain to request such movement of our bodies. We become habituated and move only to this limited template. Eventually, in old age, we become almost completely sedentary and prepare to die. Movement therapies and disciplines such as Tai Chi, Feldenkrais, Yoga, as well as Pilates, keep us moving in unaccustomed ways, keeping the mindebody connections intact and the movement control centres of the brain active, helping keep us young. Recognising that a Pilates Teacher’s decisions regarding their clients are ‘informed by their bias’ is important, but so too are the attempts a Pilates Teacher must make to balance their bias e with the choice of what extra training they should undertake in their continuing professional development, or at least being prepared to refer clients sideways to other members of their profession as well as upstream to health professionals or downstream to other types of fitness professionals (CV-fitness), or Sports Coaches.
What is pilates? My current definition of Pilates exercises are, ‘generally integrated, whole body movements, involving low and/or high threshold muscle contraction, often in sequence, exploring both neutral and full joint ranges’. The integrated movements in Pilates usually differs from traditional ‘isolated’ gym based strength training exercise, though later in this Prevention and Rehabilitation section Craig Liebenson discusses the ‘Turkish get up’ a functional
W. McNeill strength training exercise that, like Pilates, relies on the quality, not the quantity of movement. Pilates (the technique), due to the differences of its approaches of Pilates’ (the man) prote ´ge ´es, has now developed traditional and evolving strands. Traditional Pilates involves keeping the repertoire as it was when Joseph Pilates died. ‘Evolved’ Pilates teachers are likely to be reading this piece critically, ready to adapt their process once scientific proof confirms their need to, but are also ready to reject unsubstantiated, perhaps harmful belief.
Types of pilates There are many differences in the way that Pilates is taught. It is often divided into two broad types of Pilates. ‘Matwork’ and ‘Apparatus’ based work using Pilates Machines. Matwork is usually floor-based exercises practiced with the possible addition of small pieces of equipment: balls, foam rollers, theraband, and arced barrels - to mention a few. Apparatus based Pilates use machines such as Reformers, Cadillac’s (Trapeze tables), Wonder (Stability) chairs, Wall units and Ladder barrels, devised by Joseph Pilates himself. Classes are often taught ‘1 to 1’, or in small or larger groups, and often run for an hour. Another style of teaching an Apparatus based class is known as a Studio class. In this style a teacher runs a class of up to, say 6 people. The class is often longer, at around 90 min. Sometimes the clients come in as a group or the clients come in at staggered times, allowing the teacher a few minutes to work with each client individually, then setting each client on their way through a program, using exercises from the repertoire most suited to their needs. Matwork classes particularly, can be developed for the specific group attending the class. They can range from ‘Pre-Pilates classes’ for those who require more handholding than those wanting to join a ‘Beginners’ class. Those who are gaining technique and ability can go to ‘Intermediate’ classes, eventually graduating into ‘Advanced’ classes. ‘Fitness based Pilates’ often involves classes with a larger number of participants, undertaken in a gym’s aerobic studio and can be designed to cater for those who have to be sweating and ‘feeling the burn’ to know they are actually exercising. ‘Rehab’ classes can be linked to a particular condition and are often associated with clinics providing physical therapies. ‘Low back pain Pilates’ or ‘Pregnancy Pilates’ classes are examples of such groups. ‘Classical Pilates’ classes can be as Joseph Pilates himself actually taught them, using the same exercises in exactly the same order. Combining other disciplines names with Pilates (something-or-other-ilates) is also fashionable and can sell e take for example ‘Yogalates’ or possibly ‘Chair-ilates’ for the elderly.
How do Pilates Teacher assess? Fritzke and Voogt answered a question I put to them in 2007 about how Pilates Teachers assess their clients, by saying that, ‘most of the time it is about asking the client questions and seeing them walk, but from a Pilates point of
view, it is once they start the movement of the basic exercises that a Teacher starts to get feedback.The body never lies, no matter what they write on their form or ‘forget’ to tell you. You immediately see it, the evidence of that rotator cuff tear, the past ankle injury..’ They went on to say, ‘Most certification programs do not have a full assessment of the client,’ like that of a clinician. ‘Most programs of Pilates have an official basic, intermediate and advanced program, so the way we teach, is to talk to the client, see how they are, to choose which ‘start’ is appropriate. We then give them a basic exercise on the piece of equipment we have chosen. We can then quickly see that we need to go in this or that direction. You build up from there.’ To a clinician treating those with injuries this approach may seem cavalier, but for the types of Pilates in which the clients are fit and well it is entirely normal and correct. A dancer does not learn to dance by discussing the problems of movement; it is an experiential learning process. Typical Pilates assessment includes a ‘Roll down’, an exercise in standing that uses a sequential flexion pattern of the spine, through to the hips as the hands reach towards the floor. The observational skills of the Pilates Teacher come into play, looking at sequencing, flow, tightness’s, rotations of the trunk, asymmetries, and decisions are made from there. Teachers take in to account how the client is ‘today’, and ‘in relation to previous sessions.’ In fact, it is the principles of Pilates: centre, concentration, control, precision, breath, and flow that become the key points of assessment in a traditional Pilates assessment process.
Are further assessment tools and knowledge required? It is when special populations are involved that such assessments possibly become inadequate. It is in the blur between injury and risk that Pilates Teachers decisions become potentially more serious. I suggested, in a previous Editorial, ‘About Prevention’ (McNeill, 2010), that thought about a Pilates Teachers insurance policy may often be the bottom line deciding whether a Pilates Teacher can see a client in pain or not, but Pilates teachers must be trained to at least recognise red flags. (Negrini et al., 2008) These may warn of potentially dangerous findings, or illnesses such as tumours (the presence of night pain or pain at rest, the unexplained loss of weight or appetite), or spinal cord compression (urinary retention), amongst others. Yellow flags (Negrini et al., 2008) too, might be considered important for a Pilates teacher to know about, in which psycho-social factors that can affect rehabilitation and recovery are identified. Factors relating to beliefs about pain being damaging, the adoption of a sick role, and depression amongst others. Admittedly the attendance at a Pilates class may indicate the client is preparing to take on the responsibility of exercise for themselves which is likely to be a positive modifier on some of the yellow flag questions. As a Physiotherapist I have many clients referred to me by my Pilates colleagues, I assess and provide a plan to enable the client to continue with, or to return to exercise, by explanations, modification of their activities of daily living
105 and exercise prescription. I regularly spend a significant amount of contact time managing expectations of recovery time. Most clients ‘know’ it takes something like 3 weeks to heal a ligament and 6 weeks to heal a broken bone, and are shocked when I point out that those time scales are not exactly true in every case. A fracture can take a year to go through to its full recovery phase. A ligament can take longer to heal the higher the grade of the sprain. By identifying to a client the direction of movement that stresses an inflamed, injured soft tissue, they can understand that the swelling related to that inflammation can create a pressure sensitive mechanical pain. This pain will not necessarily disappear until the swelling decreases, but neither will the swelling go till the injured tissues have been protected. Stopping all movement into the aggravating direction provides the protection. Even then, the protection has to be effective for some time, possibly weeks, before the swelling can reduce significantly enough to cease triggering pain. Butler and Moselely’s (2003) Explain Pain and its tools, ‘Education and understanding’, ‘Your hurts won’t harm you’, ‘Pacing and graded exposure’ and ‘Accessing the virtual body’ are easily grasped by the layman. This book should be required reading for every Pilates Teacher and Teacher trainee. A Pilates teacher should be taught enough patho-physiology to understand healing times and to be able to manage expectations of recovery for their clients. Their clients may be out of pain but still be ‘healing’ and therefore remain at risk. The UK’s National Health Service expects its Physiotherapists to predict what percentage of improvement can be expected from a set number of treatment sessions. Perhaps realistic predictions of improvements over time could be taught to Pilates Teachers who work with rehab clients. A client who is told to expect a 50% improvement in their discomfort and movement control following their nonoperative ski injury to their knee, over a six month period, may respond more favourably than the same client being told they would be back to normal after six weeks of exercise, and didn’t achieve this prediction. Pilates can, unfortunately, injure its devotees, and keeping the rehabilitating exerciser’s injured part around a neutral position for enough time to allow healing to firmly establish, may mean modification of repertoire, for a long time, to keep the goals of the Pilates sessions on track. Most Pilates teachers are aware of some of the inherent risks within Pilates itself. Pilates has a bias towards spinal flexion in many of its exercises, and a bias to unsupported neck flexion (in exercises like ‘the hundreds’) to name but two biases. Moira Stott Merrithew of Stott Pilates, a wellknown figure in the world of Pilates, developed disk bulges in her neck after training as a Pilates Teacher. This prompted her study of anatomy and subsequent modification of Pilates repertoire. She reports this in her biography at her website. (see web source). Sahrmann (2002) describes muscle and recruitment pattern impairments in her book ‘Diagnosis and treatment of movement impairment syndromes.’ She identifies that shortened or stiff muscles may recruit earlier in a muscular synergy instead of the more appropriate prime mover. This change in muscular emphasis can alter the path that the bones make during a movement, potentially leading to
PREVENTION & REHABILITATION e EDITOR: WARRICK MCNEILL
Decision making in Pilates
PREVENTION & REHABILITATION e EDITOR: WARRICK MCNEILL
106 injury. A well-described set of variables involving relationships of muscular length, under-recruitment of stabilising musculature or over-recruitment of inappropriate musculature can be responsible for the movement impairment. When I assess clients for movement impairments I look for ‘substitutions’ e situations in which another muscle has taken over the dominance in a synergy, such as the recruitment of stronger (stiffer), and often, shorter hip flexors instead of the weaker abdominals in a trunk curl. The discussion of trunk curling sit-ups in chapter three is well worth a read in Sahrmann’s book. Pilates Teachers have the observational skills to read the sometimes, subtle, signs of a substitution. If superficial hip flexors dominate in a ‘roll up’ (a supine trunk curling pilates exercise with straight legs) the pelvis may not release into a posterior tilt to aid the lumbar flexion component of the exercise. Instead the pelvis may stay neutral or even anteriorly tilt creating a stutter in the roll up as the lumbar spine does not flex early enough. Sahrmann (2002) often identifies the Tensor Fascia Lata (TFL) and its propensity to activate in many of the hip movement impairment syndromes that she describes. A Pilates teacher therefore, may require knowledge of which hip flexor (iliopsoas vs. rectus femoris vs. TFL) is short, as this may alter decision making in exercise design, as well as altering the cueing and focus of the subsequent exercise. The Modified Thomas Test (Hattam and Smeatham, 2010) distinguishing which individual hip flexor is tight may therefore be indicated as a useful test for Pilates Teachers to know and use. I know my superficial hip flexors recruit more often in actions that my abdominals should be controlling, and I am both a physiotherapist and a Pilates teacher. I am only just starting to gain some control in this area after a year of regular once a week work on a 1 to 1 basis. (Admittedly this improvement could probably have been sped up by more regular supervised Pilates classes, and following up the sessions with homework exercise). Strengthening my under-recruited, weak abdominals has been difficult for me to even feel, let alone access, as my over-recruited superficial hip flexors work so efficiently and automatically. It took me months to ‘physically know’ how much they over contributed to my abdominal work even though I knew it intellectually. Just using Pilates exercises (which are not often functional movements), could leave a Pilates practitioner ‘good at practicing Pilates’ but ‘poor in practicing functional movement.’ In my observation of my clients some spontaneously improve in functional movement at the same time as they do during their non-functional exercise. Some do not, and these clients clearly need to be led into their functional improvement. If ‘Pilates assessments’ only look at ‘Pilates movements’ there may be motor control deficits lying undiscovered. I believe that Pilates Teachers should be taught wider forms of assessment. In the ‘About Prevention’ editorial I discussed the need for the screening of function, identifying Comerford’s (2009, & web source)‘Performance Matrix’ and ‘Cook’s (2009, & web source) Functional Movement Screen’ as possible contenders. Neural states and their effects on creating protective spasm in muscles such as the hamstrings found by slump
W. McNeill stretch tests (Butler, 2000), or in the upper shoulder musculature by the upper limb neurodynamic tests (Butler, 2000; Walsh, 2005) could alert a Pilates Teacher to avoid or alter some exercise choices. Neurodynamics as described in Butler’s, ‘The sensitive nervous system’, is an important concept for all body workers and exercise professionals. I am not saying that a Pilates Teacher should become a clinician e treating pain, I’m just asking for acceptance that those Pilates Teachers who work with clients, recently in pain, and who have the potential to slide backwards in their rehab, should be familiar with the relevant tests that confirm the need for referral.
Not just assessment Pilates Certification boards have a duty to provide up-todate medical science information and courses for their members through their continuing professional development programs. Chaitow (2010) reported to me that he has treated Pilates Teachers showing symptoms of hypertonic pelvic floors. This suggests to me that cueing Pilates exercise with a prime focus on pulling up the pelvic floor as the standard ‘way in’ to access the abdominals, can encourage an over-recruitment of the pelvic floor. This cueing, while beneficial for those with weak pelvic floors, is not necessarily beneficial for all, and can encourage pelvic floor hyper-tonicity. Seeking appropriate knowledge on this subject, particularly using texts written by experts in their fields aimed at the lay person, such as O’Dwyer’s (2008)‘My pelvic flaw’, can help Pilates Teachers alter their cueing and practice to fit current concepts. Recently linked with pelvic floor problems is the poor use of the diaphragm in breathing (Hung et al., 2010) and is highlighted in Leon Chaitow’s blog (see link under web sources). Breathing, a fundamental component of the Pilates technique (Pilates and Miller, 1945), can, in my view, sometimes concentrate on the ‘stylised’ Pilates breathing patterns so much so, that normal breathing patterns can perhaps be negatively affected. Understanding breath from a therapeutic point of view such as gleaning information from reading such books as Chaitow et al. (2002) Multidisciplinary approaches to breathing pattern disorders, may add to a Pilates Teachers knowledge base and give them more tools to apply when teaching their clients Pilates exercise.
Not just pilates In the quest for scientific proof, those that contribute to or read the Journal of Bodywork and Movement Therapies, may come from disciplines that have needed to work hard to gain a full or partial acceptance from the more pure medical science world. Like Pilates, there will be areas of those disciplines that will continue to operate outside of the ‘proofs,’ as they may be too difficult to test with our current methodologies, or, that the popular uptake assures their continuation without scientific validation. This is a perfectly appropriate state of affairs as it provides a bank of material ripe for investigation by later generations. The Pilates model can be used as a case study of other bodywork and movement therapies in which we accept the
parts of the disciplines that are currently being placed under scientific observation as having their validity assessed and other parts that may, in future times, be assessed under the same gaze. We should accept the differences within our professions, actively seeking to weed out the concepts that injure or harm, and consider new ways of justifying the things we ‘know’ work but can’t quite, just at the minute, say why.
The rest of this Prevention and Rehabilitation section I invite you to read two interesting papers. ¨ hman et al.’s Qualtative review of Feldenkrais as O a group therapy for chronic pain. Reading it in the light of this editorial may draw some similarities in the states of both Pilates and Feldenkrais professions and their development. Traditional dance, in this paper by Kaltsatou et al., is shown to be both psychologically and physically beneficial to breast cancer survivors.
References Bernardo, L., 2007. The effectiveness of Pilates training in healthy adults: an appraisal of the research literature. Journal of Bodywork and Movement Therapies 11 (2), 106e110. Butler, D., Moseley, G.L., 2003. Explain Pain. Noigroup Publications, Adelaide. Butler, D., 2000. The Sensitive Nervous System. Noigroup Publications, Adelaide, Australia. Chaitow, L., 2010 Personal correspondence.
107 Chaitow, L., Bradley, D., Gilbert, C., 2002. Multidisciplinary Approaches to Breathing Pattern Disorders. Churchill Livingstone / Elsevier. Comerford, M.J., 2009. Recurrence of injury and pain in sport what’s missing. Manual Therapy 14 (5), S1eS54. Cook, G., 2009. What is our baseline for movement? The clinical need for movement screening and assessment. Manual Therapy 14 (5), S1eS54. Fritzke, M., Voogt, T., 2007. Unpublished, recorded interview. Hattam, P., Smeatham, A., 2010. Special Tests in Musculoskeletal Examination. Elsevier, pp. 167e169. Hung, H.C., Hsiao, S.M., Chih, S.Y., Lin, H.H., Tsauo, J.Y., 2010. An alternative intervention for urinary incontinence: retraining diaphragmatic, deep abdominal and pelvic floor muscle coordinated function. Manual Therapy 15 (3), 273e279. McNeill, W., 2010. About prevention. Journal of Bodywork and Movement Therapies 14 (3), 289e293. Negrini, S., Fusco, C., Atanasio, S., Romano, M., Zaina, F., 2008. Low back pain: state of art. European Journal of Pain Supplements 2, 52e56. O’Dwyer, M., 2008. My Pelvic Flaw. Redsok Publishing. Pilates, J.H., Miller, W.J., 1945. Return to Life through Contrology. J.J. Augustin, New York. Sahrmann, S., 2002. Diagnosis and Treatment of Movement Impairment Syndromes. Mosby. Walsh, 2005. Upper limb neural tension testing and mobilization. Fact fiction and a practical approach. Journal of Hand Therapy 18 (2), 241e258. Wernick, R., 1962. To keep in shape: act like an animal. Sports Illustrated.
Web sources http://www.stottpilates.be/aboutus/biomoira.html. http://chaitowschat-leon.blogspot.com/. www.functionalmovement.com. www.performance-stability.com.
PREVENTION & REHABILITATION e EDITOR: WARRICK MCNEILL
Decision making in Pilates
Journal of Bodywork & Movement Therapies (2011) 15, 108e113
available at www.sciencedirect.com
journal homepage: www.elsevier.com/jbmt
PREVENTION & REHABILITATION e MUSCLE PHYSIOLOGY
MUSCLE PHYSIOLOGY
Abdominal hollowing and lateral abdominal wall muscles’ activity in both healthy men & women: An ultrasonic assessment in supine and standing positions Farideh Dehghan Manshadi, Ph.D. Candidate a,b,*, Mohamad Parnianpour, Ph.D. c,d, Javad Sarrafzadeh, Ph.D. a, Mahmood reza Azghani, Ph.D. e, Anooshirvan Kazemnejad, Ph.D. f a
School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran Rehabilitation Faculty, Shaheed Beheshti University of Medical Sciences, Tehran, Iran c School of Mechanical Engineering, Sharif University of Technology, Tehran, Iran d Information & Industrial Engineering, Hanyang University, Ansan, Republic of Korea e Department of Mechanical Engineering, Sahand University of Technology, Tabriz, Iran f Department of Biostatistics, Faculty of Medicine, Tarbiat Moddares University, Tehran, Iran b
Received 30 June 2009; received in revised form 21 September 2009; accepted 19 October 2009
KEYWORDS Abdominal Hollowing; Abdominal wall muscles; Rehabilitative Ultrasonic Imaging; Supine; Upright standing; Posture
Summary The objective of this study was to investigate the effects of Abdominal Hollowing (AH) maneuver on External Oblique (EO), Internal Oblique (IO) and Transversus Abdominis (TrA) muscles in both healthy men and women during the two postures of supine and upright standing. The study was conducted on 43 asymptomatic volunteers (22 males and 21 females) aged 19-44 (27.8 6.4) years. Rehabilitative Ultrasonic Imaging (RUSI) was simultaneously performed to measure muscle thickness in both rest and during AH maneuvers while activation of the TrA during AH was controlled by Pressure Biofeedback (PBF) device. Mixed-model ANOVA with repeated measures design, and Pearson correlation tests were used to analyze the data. Muscle thickness of all muscles was significantly higher for male subjects (F > 6.2, p < 0.017). The interaction effect of gender and muscle status was significant only for IO (F Z 7.458, p Z 0.009) indicating that AH maneuver increased the thickness of IO in men. Interaction
* Corresponding author. Department of Physical Therapy, Rehabilitation Faculty, Shaheed Beheshti University of Medical Sciences, Damavand Ave. Imam Hosien SQ. Tehran 1616913111, Iran. Tel.: þ98 (21)77548496; fax: þ98 (21)77561406. E-mail addresses:
[email protected] (F.D. Manshadi),
[email protected] (M. Parnianpour),
[email protected] (J. Sarrafzadeh),
[email protected] (M.reza Azghani),
[email protected] (A. Kazemnejad). 1360-8592/$ - see front matter ª 2009 Published by Elsevier Ltd. doi:10.1016/j.jbmt.2009.10.004
An ultrasonic assessment in supine and standing positions
109
Introduction The Transversus Abdominis Muscle (TrA) forms the deepest abdominal musculature, producing little force for trunk flexion, extension and lateral flexion. Despite its involvement in rotation of the trunk, it has only a small lever arm to produce rotational moment (Urquhart and Hodges, 2005; Urquhart et al., 2005). The TrA contributes to lumbo-sacral stability by its role in intra-abdominal pressure, creating tension of thoraco-lumbar fascia, and compression of sacroiliac joints (Richardson et al., 2004; Arjmand et al., 2001; Snijders et al., 1995). As Richardson’s clinical model explains, the TrA is a local stabilizer of lumbo-sacral region alongside multifidus, pelvic floor and lumbar spine musculature and also diaphragm (Richardson et al., 2004). Abdominal hollowing (AH) maneuver has been presented as an activity which exercises the TrA muscle in an isolated fashion. In order to control the contraction of TrA during this maneuver, palpation of its tendon medial to anterior superior iliac spine, and also Pressure Biofeedback (PBF) have been used. The latter is a tool developed by physiotherapists to aid the retraining of stabilizing muscles using specific exercises, and detects movement of the lumbar spine in relation to an air-filled reservoir. In prone position 4e10 mmHg reduction from the basic pressure, of 70 mmHg, and in supine position no change in primary 40 mmHg pressure may depict the person’s ability to activate the TrA muscle independently from other abdominal wall muscles (Richardson et al., 2004). Hodges et al. (1996) used electromyography to investigate the relationship between the ability of reducing the pressure in the PBD device during AH maneuver and the time of onset of TrA activity during limb movement. Their findings indicated that the quality of motor control of TrA, directly measured by fine- wire electrodes, can be estimated indirectly by PBF, as well. Cairns et al. (2000) used PBF for comparing the activity of antero-lateral abdominal musculature in prone position in people with and without low back pain. It was indicated that PBF is a useful device for recognition and investigation of antero-lateral abdominal musculature. Stroheim et al. (2002) used PBF in order to assess TrA activity in prone position and concluded that although PBF provides appropriate feedback for contraction of TrA, its application for scientific and research purposes requires further investigations. Rehabilitative Ultrasonic Imaging (RUSI) approved by the World Federation of Ultrasound in Medicine and Biology (WFUMB) since 2006, is a non- invasive method used by physiotherapists to assess the morphology and function of deep tissues and muscles, including TrA (Whittaker et al., 2007). Numerous
studies have depicted the reliability of this method in comparison to MRI and electromyography for assessing the activity of abdominal musculature (Richardson et al., 2004; Mc Meeken et al., 2004). Its validity for evaluation of abdominal muscle thickness in various contracting positions has been confirmed in several studies (Bunce et al., 2004; Norasteh et al., 2007). However, other researchers have emphasized the necessity of more extensive investigations before utilization of this method in clinical evaluation of activity of muscles of the lateral abdominal wall in different functional positions and during interventions in both genders (Teyhen et al., 2007; Mannion et al., 2008). The two objectives of this study were 1) the ultrasonic evaluation of the effect of abdominal hollowing maneuver on the activity of the muscles of the lateral abdominal wall in standing and supine postures in both genders 2) and to assess the efficiency of PBF device in depicting the isolated contraction of TrA in standing position.
Methods Study design We analyzed the muscle thicknesses with a mixed-model ANOVA with a repeated-measures design to determine the effects of gender, posture (supine and upright standing) and muscle status (rest and AH). Dependent variables were muscle thickness for the EO, IO, and TrA, and the contraction ratios computed based on literature (Mannion et al., 2008) and the independent variables were gender, posture and muscle status.
Subjects Forty-three healthy volunteers, 21 females and 22 males, in the age range of 19e44 (27.8 6.4) years, with no previous history of sporting activity, low back pain and urinary incontinence were included in this study (Table 1). The participants completed their consent form that had approved by the Ethics Committee of the Iran Medical University. Table 1 The demographic characteristics (mean SD) of both female and male participants.
data
Age (year) Height (m) Weight (kg) BMI (kg/m2) Female 26.2 6.2 Male 29.3 6.3
1.61 6.1 1.74 6.6
57.6 10.2 74.1 13.4
22.1 3.4 24.4 4.1
PREVENTION & REHABILITATION e MUSCLE PHYSIOLOGY
effect of posture and muscle status on muscular thickness indicated that changing position only affects the resting thickness of TrA (F Z 5.617, p Z 0.023). Standing posture significantly affected the TrA contraction ratio (t Z 3.122, p Z 0.003) and TrA preferential activation ratio (t Z 2.76, p Z 0.008). There was no relationship between age and muscle thickness (r Z 0.262, p Z 0.09). The PBF has been introduced as a clinical and available device for monitoring TrA activity, while RUSI showed that both TrA and IO muscles had activated after AH maneuver. We recommend performing further investigations using electromyography and RUSI simultaneously at more functional postures such as upright standing. ª 2009 Published by Elsevier Ltd.
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F.D. Manshadi et al.
Data collection protocols
EO þ IO contraction ratio Z (EO þ IO thickness contracted)/(EO þ IO thickness at rest). TrA preferential activation ratio Z (TrA contracted/ (TrA þ EO þ IO contracted)) (TrA at rest/(TrA þ EO þ IO at rest)).
The tools utilized in the study included a data form to record demographic data, PBF device manufactured by Chattanooga Ltd., USA, and a brightness B-mode ultrasound instrument manufactured by BK Medical, Denmark with 7.5 MHz linear probe, frequency range of 5e12 MHz and central frequency of 7.5 MHz.
The KolmogoroveSmirnov (KeS) goodness-of-fit test was used to evaluate normality of the distribution. Mixed-model ANOVAs with repeated measures design were used to test the effects of posture, gender and muscle status on muscle thicknesses. To further analyze bonferroni post hoc tests followed on marginal means of the model. The paired t-test was used to compare the computed contraction ratios between standing and supine postures. In addition, a two-way ANOVA was performed to assess interactions between the gender and BMI on the three muscle thicknesses. Where there was a significant main effect for groups, post hoc comparisons were made using Tukey test. Also a Pearson correlation test was used to investigate the relationship between age and muscle thickness. The significance level was set at a of 0.05.
PREVENTION & REHABILITATION e MUSCLE PHYSIOLOGY
Procedures The participants were instructed to activate their TrA muscle in standing position using the AH maneuver with biofeedback received from the ultrasonography device; this activation was controlled simultaneously with palpation of muscle insertion (Richardson et al., 2004; Mannion et al., 2008). For imaging, the individuals were lying with extended lower limbs. For EO, IO and TrA muscles, the mid-axillary line was determined, and then a mark was put 2.5 cm anterior to the line in the region between iliac crest and the last rib (Richardson et al., 2004; Whittaker et al., 2007). The abdominal wall muscles underwent imaging at this point in both standing and lying positions. The ultrasonography equipment was prepared for muscular imaging, gel was poured on the probe, and the probe was put on the skin without applying any pressure (Bunce et al., 2004; Aniscough-Potts et al., 2006). Initially, imaging was performed while subjects were in supine position with muscle at rest. Then, the person was required to perform the AH maneuver, and imaging continued while the contraction of TrA was controlled by PBF. In standing position, an inflexible piece of board, measuring 35 50 cm and weighing 400 g was fastened with two straps of elastic band to the individual’s back, like a backpack, in order to hold the PBF device between itself and the person’s back. Similarly, with simultaneous control of muscle contraction with PBF, imaging was performed at rest and with AH maneuvers. All images were taken on the left side of the abdomen and at the end of expiration. Finally, the absolute values of thickness of muscles were recorded. Furthermore, some proposed indices were calculated using the following equations (Teyhen et al., 2007; Mannion et al., 2008).
Results The p values were higher than 0.05 for all KeS tests, indicating that the variables under study have normal distribution. The descriptive statistics (mean SD) of the thicknesses of IO, OE and TrA under different experimental conditions are shown in Table 2. The summary results of the analyses of ANOVA are shown in Table 3. Muscle thickness of all muscles was significantly higher for male subjects (F > 6.2, p < 0.017). The interaction effect of gender and muscle status was significant only for IO (F Z 7.458, p Z 0.009) indicating that AH maneuver increased the thickness of IO in men. Interaction effect of posture and muscle status on muscular thickness indicated that changing position only affects the resting thickness of TrA (F Z 5.617, p Z 0.023). Main effects of posture and muscle status were significant for only IO and TrA muscle thicknesses (Table 3). The OE’s thickness was not significantly affected by posture or muscle activation. The descriptive statistics of computed contraction ratios are presented for both supine and standing postures in Table 4. Gender has no significant effect on these ratios which allowed us to use the paired t-tests which indicated that TrA contraction ratio (t Z 3.122, p Z 0.003) and EO contraction ratio (t Z 2.76, p Z 0.008) were significantly affected by posture (Table 4).
TrA contraction ratio Z (TrA thickness contracted)/ (TrA thickness at rest). EO contraction ratio Z (EO thickness contracted)/ (EO thickness at rest).
Table 2 The mean (SD) values of Lateral Abdominal wall muscles’ thickness in rest and during AH, in supine and standing positions for each gender (mm). Subject’s Position
Supine
Muscle Status
Rest
Gender
F*
M**
F
M
F
M
F
M
Muscles EO IO TrA
3.1 0.8 4.1 0.9 2.3 0.6
4.5 1.7 6.7 2.09 3.06 0.7
3.3 0.9 4.5 1.03 3.5 1.2
4.9 1.8 7.5 2.5 4.6 1.7
3.4 1.1 4.7 1.01 3.1 0.8
3.7 1.3 6.6 2.2 3.7 1.2
3.4 1.3 5.1 1.5 4.09 1.4
4.9 1.8 8.2 2.5 4.5 1.4
*F: Female, ** M: Male.
Standing During AH
Rest
During AH
An ultrasonic assessment in supine and standing positions
111
Table 3 The summary statistics (F and P values) of ANOVA testing the effects of Gender (G), Status (S), and Posture (POS) on abdominal muscle thicknesses. Muscle
Main Effects Gender
EO IO TrA
Interaction Effects Posture
Status
G*POS
G*S
POS*S
G*POS*S
F
p
F
p
F
P
F
p
F
p
F
p
F
p
13.744 28.960 6.203
0.001* 0.0001* 0.017*
0.916 5.189 18.488
0.344 0.028* 0.001*
2.791 43.251 82.082
0.102 0.0001* 0.001*
0.043 1.139 2.832
0.838 0.292 0.100
0.779 7.458 0.228
0.383 0.009* 0.636
2.415 3.481 5.617
0.128 0.069 0.023*
0.03 3.070 1.405
0.864 0.087 0.243
The cross tabulation of muscle thickness about BMI and gender is provided in Table 5. No significant interaction effect of gender and BMI was seen on muscle thickness (F Z 0.865, p Z 0.46) using two-way ANOVA. Pearson test did not show relationship between age and muscle thickness (r Z 0.262, p Z 0.09).
Discussion Measuring the thickness of lateral abdominal wall muscles sonographically indicated that a significant increase in thickness of TrA was observed in both standing and supine positions, demonstrating the activation of this muscle during AH maneuver (Teyhen et al., 2007; Mannion et al., 2008). As for the IO muscle, several studies (Mc Meeken et al., 2004; Misuri et al., 1997) that have investigated the sub-maximal activity of muscle electromyographically, have reported a good correlation between the activity of TrA and IO muscles. In a recent research, 26 healthy individuals performing classic Pilates exercises were assessed ultrasonically to conclude that TrA and IO muscles do not work independently (Critchley, 2008). Our study also observed this coordination and synergy; that is, performing the AH maneuver causes activation and therefore an increase in thickness of IO muscle compared to resting state. We also found that during AH maneuver, males activate IO muscle more than females, demonstrating gender dependency of abdominal muscle activation strategies (Kulas et al., 2006). Previous studies have indicated that a person’s ability to contract TrA muscle in an isolated fashion depends on three factors; namely: deep sensation, respiratory pattern, and capacity of motor learning (Teyhen et al., 2007). Furthermore, a study conducted by Stevens et al. (2007) indicated that muscular training programs based on neuro-muscular control in healthy individuals alter the patterns of muscular
Table 4
activity. The fact that isolated contraction of TrA muscle was not observed ultrasonically in our study may be accounted for by lack of homogeneity among the above factors in people participating in the study. The findings of this study indicate that the change in thickness of TrA muscle during AH maneuver compared to resting state was the same in lying and standing positions. Also, the resting thickness of the muscle was significantly greater in standing position; in other words, changing position activates the TrA muscle with a feed forward mechanism and increases the thickness significantly (Richardson et al., 2004; Hodges et al., 1997). This conclusion was confirmed by comparing the TrA indices in standing and supine positions. Therefore, it is affirmed that changing from a stable position to a less stable one can affect the resting thickness of TrA muscle (Teyhen et al., 2007). Bunce et al. (2004) reported a significant difference in the resting thickness of TrA in standing and supine positions. However, Norasteh et al. (2007) did not observe a significant difference in the resting thickness of TrA between standing and supine positions, concluding that the standing position cannot cause sufficient instability and load, whereas they had actually selected standing position to apply greater load and instability. Moreover, change in thickness of IO was observed in standing position compared to supine position (Tables 2 and 4). The study conducted by Aniscough-Potts et al. (2006) on 22 healthy individuals for measurement of muscular thickness in different positions, both TrA and IO muscles equally responded to postural changes. Sparkes’s electromyographical study on 20 young and healthy individuals demonstrated that with development of stabilizing exercises from a position with 3 fulcra to one with 2 fulcra (i.e. decreasing level of stability), activity of IO muscle develops alongside TrA. This study highlights the pivotal role of IO in spine stabilization (Sparkes et al., 2006). In a study conducted by Arjmand et al. (2008) the
The means (SD) for abdominal muscle Computed Contraction Ratios in the present study and Mannion et al. (2008).
Computed contraction ratios
TrA contraction ratio EO þ IO contraction ratio TrA preferential activation ratio EO contraction ratio
Mannion et al. (n Z 14) supine position
Supine
Standing
t
p Value
1.45 0.21 1.05 0.05 0.06 0.03
1.53 0.37 1.09 0.15 0.06 0.04
1.29 0.32 1.11 0.18 0.02 0.06
3.122 0.524 2.76
0.003 0.6 0.008
1.1 0.2
1.03 0.2
1 0.1
Present study (n Z 43)
1.750
0.08
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*Significant level.
112
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Table 5
F.D. Manshadi et al. The mean (SD) values of Lateral Abdominal wall muscles’ rest thickness based on BMI in both genders (mm).
BMI
Underweight
Normal
Overweight
Gender
F
M
F
M
F
M
F
M
Muscles
(n Z 4)
(n Z 2)
(n Z 13)
(n Z 12)
(n Z 3)
(n Z 5)
(n Z 1)
(n Z 3)
EO IO TrA
2.96 1.11 3.87 0.86 1.96 0.39
3.90 1.54 6.62 2.23 2.91 0.41
3.28 0.81 4.351.08 2.36 0.68
4.09 1.58 6.443 2.21 2.81 0.79
2.99 0.53 3.56 0.23 2.17 0.27
5.41 2.07 7.07 1.30 3.22 0.39
2.59 0 4.56 0 3.11 0
5.32 1.71 9.29 1.86 3.93 0.77
IO muscle is attributed a greater role in maintaining upright stability compared to external oblique and TrA. In summary, the above findings corroborate Richardson’s theory that with lowering stability, the activity of IO and TrA increases (Richardson et al., 2004). Clinically in rehabilitative programs for low back pain patients, it has been suggested to lower the stability of underlying surface in order to augment the activity of muscles responsible for stability of the region, including IO and TrA (Richardson et al., 2004; Teyhen et al., 2008). A study conducted by Vera-Garcia et al. (2000) indicated that compared to fixed surfaces, performing exercise on oscillating surfaces increases the activity of abdominal muscles (TrA and EO) and facilitates their synchronized activity in maintaining vertebral and corporal stability. To what extent the activities of EO and IO could have been isolated in that study is unclear. In our study, we found much more coordination between IO and TrA than between EO and TrA. More detailed biomechanical studies of the kind performed by Arjmand et al. (2001, 2008) is needed to increase our understanding of this issue. In our study, the absolute value of muscle thickness in lateral abdominal wall was greater in men compared to women; a finding in keeping with previous studies (Norasteh et al., 2007; Teyhen et al., 2007). In this regard, Teyhen et al. (2007) stated that this difference between genders may bear a clinical significance in terms of exercise recommended; however, no study has been conducted so far to indicate whether rate of success for neuromuscular rehabilitation programs is affected by gender (Teyhen et al., 2007). A lack of relationship between muscular thickness and age in this study corroborates the findings of previous studies (Norasteh et al., 2007; Teyhen et al., 2007). Age was not considered as independent variable in our study, and the small range of participants’ age may limited the ability to detect any possible correlation. Our study measured muscular thickness only at one point; however, recent explorations have indicated morphological variations in IO and TrA muscles and suggested that each part of these muscles may involve a specific function (Urquhart and Hodges, 2005; Urquhart et al., 2005). Furthermore, the probability has been proposed that neuro-muscular control of different muscular segments in the abdomen may be independent of each other and dependent on the activity levels (Moreside et al., 2008). Therefore, investigating the change in muscle thickness at different anatomical points and with different degrees of activity in both genders may enhance our knowledge of the function of abdominal muscles. Moreover, since the results of imaging method is partly dependent on operator (Hodges et al., 1996), we recommend
Obese
conducting studies in order to investigate the repeatability among operators.
Conclusion Regarding the effects of AH maneuver and changing position on TrA thickness, it appears that performing AH maneuver in standing position can be effective on TrA training. Although, the PBF has been introduced as a clinical and available device for monitoring TrA activity, RUSI showed that both TrA and IO muscles had activated during AH maneuver. We recommend performing further investigations using electromyography and RUSI at the same time.
Acknowledgements The partial supports of the Research Foundation of Iran University of Medical Sciences University for FDM and the Hanyang University Research Foundation HY-2009-N9 for MP are greatly appreciated.
References Aniscough-Potts, A.M., Morrissey, M.C., Critchley, D., 2006. The response of transversus abdominis and IO muscles to different postures. Manual Therapy 11 (1), 54e60. Arjmand, N., Shirazi-Adl, A., Parnianpour, M., 2001. A finite element model study on the role of trunk muscles in generating intra-abdominal pressure. Biomedical Engineering, Applications, Basis and Communications 13), 181e189. Arjmand, N., Shirazi-Adl, A., Parnianpour, M., 2008. Trunk biomechanics during maximum isometric axial torque exertions in upright standing. Clinical Biomechanics 23, 969e978. Bunce, S.M., Hough, A.D., Moore, A.P., 2004. Measurment of abdominal muscle thickness using M-mode ultrasound imaging during functional activities. Manual Therapy 9, 41e44. Cairns, M.C., Harrison, K., Chris, Wright, 2000. Pressure biofeedback: a useful tool in the quantification of abdominal muscular dysfunction? Physiotherapy 86 (3), 127e1382. Critchley, D.J., 2008. Transversus abdominis and obliquus internus activity during Pilates exercises: measurement with ultrasound scanning. Arch. Phys. Med. Rehabil. 89, 2205e2212. Hodges, P.W., Richardson, C.A., Jull, G.A., 1996. Evaluation of the relationship between the findings of a laboratory and clinical test of transversus abdominis function. Physiotherapy Research International 1, 30e40. Hodges, P.W., Butler, J.E., Mckenzie, D.K., Gandevia, S.C., 1997. Contraction of the human diaphragm during rapid postural adjustments. Journal of Physiology 505, 539e548. Kulas, A.S., Schmitz, R.J., Shultz, S.J., Henning, J.M., Perrin, D.H., 2006 OcteDec. Sex-specific abdominal activation strategies during landing. J. Athl. Train. 41 (4), 381e386.
Mannion, A.F., Pulkovski, N., Gubler, D., Gorelick, M., O’Riordan, D., Loupas, T., Schenk, P., Gerber, H., Sprott, H., 2008. Muscle thickness changes during abdominal hollowing: an assessment of between-day measurement error in controls and patients with chronic low back pain. European Spine Journal 17, 494e501. Mc Meeken, J.M., Beith, I.D., Newham, D.J., Milligan, P., Critchley, D.J., 2004. The relationship between EMG and changes in thickness of transversus abdominis. Clinical Biomechanics 19 (4), 337e342. Misuri, G., Colagrande, S., Gorini, M., et al., 1997. In vivo ultrasound assessment of respiratory function of abdominal muscles in normal subjects. Eur. Respir. J. 10, 2881e2887. Moreside, J.M., Vera-Garcia, F.J., McGill, S.M., 2008. Neuromuscular independence of abdominal wall muscles as demonstrated by middle-eastern style dancers. Journal of Electromyography and Kinesiology 18, 527e537. Norasteh, A., Ebrahimi, E., Salavati, M., Rafiei, J., Abbasnejad, E., 2007. Reliability of B-mode ultrasonography for abdominal muscles in asymptomatic and patients with acute low back pain. Journal of Body Work and Movement Therapies 11, 17e20. Richardson, C.A., Hodges, P.W., Hides, J., 2004. Therapeutic Exercises for Lumbopelvic Stabilization, second ed. Churchill Livingstone, Edinburgh. Snijders, C.J., Vleeming, A., Stoekart, R., Mens, J.M.A., Kleinrensink, G.J., 1995. Biomechanical modeling of sacroiliac joints stability in different postures. Spine: State of the Art Reviews 9, 419e432. Sparkes, V., Lambert, C., Keith, A., Rees, D., Terry, G., 2006. Spinal stability exercises: evidence of preferential activation of internal oblique muscle in 3 and 2 point kneeling exercises. Conference Proceeding /Physical Therapy in Sport 7, 171e180.
113 Stevens, V.K., Coorevits, P.A., Bouche, K.G., Mahieu, N.N., Vanderstraeten, G.G., Danneels, L.A., 2007. The influence of specific training on trunk muscle recruitment patterns in healthy subjects during stabilization exercises. Manual Therapy 12, 271e279. Stroheim, K., Bø, K., Pederstad, O., Jahnsen, R., 2002. Intra-tester reproducibility of pressure biofeedback in measurement of transversus abdominis function. Physiotherapy Research International 7 (4), 239e249. Teyhen, D.S., Gill, N.W., Whittaker, J.L., Henry, S.H., Hides, J.A., Hodges, P.W., 2007. Rehabilitative ultrasound imaging of the abdominal muscles. J. Orthop. Sports Phys. Ther. 37 (8), 450e466. Teyhen, D.S., Rieger, J.L., Westrick, R.B., Miller, A.C., Molloy, J.M., Childs, J.D., 2008. Changes in deep abdominal muscle thickness during common trunk-strengthening exercises using ultrasound imaging. J. Orthop. Sports Phys. Ther. 38 (10), 596e605. Urquhart, D.M., Hodges, P.W., 2005. Differential activity of regions of transversus abdominis in trunk rotation. European Spine Journal 14 (4), 393e400. Urquhart, D.M., Barker, P.J., Hodges, P.W., Story, I.H., Briggs, C.A., 2005. Regional morphology of the transversus abdominis and obliquus internus and external abdominis muscles. Clin. Biomech. 20, 233e241. Vera-Garcia, F.J., Grenier, S.G., McGill, S.M., 2000. Abdominal muscle response during curl-ups on both stable and labile surfaces. Phys. Ther. 80, 564e569. Whittaker, J.L., Thompson, J.A., Teyhen, D.S., Hodges, P.W., 2007. Rehabilitative ultrasound imaging of pelvic floor muscle function. J. Orthop. Sports Phys. Ther. 237 (8), 487e498. doi: 10.2519/jospt.2007.2548. Epub 30 May 2007.
PREVENTION & REHABILITATION e MUSCLE PHYSIOLOGY
An ultrasonic assessment in supine and standing positions
Journal of Bodywork & Movement Therapies (2011) 15, 114e124
available at www.sciencedirect.com
journal homepage: www.elsevier.com/jbmt
PREVENTION & REHABILITATION e SYSTEMATIC CRITICAL REVIEW
SYSTEMATIC CRITICAL REVIEW
The assessment of the cervical spine. Part 1: Range of motion and proprioception Nikolaos Strimpakos a,b,* a b
Department of Physiotherapy, TEI Lamias, 3rd Km Old National Road Lamia-Athens, Lamia 35100, Greece Centre for Rehabilitation Science, University of Manchester, UK
Received 4 February 2009; received in revised form 29 May 2009; accepted 5 June 2009
KEYWORDS Neck pain; Cervical spine; Assessment; Range of motion; Proprioception
Summary Neck pain and headache of cervical origin are complaints affecting an increasing number of the general population. Mechanical factors such as sustained neck postures or movements and long-term ‘‘abnormal’’ physiologic loads on the neck are believed to affect the cervical structures and compromise neck function. A comprehensive assessment of neck function requires evaluation of its physical parameters such as range of motion, proprioception, strength and endurance/fatigue. The complicated structure of the cervical spine however, makes it difficult for any clinician to obtain reliable and valid results. The aim of the first part of this systematic critical review is to identify the factors influencing the assessment of range of motion and proprioception of the cervical spine. ª 2009 Elsevier Ltd. All rights reserved.
Clinical relevance of review findings The assessment of neck range of motion and proprioception by researchers or clinicians can be influenced by many factors because of the complicated nature of the cervical spine. For this reason, examiners should use the same position (sitting or standing) for each subject, and should take care to control lumbar spine posture during any measurement. Torso stabilisation can overcome this problem. Ideally assessments should be performed after undertaking warm-up exercises and a full practice session at the same time of the day (preferably not early morning). For proprioception assessment, active movements give more information from muscle and joint receptors while fatigue and external influences such as noise and cutaneous stimulation should be avoided.
* Department of Physiotherapy, TEI Lamias, 3rd Km Old National Road Lamia-Athens, Lamia 35100, Greece. Tel.: þ30 22310 60203; fax: þ30 22310 67770. E-mail address:
[email protected] 1360-8592/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2009.06.003
The assessment of the cervical spine
A comprehensive clinical evaluation of the cervical spine requires consideration of more than a single-factor and includes assessment of both symptoms and physical deficits. Pain is the primary complaint which has attracted the attention of most researchers and clinicians, however pain is only a symptom and not a cause. Also, pain, disability and other symptoms are subjective in nature and may depend on many other factors than the problem itself. The assessment of physical impairments of the neck has been proposed as a more objective measure for the diagnosis and prognosis of neck pain and headache as well as an essential part of their overall management (Strimpakos et al., 2005b; Jull et al., 1999; Hermann and Reese, 2001; Dumas et al., 2001; Nakama et al., 2003; Strimpakos et al., 2004; Strimpakos et al., 2005a; Strimpakos et al., 2006; Nordin et al., 2008; Vaillant et al., 2008). Interest in the assessment and treatment of strength, endurance, range of motion and proprioception of the cervical spine has increased exponentially in the last two decades (Strimpakos et al., 2005b; Jull et al., 1999; Hermann and Reese, 2001; Dumas et al., 2001; Nakama et al., 2003; Strimpakos et al., 2004; Strimpakos et al., 2005a; Strimpakos et al., 2006; Nordin et al., 2008; Vaillant et al., 2008). To a large extent this appears to be linked to an increased incidence and recurrence of neck problems in combination with a growing dissatisfaction regarding the current methods of identifying the causative factors of cervical spine dysfunction. The objective assessment of several physical parameters has been proposed by many researchers and clinicians as important components of a thorough evaluation of the cervical spine that could possibly contribute to the ‘‘cause and effect’’ justification of neck disorders. It is widely accepted that structural pathology does not generally correlate with pain therefore many therapists have focused on restoring function. Strength, endurance, flexibility, proprioception and coordination are basic elements for performing activities of daily living (ADLs) such as sitting, carrying and posture therefore assessing and restoring their deficits have become a primary objective of many clinicians (Liebenson, 2002). From a previous extended literature review, relevant studies demonstrated great diversity concerning the measurement tools, the methodologies undertaken and analysis of the data used (Strimpakos and Oldham, 2001). Unfortunately, many of these studies were shown to be methodologically flawed. In order, therefore, to determine the best protocol for measuring physical deficits in the cervical spine this critical systematic review aims to identify the factors influencing their assessments and estimates. The first part of this review addresses the issues influencing ROM and proprioception measurements; and the second part, appearing in a subsequent paper, relates to the strength and endurance/ fatigue measurements. A computerized search was performed through the Medline, EMBASE, CINAHL and AMED databases from 1966 to December 2008 using broad as well as specific key words e individually or in combination. They included: cervical spine, neck, function, reliability, validity, intra-observer,
inter-observer, strength, endurance, fatigue, range of motion, flexibility, proprioception and kinaesthesia. This was followed by a search through references cited in the retrieved articles. Only English language articles were included. Reliability and validity studies were included if they reported at least one measurement tool concerning cervical strength, endurance, ROM and proprioception, regardless of whether the studies were in healthy or symptomatic subjects. Studies were excluded if measurements were limited to an individual vertebra or focused on a small portion of the cervical spine, such as the upper cervical spine.
Range of motion Measurement of cervical ROM has been used to evaluate the severity of impairment or disability in patients with workrelated cervical disorders and whiplash injuries (Hagen et al., 1997; Hermann and Reese, 2001; Klein et al., 2001; Cagnie et al., 2007; Nordin et al., 2008). It has also been used as part of the clinical criteria in disease classification (Headache Classification Commitee of the International Headache Society, 1988) as well as to evaluate the efficacy of a rehabilitation programme (Hagen et al., 1997; Jordan et al., 1998; Huston et al., 2000; Wang et al., 2003; Nordin et al., 2008). Many systematic reviews on neck pain and headache have demonstrated that range of motion is the most frequently reported objective outcome measure in published trials (Aker et al., 1996; Borghouts et al., 1998; Kjellman et al., 1999; Nordin et al., 2008). Although the terms range of motion (ROM) and flexibility have been considered synonymous by many authors they are not exactly the same (White and Panjabi, 1990); (Kriviskas, 1999). In this review flexibility is expressed in terms of ROM (passive or active). ROM is muscle and joint specific and is influenced by many factors such as age, gender, temperature and even the race of the individual (Kriviskas, 1999). Furthermore, the present review reveals that measurements of neck function can be affected by intrinsic factors such as the joint complexity and diurnal variation of ROM. It may also be influenced by factors arising during the measurement procedure such as the position and posture of the subjects, the use of active or passive movement, whether the subjects have open or closed eyes, the use of stabilisation and isolation of the cervical spine. The importance of each of these factors and their influence in neck ROM assessment is discussed below.
Factors influencing range of motion measurements and estimates Joint complexity and range of motion Reliability of measuring ROM is specific to the action measured and to regional structure and function. For example, measurements of the elbow, generally considered a simple hinge joint, show less day-to-day variation in ROM than measurements of the wrist, the movement of which is affected by multiple joints and numerous muscles (Gajdosik
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Introduction
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N. Strimpakos
Figure 1 Change in posture of the head affects the relationship of the upper and lower cervical spine and consequently the neck ROM (From Neumann, 2002, with permission).
and Bohannon, 1987). Many authors have demonstrated that even complex movements can be measured reliably when the measurement procedures are controlled. Clinicians and researchers must recognise the complex anatomy of the cervical spine and the greater normal variation in comparison with other joints of the body. During the assessment of neck flexion and extension motion occurring in both the upper and lower regions of the cervical spine must be controlled as much as possible if the full potential of cervical flexion or extension is to be reliably assessed. Furthermore, the usual slump position that many individuals adopt in everyday activities (especially in sitting) leads to a forward head posture and affects greatly the kinematics of the cervical spine (White and Sahrmann, 1994) (see Figure 1). Lack of such control in addition to the wide variety of instruments and lack of standardised procedures may be responsible for the wide range of reported values for normal neck motion (Chen et al., 1999; Solinger et al., 2000).
Neutral position, half cycles or full plane motions Neutral head position, defined as the anatomical position, has been commonly used but poorly controlled for in most studies (Chen et al., 1999; Solinger et al., 2000; Cagnie et al., 2007). In some reports, the initial head position was adjusted by the examiner using anatomic landmarks, a bubble level or a single inclinometer (Chen et al., 1999). Many other studies used a target in front of their subjects or simply asked them to look straight ahead and to put their head subjectively in a neutral position. The ability to reliably assume the same neutral head position relative to the thorax is essential in measuring half-cycle ROM or assessing
asymmetry accurately and precisely. On the other hand, studies have suggested that the inability of a patient to resume their neutral head position may serve as an additional indication of spinal pathology. Therefore, clinicians and researchers assessing cervical ROM have to be able to standardise and reproduce the head and body posture in each test session in order to have reliable and valid motion estimates.
Stabilisation effect To assess the range of motion of muscles that cross more than two joints, the body or segments of the body have to be positioned appropriately, stabilising them to ensure validity and reliability (Mellin et al., 1991; Kriviskas, 1999). The lack of isolation of the cervical spine from the rest of the body can affect both the reliability estimates as well as the normative cervical ROM values. Many studies however, did not isolate adequately the cervical spine jeopardizing the validity and reliability of their results (they used manual stabilisation or stabilised only the lumbar spine or asked the subjects to hold a handle) (Christensen and Nilsson, 1998; Lantz et al., 1999; Petersen et al., 2000). The use of sophisticated instruments which are able to record motions only from the cervical spine (e.g. 3D electromagnetic or ultrasound-based devices) can overcome this limitation although in practice the problem is not completely solved (Strimpakos et al., 2005b; Solinger et al., 2000; Dvir and Prushansky, 2000; Petersen et al., 2000). The need therefore for a firm stabilisation of the torso (even when the above instruments are employed) as well as the use of a specially constructed seat adjustable to each subjects’ height are essential for repeatable assessments and for recording true ROM values (see Figure 2).
The assessment of the cervical spine
117
Open or closed eyes The influence of vision on cervical ROM has not been examined extensively in the literature with most studies examining cervical ROM with subjects’ eyes open (Dvir and Prushansky, 2000; Irnich et al., 2002; Dvir et al., 2002). Some authors have found that passive end-range values were much more variable if goniometric assessments were performed with the subjects’ eyes open (Wong and Nansel, 1992). Dvir et al. (2002) suggested that elimination of visual stimulation would allow a clearer delineation of the factors involved in ROM reliability measurements as subjects may use vision to attain higher reproducibility. In a recent study however, both procedures yielded reliable values (Strimpakos et al., 2005b).
Direction effect Figure 2
Operator with stabilisation frames.
Initial position effect The initial body position (namely supine, sitting or standing) could affect the values of the measurements (Nitz et al., 1995; Lantz et al., 1999). Results of recent experiments showed that both initial standing and sitting positions yielded high reliability estimates with standing being slightly better in most movements (Strimpakos et al., 2005b). A probable cause for these discrepancies could be the change of the normal spine curvatures when different initial positions are utilised resulting thus in different ROM values. It seems therefore that it does not matter if measures are made in sitting or standing providing the same position is adopted in subsequent measures.
Active or passive motions Another issue concerns whether the measurement should be made actively or passively (Nordin et al., 2008). Chen et al. (1999) and (Jordan, 2000) identified some investigations in which passive motion gave greater range of motion values than active movement and also higher reliability estimates. In trying to explain the differences between active and passive motions some authors noted that active ROM may be more idiosyncratic and therefore more difficult to interpret than those using passive ROM techniques, particularly when end-range asymmetry information is considered to be of primary clinical importance (Wong and Nansel, 1992). Passive movement has been considered thus
The examination of differences in reliability according to a specific direction reveals that in most studies the best correlations were obtained for lateral flexions and axial rotations. Flexion and extension movements seem to be the least reliable. This fact may be related to the position of the trunk relative to the seat. Since the lumbar spine’s convexity was not precisely controlled in most of the studies, the initial position could be different with repeated measures. This could result in a different head versus thorax inclination and hence could lead to a larger measurement error (Dvir and Prushansky, 2000). Another explanation is that motion in the sagittal plane involves the upper and lower cervical spine with the larger number of elements giving rise to a larger error. Sterling et al. (2002) suggested that the lower reliability in flexion could be attributed to an order effect as flexion was always the first movement being measured in their study (Sterling et al., 2002). This explanation is rejected however from the results of other studies which assessed other movements first and still found flexion to be less reliable (Lantz et al., 1999). Differences in reliability also exist between sides although there is no specific trend in favour of the right or left direction (Normand et al., 2007). With regard to normal ROM values, there is general agreement that transverse plane motion displays larger motion ranges as compared to flexion-extension and lateral flexion. Some studies have shown an asymmetry between right and left axial rotation in normal subjects (Chen et al., 1999; Dvir and Prushansky, 2000) and have attributed these differences to hand dominance. More possible however, is the explanation that the inability of most studies to control
PREVENTION & REHABILITATION e SYSTEMATIC CRITICAL REVIEW
by some to be a more suitable option for cervical ROM estimation than active movement (Dvorak et al., 1992; Morphett et al., 2003). On the other hand, the advantage of active ROM assessment is the fact that coupled-motion sequences can be better represented and everyday physiologic motions can be measured (Castro et al., 2000). Additionally, measurements of active ROM are not vulnerable to over-pressure variations among different examiners. Despite the above inconsistencies however, no protocol seems to be significantly superior over the other, suggesting that both can be used in clinical settings (Strimpakos et al., 2005b; Nordin et al., 2008).
118 the reproduction of the neutral head position could lead to false asymmetries between sides. This is yet another area requiring further investigation.
PREVENTION & REHABILITATION e SYSTEMATIC CRITICAL REVIEW
Warm-up and range of motion In addition to elevating core temperature, warm-up exercises are used to increase the range of motion about a joint (Smith, 1994). Increases in core temperature whether due to muscle contractions or a passive heat source, enhance the extensibility of the tissues around a joint (Kriviskas, 1999). This effect is evident only while the temperature remains elevated (Enoka, 2002). Cold muscles are stiffer and possibly more predisposed to injury (Best et al., 1997). Frequently no distinction is made between warm-up exercises and those designed to increase flexibility. Differences in flexibility between joints and individuals are due to longterm adaptations, not the changes that take place after a set of warm-up activities (Enoka, 2002; Zakas et al., 2006; Beedle and Mann, 2007). Cervical spine studies have suggested that warm-up exercises which simulate the actual testing procedure increase the compliance of neck soft tissue and minimise the process of creep associated with repetitive measurements (Troke et al., 1996, 1998). Practice of the real tests would also allow the examiner to correct possible incorrect performances from the subjects and it is generally accepted that in any future developments a warm-up session should be included.
N. Strimpakos
Proprioception Proprioception is a term commonly used to describe the complex interaction between afferent and efferent receptors that control the position and movement in space of the body or part of the body (Newcomer et al., 2000). Many authors have stated that proprioception encompasses the sensation of joint movement (kinaesthesia) and joint position (joint position sense) (Lephart et al., 1997; Swinkels and Dolan, 1998; Brumagne et al., 1999; Newcomer et al., 2000). Perception of the orientation of the head in space as well as on the trunk demands not only the contribution of vestibular and visual cues but also proprioceptive information from the cervical spine (Taylor and McCloskey, 1988; Revel et al., 1991). This information comes from many structures around the cervical spine such as muscles, joints and skin (McCloskey, 1978; Taylor and McCloskey, 1988; Hogervorst and Brand, 1998). Conscious proprioception is essential for proper joint function in sports and activities of daily living or work-related tasks. Deficits in motor performance arise when the reliance on proprioceptive feedback is abolished either experimentally or because of a disorder (Gandevia and Burke, 1992; Lephart et al., 1997; Loudon et al., 1997; Karjalainen et al., 2003; Malmstrom et al., 2007; Sjolander et al., 2008; Field et al., 2008; Sandlund et al., 2008; Armstrong et al., 2008) although some studies showed little evidence of impaired cervicocephalic kinaesthetic sensibility in neck pain patients (Rix and Bagust, 2001; Dumas et al., 2001).
Diurnal variation and range of motion Sources of proprioception Ranges of motion are not stable with time (Bogduk, 1994; Reilly et al., 2007). Lumbar spine studies have shown that ROM increases during the day (Adams et al., 1987; Wing et al., 1992; Ensink et al., 1996). Moreover, forward bending movements subject the lumbar spine to higher bending stresses in the early morning compared with later in the day (Adams et al., 1987). It is clear however, that for a measurement to be reliable it is important to investigate ROM at the same time of day (Ensink et al., 1996; Reilly et al., 2007) and normative data should encompass diurnal changes. In addition, to overcome the initial stiffness of the spine all measurements are better carried out at least 2 h after arising in the morning (Mannion and Troke, 1999). Implications for clinicians and researchers regarding neck ROM assessment The assessment of neck ROM requires awareness of the complexity of this body region. More specifically, the examiner has to use the same subject position (sitting or standing) and has to take care with their lumbar spine posture (forward/backward inclination). Stabilisation of the torso could overcome this problem. All assessments should be performed after undertaking warm-up exercises and a full practice session at the same time of the day and preferably not early morning. The use of active or passive movements with open or closed eyes is left to the choice of the examiner as long as the same protocol is retained in subsequent assessments. Finally, it is essential when assessing the ROM in one particular plane (e.g. left or right side flexion) to ensure a standardised neutral head position.
The word ‘joint’ in ‘joint position and movement sense’ should not be interpreted as meaning that the receptors responsible for these sensations are located solely in the joints. These receptors can be found in different structures such as joints, muscles, tendons, capsules and skin which function as transducers converting the mechanical energy of physical deformation into the electrical energy of a nerve action potential (McCloskey, 1978; Taylor and McCloskey, 1988; Barrack et al., 1994; Hogervorst and Brand, 1998). Mechanoreceptors (muscle spindles, Golgi tendon organs, Pacinian corpuscles, Ruffini endings, free nerve endings) can be classified as either rapidly adapting or slowly adapting. Rapidly adapting receptors such as Pacinian corpuscles are associated with detection of acceleration, deceleration, or any sudden change in deformation of the mechanoreceptor (Barrack et al., 1994; Lephart et al., 1997). Slowly adapting receptors such as Ruffini end organs and Golgi organs are sensitive to the position of the body in space and to a slow change in position, since they exhibit a differing rate of impulse generation throughout the range of motion rather than a sudden burst of impulses typical of rapidly adapting receptors (Barrack et al., 1994; Lephart et al., 1997). Afferent information from tendon organs contributes to joint position and movement sense under active conditions, but has little or no proprioceptive role when muscles are relaxed (Goodwin, 1976; Colebatch and McCloskey, 1987). Static (predominantly secondary) muscle spindle endings and dynamic (predominantly primary) muscle spindle
endings may have a greater role in joint position sense and joint movement sense respectively. The contribution from muscle spindle receptors to joint position and movement sense may be substantially augmented during even lightly resisted muscle contractions. Approximately 80% of all muscle and joint afferents stem from free nerve endings (Heppelmann et al., 1988; Lobenhoffer et al., 1996). Since most mechanoreceptive free nerve endings in normal joints are only stimulated by extreme joint movements, they are probably not normally significant sources of position and movement sense. However, as with muscular free nerve endings, when there is inflammation, a large proportion of the free nerve endings are sensitised by the milieu of chemical substances produced during the inflammatory process (Grigg et al., 1986; He et al., 1988). In turn, this may result in abnormal joint position sense. A majority of cutaneous receptors are also free nerve endings (and hair follicle receptors in hairy skin). Slowly adapting skin receptors, especially Ruffini endings, play a significant part in the perception of finger joint positions and movements; but because of the specialised function and innervation of the human hand, it cannot be assumed that skin receptors have a similar proprioceptive role elsewhere in the body including the cervical spine (Perl, 1996; Craig and Rollman, 1999). In summary, studies suggest that muscle, joint and skin mechanoreceptors usually contribute to joint position and movement sense to a varying extent dependent on the test conditions and the region being examined. All proprioceptors are most active near the limits of joint movements, and it is widely believed that muscle receptors are of greatest importance. Comprehensive accounts of the sources of proprioception have been reported (McCloskey, 1978; Gandevia and Burke, 1992; Lephart and Fu, 2000; Proske et al., 2000).
Tests of proprioception In general there are different ways in which to evaluate proprioceptive capabilities: histological, neurophysiological and clinical. In the clinical environment most authors apply the threshold for detecting joint motion or a position sensation test during movement to evaluate kinaesthesia and the angle of reproduction capability (active or passive) for measuring joint position sense (Jerosch and Prymka, 1996; Marks, 1998; Rozzi et al., 2000; Kristjansson et al., 2004; Swait et al., 2007; Juul-Kristensen et al., 2008). These tests utilise a number of measurement tools ranging from visual estimation to sophisticated computerized instruments (Lincoln et al., 1998; Bruton et al., 1999; Strimpakos and Oldham, 2001; Strimpakos et al., 2006). The threshold of perception test requires customised motordriven apparatus to produce low velocity movements. Each subject is usually required to listen to white noise or music through headphones to block out noise from the motor, and a pneumatic sleeve is placed around the proximal and distal joint segments to minimise extraneous skin stimulation (MacDonald et al., 1996; Stillman, 2000). These precautions are at best inconvenient for routine clinical assessments of some joints, and impractical for many others which limit the ability to establish normality, to quantify severity, or to
119 demonstrate changes over time. This is especially so with respect to mild disorders, or assessments which simultaneously involve more than one joint such as in the cervical spine. On the other hand, research has shown little correlation between performances with the position sensation test during movement and the cervical joint position test raising questions as to their validity (Swait et al., 2007). In the subsequent paragraphs this review aims to present the most important factors capable of affecting the results of neck proprioception assessment in both clinical and research environments. More specifically, factors such as the cutaneous receptors involved in skin contact and stretch, memory and distraction, the position of the subjects, the speed of the test movement, the existence of fatigue, the number of repetitions, the learning effect, the active or passive assessment and the direction of the movement all have to be considered in any assessment.
Factors influencing proprioception measurements Cutaneous influence The possibility that skin contacts might influence joint position sense assessment is suggested by findings from a wide variety of clinical and laboratory experiments (Ferrell and Smith, 1989; Barrack et al., 1994; Stillman, 2000). For the purposes of moving a joint to and from different test positions, and when it is necessary to support any body part during maintenance of a test position, the examiner should keep contact with whatever surface(s) is/ are the most convenient using a comfortable grip with the minimum necessary pressure. Care should be taken to avoid skin stretch or a combination of stretch with relaxation. Most importantly, whatever method of manual contact is chosen, it should be comfortable for the patient, convenient for the examiner and consistent between measurements. In active tests, employing mid-range movements is a way to avoid skin stretch and thus reduce the influence of cutaneous receptors. Direct contact with clothes should also be avoided in order to eliminate their contribution to the outcome especially in the cervical spine where should be evaluated without a shirt or wearing only a T-shirt.
Memory and distraction The effect of memory and distraction on proprioceptive acuity has been examined in several studies with inconsistent results. It has been found that less than a 12 s delay between successive tests, with or without accompanying distraction, significantly increases joint position sense accuracy, and minimally effects reliability (Williams et al., 1969; Laabs, 1973; Stillman, 2000). It has also been found that a 60 s delay between passive tests and ipsilateral matching responses produces significantly worse results than a 15 s delay (Kaplan et al., 1985). Conversely, Horch et al. (1975) found that a 45 s delay between passive tests and contralateral matching responses had no effect on their results (Horch et al., 1975). The time delay which would normally occur during uninterrupted joint position sense tests with ipsilateral
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120 matching responses (less than 6 s) is unlikely therefore to have any discernable effect on results (Leonard and Milner, 1991; Sandlund, 2008). Wells et al. (1994) found that when subjects concentrated on their position sense task they presented higher accuracy in the joint position matching than with the addition of a distractive task. For all patients, but especially those with poor memory, inattention or emotional lability, the time interval between test and response should be kept to a minimum, and distractions avoided (Leonard and Milner 1991; Wells et al., 1994). As a matter of principle, clinicians should abort and recommence all assessments whenever there is a possible source of distraction between the start of a test and completion of the associated response.
Speed of the movement The speed of the movement is also an additional factor which can affect measurements and requires a high level of concentration particularly in neck proprioception testings. No speed instructions were mentioned in most of the reviewed articles and this seemed to be in accordance with low back studies (Swinkels and Dolan, 1998; Brumagne et al., 1999) although some researchers asked their subjects to perform three repetitions within 60-s (Loudon et al., 1997; Newcomer et al., 2000; Koumantakis et al., 2002). Therefore, uniformity remains to be established for the utility of speed instructions in proprioceptive measurements as well as for the time the subjects have to stay on the target location in order to memorize the movement and position of the cervical spine.
Fatigue and proprioception Several human clinical studies have found abnormal position and movement sense associated with muscle fatigue (Saxton et al., 1995; Voight et al., 1996; Brockett et al., 1997; Carpenter et al., 1998; Taimela et al., 1999; Rozzi et al., 2000; Bjorklund et al., 2000). Only one study has evaluated the effect of fatigue on neck proprioception acuity (Wong et al., 2006) and until future research clarifies this issue clinicians and researchers have to avoid multiple repetitions during assessments and should suggest to their subjects that they avoid any strenuous activities for one or two days before the tests.
Active and passive joint position sense Another point which has provoked controversy is the use of passive or active movements for reproduction of the desired position (Loudon et al., 1997; Strimpakos and Oldham, 2001; Kristjansson et al., 2001). Research has shown that sensory inputs may differ depending on whether the head is moving actively or passively (Cullen and Roy, 2004). Marks (1998) stressed that passive positioning cues are considered less sensitive than active positioning cues or constrained movements, and may produce an underestimate of a subject’s actual positioning ability. Most studies use the active relocation of their target. Although investigation of passive movements could give useful information on proprioceptive sensations it seems more rational to examine active head
N. Strimpakos excursions since these stimulate both joint and muscle receptors and provide a more functional assessment of the afferent pathways.
Test position and joint position sense Although it is often stated that joint position sense assessments may be influenced by the choice of test position, this view has been based on a limited and less than systematic study of only a few joints, movements and pathologies (Lonn et al., 2000). There is no information regarding the cervical spine and thus the question may be asked whether in current clinical practice the choice of test positions is always based on physiological and pathological considerations, or whether examiner convenience is more often the determinant. For example, some clinicians who chose to test right-angled joint positions, may do so because right-angles can be easily judged subjectively by the examiner, and not because they have particular clinical relevance for the patients. Gray and Regan (1996) have shown that right-angles (and 0 and 180 ) are the only angles which can be accurately judged subjectively (Gray and Regan, 1996). At the physiological or pathological limits of joint movement, stretch of articular and periarticular tissues on one side of a joint, and compression on the other, may be proposed as the reason why end-range test positions might produce different joint position sense assessment results compared to mid-range positions. Some other factors which might contribute to significantly different results at different test positions especially in the cervical spine include the variation in the lengths and tensions of muscles overlying the examined joint at different joint positions (Refshauge and Fitzpatrick, 1995; Refshauge et al., 1995, 1998), the variation in gravitational resistance of the contracting muscles during active tests at different joint positions, particularly the proximity of the test position to the gravitational horizontal and vertical (Papaxanthis et al., 1998), the variation in the capacity of subjects to relax with the joint in different positions and the amplitude of movement required to bring the joint to the chosen test position (Wells et al., 1994). Finally, it is probable that the effect, if any, of adjacent joint positions on the results from active and passive joint position sense assessments will vary at different joints depending on the particular multiarthrodial muscle biomechanics at each joint (Refshauge et al., 1998). It is therefore recommended that clinicians keep both the examined joint positions and adjacent joint positions constant during repeated assessments to minimise possible variations in the obtained results caused by different biomechanical test conditions. This requires a stabilisation system capable of isolating the joint or joints under investigation from the rest of the body which in the case of the neck proprioception measurements seems to have been forgotten (see Figure 2).
Number of test repetitions and learning effects Although some brief explanation is almost mandatory when subjects are to be asked to perform joint position sense
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tests for the first time, most published studies of joint position sense make no reference to any preliminary explanation or practice having taken place (Skinner et al., 1984; Clark et al., 1995). In the clinical environment, the amount of initial practice and the number of formal repetitions at each test position must take into account the attention span and compliance of the patients, each patient’s propensity to fatigue, how many test positions need to be examined, and at how many joints. Also, consistency of instructions and the tone of voice are important for obtaining more reliable results (Troke et al., 1998; Juul-Kristensen et al., 2008). Undoubtedly, clinicians will also be concerned about the total time required to gather and process the data. Due to the lack of extensive investigations on neck proprioception none of the above considerations have been examined in any of the reviewed studies. Concerning the possible influence of preliminary practice and the number of test repetitions, a more extensive practice and/or an increased number of formal test repetitions per target position might lead to less variability in the obtained results (Swait et al., 2007; Pinsault et al., 2008). However, the protracted assessment might equally cause deterioration in the performance of some patients as a consequence of reduced compliance or fatigue.
Conclusion
Direction effect
References
Only a few studies have presented separate reliability values for each side or direction tested (Kristjansson et al., 2001; Strimpakos et al., 2006; Lee et al., 2006). However, in most cases any observed differences between left and right directions were not statistically significant. The same conclusion was drawn by most other studies which did not find any significant difference between repositioning accuracy in the horizontal plane or the vertical plane (Revel et al., 1991; Heikkila and Astrom, 1996; Loudon et al., 1997; Rix and Bagust, 2001). Any further studies could therefore take the summation of both directions into account.
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Implications for clinicians and researchers regarding neck proprioception assessment There is no consensus concerning the best method of assessing neck proprioception in the current literature. Whatever the assessment of proprioception however, some precautions to ensure valid results have to be taken. According to present knowledge, all subjects should be examined without a shirt or wearing only a T-shirt and avoiding end-range movements. Fatigue should be eliminated because of its possible effect on proprioception measurements. Any factor that could distract the attention of the subjects should also be eliminated. More than three repetitions seem to be needed in order to reduce variability of the results but less than ten to avoid fatigue and noncompliance of the subject. A full practice session is also important. Active assessments give more information about muscle and joints and are more functional. Finally, the test position has to be kept constant between measurements and torso stabilisation could help in this way. The direction and the speed of the movement have not been proven to have any effect on test results.
It is obvious from the above that despite the widespread clinical use of cervical ROM and proprioception assessment the scientific literature reflects little agreement regarding the instruments as well as the methodologies utilised. The anatomical, biomechanical and physiological considerations in the assessment of physical parameters presented so far in this review have revealed the complicated nature of the cervical spine and the multiple issues a clinician or researcher has to take into account throughout its evaluation. Maintaining consistent procedures by isolating the cervical spine movement, by the use of a stabilisation frame, the avoidance of fatigue, the undertaking of a warm-up and a full practice session before measurements are all essential for reliable and valid results in both neck ROM and proprioception assessments. Furthermore, any external influences such as noise or sensory information from clothes have to be controlled when assessing neck proprioception.
Acknowledgements I would like to thank my colleague Dr. M.J. Callaghan for reviewing the manuscript.
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Journal of Bodywork & Movement Therapies (2011) 15, 125e127
available at www.sciencedirect.com
SELF-MANAGEMENT: PATIENT SECTION
The Turkish Get-Up Craig Liebenson, D.C.*, Gabrielle Shaughness, D.C. L.A. Sports & Spine, 10474 Santa Monica Blvd. #304, Los Angeles, CA 90066, USA
Prevention & rehabilitation e self-management: patient section Most people who exercise regularly perform either floor or machine based exercises. A recent development in rehabilitation and fitness training is the use of more functional exercises to teach patients the motor control needed for their daily activities, occupation, and sports. One such functional, whole body exercise is the Turkish Get-Up. This exercise is a very challenging performance exercise. It combines features of a lunge, bridge, and side plank into a functional whole body exercise. Start: Lay on your side and grasp a kettle bell with a neutral wrist (if the weight is heavy use a pistol grip so the wrist doesn’t buckle) and wrap fingers around the handle. Support the kettle bell with both hands (see Figure 1) Roll onto your back with one knee bent and one leg extended. The bent knee is on the same side as the
Figure 1
Start on side and grasp kettle bell with a neutral wrist.
arm you are holding the kettle bell with. Keep your opposite arm at a 45 angle, flat on the floor. As you roll onto your back hold the kettle bell close to your chest, then prepare to raise your arm by placing your upper arm holding the kettle bell, onto the floor, with the elbow bent (see Figure 2) Then extend the arm that is holding the kettle bell upwards (directly overhead) (see Figure 3) Shift your weight onto your elbow on your support side (see Figure 4) Or, start directly on your forearm, and then go to palm support (see Figure 5) For momentum to get up, corkscrew the support hand out and push off the palm of the hand that is on the floor. Simultaneously, drive through the heel of the bent leg, until your buttocks on that side begins to lift up. After which both sides lift up (see Figure 6a) Then, bridge up all the way (see Figure 6b) Extended leg should thread the needle behind the bent knee until you are in a kneeling position on that knee (see Figures 6b and 7)
Figure 2
Turn on your back.
* Corresponding author. Tel. þ1 31047 02909; fax: þ1 31047 03286. E-mail addresses:
[email protected] (C. Liebenson),
[email protected] (G. Shaughness). 1360-8592/$ - see front matter ª 2010 Published by Elsevier Ltd. doi:10.1016/j.jbmt.2010.10.004
PREVENTION & REHABILITATION e SELF-MANAGEMENT: PATIENT SECTION
journal homepage: www.elsevier.com/jbmt
PREVENTION & REHABILITATION e SELF-MANAGEMENT: PATIENT SECTION
126
C. Liebenson, G. Shaughness
Figure 3
Press kettle bell upwards.
Figure 5
Figure 4 Shift weight onto hip and elbow (this is an optional position).
Position your back knee so that it is fairly close to your palm. This will make it easier to continue to push yourself up Move your back foot and shin out slightly (i.e. windshield wiper your shin outwards) and take your hand off the ground and lift your torso straight up (see Figure 8) Stand all the way up (see Figure 9) Sets/reps/frequency:
a and b - Transfer support to forearm and then palm.
Perform 1 set 8e12 repetitions 1e2 per day Progressions: Perform Turkish Get-Up in reverse Perform 2 additional sets using Russian Reverse Pyramid approach For example: B Set 1e12 reps B Set 2e8 reps B Set 3e4 reps
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Figure 8
Figure 6
Straighten up in kneeling position.
a and b - Shift weight onto palm and bridge up.
Figure 7
Shift lower leg to kneeling position.
Figure 9
Stand up.
PREVENTION & REHABILITATION e SELF-MANAGEMENT: PATIENT SECTION
The Turkish Get-Up
